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An Ethnography
of a Chiropractic Clinic

Chapter 4: Subsetting Interaction

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

The previous chapter was primarily concerned with the delineation of nonbehavioral features (time and space characteristics) and standing patterns of behavior in the Clinic. This section focuses upon the interplay between the two.

In a traditional health care setting, behavior is less problematical, conscious impression management is minimal, and the social atmosphere is not strained. The chiropractor, on the other hand, is repeatedly confronted with a variety of patients who experience great difficulty in defining the situation. As will be later demonstrated, not all patients respond to the elements in the setting in the same way.

When patients were exposed to the physical-temporal elements and the contrived plans of action in the Clinic, their responses generated interactional problems for the practitioner, who in turn had to reciprocate in a fashion appropriate to the situation.

Continuing in the manner established in the last chapter, this section will accompany the reader through the Clinic, following standing patterns of behavior from one subsetting to another. Typical interaction between the practitioner and his staff and various types of patients will be presented. The actual typing of these patients by the practitioner is the subject of the following chapter.

THE WAITING ROOM: SITUATIONAL INTERACTION

The prospective patients entering the Clinic for the first time were generally unprepared for what awaited them. (A review of the content of waiting room interaction indicates that there does not exist for the general public a clear set of definitions concerning what "a chiropractic clinic looks like." Due to the deviant status of chiropractic health care practice, persons are reluctant, it seems, to make public their experiences.) Except for what they had possibly been told by more experienced patients, new patients had to rely upon a general set of expectations derived from past experiences in the offices of medical doctors. As one patient explained:

I guess I knew there would he a waiting room and a nurse, but I didn't know what to expect. He calls himself a doctor and I figure his office would look like . . . you know, a doctor's office.

The conservative appearance of the waiting room tended to relieve some of the anxiety expressed by new patients. The wall rhetoric served to neutralize the deviant reputation of the chiropractic Clinic. (See Ball's comments on the rhetoric of legitimization [1].) According to an older man who had come to the Clinic accompanied by his wife:

When we first came in and saw the magazines and the furniture, I kinda knew where I was . . . . When the secretary said "hi" and was real nice, I didn't worry too much any more. When we came up to the door we still weren't real sure if we were going to come in.

Meaningful human interaction implies intentionality relative to the perceived intentions of others. When there is no basis available for the perception of these intentions (definition of the situation), of course no focused interaction is possible. An indication of the general lack of an adequate definition of the situation is indicated by the confusion in role terminology. The chiropractic assistant has been addressed by the new patient variously as "secretary," "nurse," "girl," "helper," "sign-in girl," etc.

Interaction patterns in the waiting room depended primarily upon whether or not the actors involved were experienced or inexperienced patients. Although the waiting room was the most open region in the total configuration (patients, supportive others, assistants, the janitor, the mailman and others were continually entering and leaving the area), conversation was usually held to a minimum in spite of no formal conversational restrictions.

Unfocused Interaction

Waiting room interaction was generally unfocused in that it was limited to simple acknowledgments of the other's copresence. The chiropractic magazines, pamphlets, and brochures which had been made available were almost invariably taken up by the new patient, allowing for minimal involvement in the setting and precluding the uncertainty of a main involvement with others. These so-called emergency supplies, which are placed in public places, are seen by Goffman as assisting in the prevention of self-exposure and "over-presence." [2:51-52]

Typically the waiting room was occupied by persons unknown to each other, and they constituted an unfocused gathering. There was, for the most part, an absence of formal group organization in the sense of a mutually agreed-upon set of rights and obligations. The one exception to this was the matter of turn-taking. As indicated in Chapter 3, patients entering the Clinic sign in and thus ordered themselves in terms of behavioral priorities. The signing-in procedure served as a claiming mechanism for the patients and supplied them with a time orientation within the setting. Their relationship with the others was now clarified, and they had some basis for determining a situational course of action for themselves and others present.

The situational definitions (or lack of them) unique to the chiropractic setting -- as distinct from those characteristic within the more familiar medical doctor's office -- became obvious when the behavior of persons known to each other is examined. Occasionally a prospective patient, when entering the Clinic for the first time, would encounter a friend, neighbor, or someone familiar. In an establishment medical setting, a surprise encounter might naturally develop into a prolonged discussion of each individual's illness, treatment, doctor-patient relationship, and other topics of a more or less personal nature. Often this conversation would be carried out within the hearing distance of others.

Interactional encounters between chiropractically inexperienced acquainteds, however, differed markedly. The following conversation (which uses fictional initials or first names in all cases) is illustrative of the conversational restraint observed even among those persons intimately acquainted outside the Clinic's setting. Mrs. Z had been seated quietly alone in the waiting room for approximately twenty minutes when Mrs. X entered. Both had had no previous experience with chiropractic care either in the Clinic or elsewhere. Both lived in the same neighborhood, attended the same church, and on several occasions had visited each other in their homes.

Mrs. X [after quickly surveying the waiting room and seeing Mrs. Z]: Uh . . . well, hi. Good morning.

Mrs. Z: It's pretty . . . it's too early for me [short laugh] . . . can't wake up. How 'bout you? [Although Mrs. Z had started to continue some line of conversation, Mrs. X quickly moved to the sign-in window and was greeted by the assistant and was asked to sign in. Mrs. Z returned to her magazine. Although a seat was available immediately adjacent to the one occupied by Mrs. Z, Mrs. X selected one several chairs away and picked up some reading material from the central table.]

Mrs. Z: I thought I saw you drive by a few minutes ago but I wasn't sure.

Mrs. X: Yeah, same old car . . . finding a parking space gets harder all the time. How's [husband] Henry? I heard he was sick.

Mrs. Z: Oh, he's fine. Working everyday,

Mrs. X: Well that's fine. [Both return to their reading.]

Mrs. Z [after several minutes]: Been here long?

Mrs. X: Not too long.

Again the conversation was terminated and was not picked up again. Mrs. Z, being told "the Doctor will see you now," walked directly past her friend and entered the hall door with no noticeable eye contract or other form of copresence acknowledgment with Mrs. X. When she left, a short but friendly farewell served to terminate the encounter.

At no time during this or similar encounters between inexperienced acquainted persons did the subjects of specific ailments, chiropractic experience, or similar topics become the focus of attention of these persons.

The Necessity of Focused Interaction

The practitioner was well aware of the situational difficulties faced by the new patient. Much of the backstage conversation (discussed below) between practitioner and staff involved discussions of the importance of the assistant-patient relationship. We were urged to "get involved with the patient." The general office duties of the assistant were incidental to the primary task of interaction stimulation.

That dramaturgical discipline and loyalty are main concerns for file performance team in the Clinic was evidenced by the training procedure I experienced when beginning the job of assistant. After having been "immersed" in the chiropractic philosophy and familiarized with the techniques employed, I was carefully supervised during the first days of my apprenticeship. The trained assistant was left in charge of my patient-relationship training whenever the practitioner was occupied elsewhere. It was repeatedly emphasized that:

These people don't know what's going on. We've got to make them feel at home and let them know that there's nothing to be scared of. Be friendly. Talk to them and get them to relax.

The practitioner was indeed aware of the role-playing nature of the assistant's performance in the waiting room:

Look. It's going to take you a long time to learn what this is all about . . . but You've got to let that patient know that he's in good hands. You don't have to talk chiropractic. In fact you might even confuse them. Just make them think that this place is the nicest place on earth.

Focused Encounters

The chiropractic assistant occupies what Goffman [2:128-131] has termed an "opening position" in that he has the license to approach those persons in the waiting room with whom he is unacquainted. In a sense he is a host whose recognized duties necessarily involve direct contact with patients. The assistant not only has the right to initiate encounters but is obligated to initiate face engagements of welcome during the sign-up procedure with all entering the Clinic. The structured interaction which follows, however, is different in two respects from that which is normally observed in the office setting of the medical doctor.

First, the receptionist-patient relationship in the establishment doctor's office is normally an end in itself, initiated to secure specific information concerning the patient's medical background. This was not the practice in the Clinic. For reasons that will become clear later, the assistant intentionally avoided eliciting information concerning the patient's ailments.

A second distinction, closely related to the first, pertains to the directional flow of interaction. Whereas in the medical setting, the assistant opens a channel of communication through which the patient is expected to respond, in the Clinic the assistant initiated and sustained the flow of communication by supplying a set of definitions concerning the nature of the behavior setting.

Although the assistant was encouraged to engage patients in chiropractic conversation, it should not be construed that the waiting room was a center of constant ongoing focused interaction. The assistant was limited in his endeavors to sustain patients' attention by their receptivity. Tentative overtures were offered to patients with the hope of directing their attention to the topic of chiropractic care. However, if it was seen that an individual for one reason or another was reluctant to pursue the topic, it was tactfully avoided and the conversation directed to a general topic -- or the exchange was terminated. The relative success of the assistant in this respect was both situational and problematical: it depended upon the number of persons in the waiting room, the nature and extent of their acquaintance, and the varying degrees of their chiropractic experience.

Supportive Others and the Inexperienced Patient

Approximately half of all the new patients observed during the time of the study were accompanied by one or more supportive others. Usually these persons were relations of the patient. As in a normal nondeviant medical setting it is quite common for parents to accompany a young child, an adult person to accompany spouses, or the young to assist the elderly. Unlike the traditional setting, however, interaction between the inexperienced patient and his supportive others was minimal. Evidence of mutual involvement was limited almost entirely to nonverbal indicators of togetherness, such as physical proximity, hand-holding, exchange of reading materials, primary eye contact, and the taking of other similar interpersonal liberties.

When children were brought to the Clinic, they were required by their parents to remain seated and stern silence was usually demanded. Since literature and other forms of diversion for children were not available in the waiting room, discipline was sometimes a problem for parents concerned with maintaining proper appearances. Here, once again, a general lack of situational definitions was reflected by the parents' doubts concerning permissible latitudes of behavior for their children. According to one parent:

When Stevie hurt his back, 'course we took hint to the [medical] doctor right quick . . . but he never got all better. When a neighbor told us to try a chiropractor, we didn't know if they worked on kids. We called Dr. [the Clinic] to find out if Stevie could come.

And again in a later conversation with the same couple, the wife apologized for the waiting room behavior of the son:

Stevie just won't stay still. I tried to get him to . . . but I guess he was nervous like we was. The girl [assistant] was so nice, she came out and talked to us and told Stevie about the couch [adjustment table], and well, it just made us feel better knowing we could all go in together, for one thing.

The presence of supportive others was reassuring and whenever possible the assistant Would stimulate interaction between the patient and his Supportive others thus promoting solidarity and relaxed confidence. Various conversational topics were pursued depending upon their appropriateness in the situation.

The subject of children and the problems of child-rearing provided natural opening gambits for the assistant. At times the practitioner's wife, when serving in the capacity of assistant, would bring her young child with her to the Clinic. (It was not possible to ascertain whether this was apurposeful maneuver or done simply for the sake of convenience.) At those times when a child of a similar age was present, play would be encouraged in the waiting room. The children would be the focus of attention and the conversation would inevitably be steered in the direction of chiropractic and child care. (This is in important facit of chiropractic practice-building in that whole families are encouraged to come to the Clinic for periodic checkups and adjustments "at reduced rates, of course.") If possible, interaction was initiated among unacquainted persons who may have children of their own. Under ideal conditions, the initial encounter group, consisting of parents, children, and assistant was expanded to include several unacquainted persons in the waiting room.

Experienced Supportive Others

An earlier study [3:233] observed that, as a general rule, it is favorable comments about the chiropractor from another person that persuaded the patient to try chiropractic and to select the particular practitioner that he does. This observation is supported in the present study. What was not indicated in this earlier work, however, is the significance of the knowledgeable supportive other in the behavior setting. In the Clinic it was not uncommon for the new patient to be accompanied by the referring significant other. Although many of these experienced supportive others were members of the immediate family, to be accompanied by a friend or acquaintance was not exceptional.

An established friendly relationship between the experienced patient and the assistant (and later the chiropractor himself) was characterized by a mutual openness [2:131]. The assistant greeted the new arrivals with a warm welcome and in turn was introduced to the prospective patient. The exposed position of the new patient provided the assistant with the license to approach him in a more direct fashion concerning chiropractic than was normally possible. Through the efforts of the assistant, the experienced patient was initially made the focus of interaction in the early stages of the encounter. The assistant could recall the experienced patient's success with chiropractic, or if possible, elicit a testimonial directly from him. The mutual regard and good will expressed in the encounter, combined with a fairly adequate supply of definitive ground rules supplied by both the assistant and the supportive other, served to sustain the new patient in his involvement in the chiropractic situation.

Supportive Interchanges

The sympathetic experienced patient was situationally supportive in two analytically distinguishable ways: first, he served to lend credence and support to the assistant's claims concerning the promise and effectiveness of chiropractic; second, he supplied the new patient with assurance in the setting, thus satisfying an implicit demand for a satisfactory definition of a deviant situation.

That the supportive other relieves the assistant of some of the "burden of proof" and the new patient of situational anxiety was illustrated by the following representative encounter. Howard K, a foreman and a regular chiropractic patient, and William S, a laborer on the same crew, entered the Clinic late in the afternoon and were greeted by the assistant.

ASSISTANT: Hello Mr. K. Back so soon? Your regular appointment is scheduled for Thursday. Can't stay away, huh?

HOWIE: Nope. No trouble with me. Seems to be O.K. this week [referring to his arthritis]. But I got a man here who fell on the job this morning and can't get the tingle out of his leg. This is Bill S.

ASSISTANT: Please have a chair, and I'll see if the doctor can examine you right away. [Exits and returns immediately]. It will be just a few minutes.

In this instance, as in others, the assistant knew that the practitioner was unoccupied with other patients, and probably available. The new patient, especially if he or she is accompanied by a supportive other, is made to wait, the specific purpose being interaction engagement.

ASSISTANT: [Seating herself next to me, but addressing the new patient]: I'm sure the doctor can help you. Sometimes these things can be cleared up right away. Right, Mr. K.?

HOWIE: Well, I'm working every day and feeling pretty good, that's for sure.

WILLIAM S: [visibly nervous] Well, I know I got something wrong with my legs and back, and if it's pinched nerves or something, well . . . [glancing at the assistant] I hope he doesn't mess it up worse.

HOWIE: Come on. He'll adjust it back into place. Listen, I've never walked out of here worse than when I come in. Usually it lot better. You'll probably feel as good as new tonight. [The use of the term "adjust" indicates that this patient has begun to acquire at least a minimal chiropractic vocabulary.]

ASSISTANT: Well, we can't always tell about these things, but the doctor will know what's best for you. [To Howie]: Thanks for bringing him in, Mr. K. I know we can help him. After all, hospital and drug bills can run hundreds of dollars and you still won't be really well.

HOWIE: Yeah, for five bucks, what've you got to lose? [As part of the training process, the practitioner admonished me to "never use the term 'medical' bills. The term 'drug' today means something bad, like 'drug user.'"]

Although the above encounter was restricted to the three actors and could easily have taken place in the adjustment area, it wits intentionally carried out in the waiting room as part of the standard pattern of behavior in the Clinic. Ideally such conversations took place in the presence of others with the hope of including them in the interaction or, at least, exposing them to it.

THE ADJUSTMENT AREA SUBSETTING

Chiropractic Teamwork

As noted, the practitioner and his assistants constituted a performance team that they cooperated in the staging of a behavioral routine that served to supply the patient with a specific and consistent set of definitions and expectations within the total configuration of the chiropractic setting. This cooperative teamwork was not immediately observable except in the most overt instances of normal role performance.

In a dramaturgical sense, the practitioner could have been viewed as not only the lead actor but also the behind-the-scenes director. He was primarily responsible for the appearance of the setting and behavioral regulation of the actors within it. For example, the assistant, while in the waiting room, by design had had the opportunity to "read" the patient and, at that time, make a tentative judgment of the patient's receptivity to chiropractic health care.

The first specific evidence of behavioral collusion on the parts of the chiropractic actors in the setting was the exchange that took place between the assistant and the practitioner when the new patient was introduced into the adjustment area.

Often, just before the patient was taken in, the assistant would once again "see if the Doctor is free now," thus passing along any information about the patient in private. However, just as often, the assistant would take the patient directly to the practitioner with only a brief introduction.

In the event the assistant had no opportunity to talk to the patient, this would he indicated to the practitioner:

Dr. _________, this is __________. We've been so busy this morning, we haven't had much of a chance to get to know each other. Maybe you can make her feel welcome.

Lack of information about a new patient was deemed undesirable by the practitioner. Normally the approach taken by the practitioner when initiating the encounter depended primarily upon the cues he had already been given by the assistant, which were based on the waiting-room experience.

These essential but sketchy definitions of the patient were most helpful to the practitioner because he had learned from experience and training that patient attitudes toward chiropractic and the practitioner ranged from nervous anxiety to open hostility. Seldom did a new patient come to the Clinic with high positive expectations and confidence. How the practitioner handled this range of patient responses will be the focus of the next chapter.

The Presentation of the Chiropractic Self

Whether the patient entering the adjustment area was new or a regular, the practitioner welcomed him with easy warmth, inevitably indicating to the patient to "have a seat [at the table] and let's get to know each other a little," or, in the case of a regular, "let's bring ourselves up to date." Rarely was the patient directed immediately to the adjustment table except in the case of patients (almost always regulars) who demanded a quick adjustment because of time limitations or excessive pain.

With the exception noted above, all patients were engaged in conversation that was initiated, directed, and sustained by the practitioner. Whereas in the waiting room the assistant's task was to supply the patient with the assurance of an non-threatening situation, the practitioner in the adjustment area defined his own role in terms of supplying a specific set of definitions and ideas concerning the nature, purpose, philosophy, and promise of chiropractic. For the most part the practitioner assumed control of the interactional situation from the outset, leading and directing the flow of substantive topics.

I give him the works right off the bat . . . spell it out for him in black and white. If he's going to buy it, I've got to find out right away. I can usually tell in the first five minutes of talking to him and watching him how far I can go with some things [topics], and then I can kinda feel my way from there.

Opening statements dealt with the fundamentals of chiropractic and closely resembled the information that the patient had familiarized himself with by reading the brochures and pamphlets given to him in the waiting room. Besides supplying a degree of consistency in the behavior setting, it also allowed the practitioner to clarify any confusion or misconception held by the patient.

Beginning with the most general statements ("Chiropractic health care is as natural as blue skies and green grass!"), the conversation was systematically directed to the more specific. Emphasis on the naturalness of chiropractic was emphasized repeatedly: "Chiropractic enables the natural physiology of the body to take charge. Once we can get the natural energy within your body to flow like nature intended it to, we can get you well again."

Note the repeated use of the plural "we." The patient is encouraged to believe that successful treatment is a matter of cooperative effort between doctor and patient, e.g., regular appointments.

One of the most obvious and repeated techniques of chiropractic salesmanship, evidenced in both the reading materials and in actual conversation, was the use of simple analogies:

You can understand that a house is in danger of collapse when its frame is out of line, or that the function of an automobile will prove defective and dangerous if its supporting structures are bent and distorted, and its movable parts out of alignment. Of course you can understand that bent and twisted body frameworks cause ailments throughout the entire body. But some people don't understand this.

In the attempt to anticipate an obvious question, the chiropractor eventually raised the problem of why there exists such misunderstanding of chiropractic. Stock explanations were offered such as a general lack of knowledge, the vested interests of powerful medical lobbyists, and an erroneous faith in the germ theory of disease. It is at this point that the chiropractor attempted to rationalize, for the patient, the patient's curiosity, interest, and actual presence in the Clinic:

Mrs. R [addresses her with the utmost seriousness and solemnity], you have no idea at this time just how fortunate you are having the courage to try chiropractic. If we could just convince more open-minded persons like yourself to come to us with their problems, much of the ignorance and Suffering of the world would be solved. Thank you for having faith. [Standing up, he finishes.] Now let's get you well!

Before the actual examination procedure began, the patient was given ample opportunity to raise questions. The practitioner would insist that "it is especially important to get him to express his objections. I always hear him out. If I let him get on that [adjustment] table and he's full of negatives, he won't respond at all." By "respond," the practitioner was referring not just to a favorable acceptance on the part of the patient, but to an actual physical response, i.e., the cure."

During the "warm-up" period in the adjustment area, the practitioner moved freely around the room taking advantage of the techniques of "stage business": pointing to wall charts and spinal displays, secur1ng, literature from the wall rack, making absent-minded adjustments on the adjustment table, and so forth. These movements all served to convey a relaxed and informal scene. The patient would be directed to I wall chart or to a small handwritten sign.

Repeated observations of the practitioner during this time revealed standing patterns of behavior that ordinarily would go unnoticed by the casual observer. For example, when the patient had been directed to the display skeleton for the purpose of informing him of the critical importance of nerve impingement, he was invariably referred to the small handwritten sign above it, which seriously proclaimed: "Accuse not Nature! She hath done her part; do thou but thine." This philosophy was "a natural for getting them on the table."

After the patient was judged ready he was told, "Let's try out the table. We'll go slowly at first and you'll see that it's easy." When the adjustment table and the patient were lowered into a horizontal position, the practitioner gently placed his hands on the high-back, shoulder area of the vertebra. He often remarked to the new patient, "I can feel the tenseness throughout your body, especially your legs. Now I want you to relax and concentrate on your spine."

This observation and admonishment conveyed to the patient two things: (1) that the chiropractor was able to detect things throughout the body by a careful and probing examination of the spine, and (2) that the pattern of conversation had changed. Although the practitioner remained in control of the overall experience, the patient's social presence (as an interactional target) was no longer the center of attention.

Occult Involvement. At this point in the practitioner-patient encounter, the practitioner displayed what Goffman [2:75-79] has termed an "occult involvement." He became engrossed in a specific and minute examination of the spinal column while at the same time displaying a marked inattention to the social presence of the patient. This is a modification of Goffman's use of the term which designates "a kind of awayness where the individual gives others the impression . . . that he is not aware that he is 'away'." Further, Goffman uses it to refer to a form of negatively defined behavior -- "unnatural . . . bodily activities" creating "disturbing impressions." The selection of the term occult rather than "away" seems appropriate. The practitioner was engaged in an activity, as mysterious as it may seem, as part of the practitioner's training and professionalism. "I didn't know what he was doing there, and I still don't. But after he told me what was wrong with me, I knew that he knew what he was doing."

The practitioner, at the beginning of the actual physical examination, would tell the patient to remain quiet so that both could concentrate on the spine, thus indicating to the patient that he was, for the moment, "going away." Several moments would pass during which time the patient would ask the practitioner a simple question which may or, as was quite often the case, may not elicit a reply. Here was an activity which, it must be assumed, was meaningless to the patient, except in the gross sense of knowing that he was somehow being examined.

The aura of mystery was increased when the practitioner suddenly and without apparent reason would ask, for example, if the patient had experienced "any stomach trouble in the last few weeks: gas, indigestion, anything like that?" These inquiries varied, of course, from patient to patient and from visit to visit. In most cases, however, they referred to the common complaints expressed by persons in everyday conversations. In most cases, for example, women were asked if they ever experienced difficulties during menstruation.

In most instances the patient would reply in the affirmative and at times would attempt to describe the complaint, only to be told, "Well, we can discuss that later, after your examination is completed." Several other specific inquiries concerning the patient's recent or not so recent history of symptoms were made. (It should be recalled from an earlier section that the assistant purposefully and tactfully avoided eliciting information concerning the patient's symptoms. The reason for this practice should he clear at this point: if the patient is allowed to know that the practitioner has been foretold of various complaints, the impact of these proclamations would he lessened or lost.)

While these questions could be interpreted its general inquiries concerning the patient's overall health, it was natural for the patient to conclude that there was some specific basis for each. This impression was reinforced by the following technique.

Just prior to each inquiry or observation the practitioner made it clear that he had found something which he had quite obviously been looking for. This was accomplished by a series of apparently non-communicative utterances:

Hmm . . . there seems to be a curvature here, so . . . let's see, there should be subluxation about here . . . no . . . uh, yes. Here, do you feel that: is that a little sensitive? Now tell me, have you had a recent fall or injury affecting your arms . . . ? Your right arm? Ah, yes. That's indicated.

It should not be construed that this procedure is fraudulent. Although the practitioner indicated to me that he sometimes guessed at probable common symptoms, he remained, as far as can be determined, convinced that he did indeed have the ability to accurately detect and assess the effects of vertebral subluxations.

It is not the purpose of this work to determine the quality of chiropractic care. The literature is replete with endless debate concerning the validity of chiropractic claims. Both sides involved in the argument cite research and authority. The controversy surrounding chiropractic may well be a political, rather than a scientific, debate. A similar point has been made regarding the marijuana issue in contemporary society: See Eric Goode's article, "Marijuana and the Politics of Reality." [4]

This form of examination procedure did have an impressive impact on most patients. Many saw the practitioner as having the power to see into the human body in what appeared to be a practical and straightforward way."' When the patient expressed surprise (and most did) at the chiropractor's observations, he was quick to follow up with the following comment:

Well, You see, this points up one of the major differences between the chiropractor and the medical doctor. When you go to the medical man you pay a lot of money so that you can tell him what's wrong with you. I feel that I should earn my money -- [laughing] a lot less money, I should add -- by telling you those things.

And further:

We're here not only to treat a specific problem but our goal is to do something about your total health. I know you didn't come here about a lot of those things [reviewing those symptoms which the patient has just acknowledged], but we're going to see a lot of improvement in things that you didn't know were wrong with you when you came in here.

Supportive Evidence: The X ray. The chiropractor saw the use of X rays as essential for three reasons: ( I ) they provided a source of immediate and substantial income; (2) once the patient had spent that sum of money he usually committed himself to at least a short series of appointments; and (3) the X rays offered much support to the statements made by the chiropractor concerning the patient's physical condition. If the patient queried, "Do I have to be X-rayed?," the reply was invariably, "Do you want relief or correction'? Very few patients refused. (This point is emphasized in McCorkle's short article [5] dealing with chiropractic in rural Iowa.)

After the X rays had been taken, the practitioner in most cases would employ the following procedure: (1) he reiterated the patient's condition; (2) he showed the patient the nerve chart on the wall, pointing to the patient's alleged difficulties; (3 ) the skeletal vertebral column was picked up and manipulated in various positions In order to demonstrate spinal distortions and Subluxations; and (4) the X rays were shown. This procedure is explicitly spelled out in a manual shown to me by the practitioner, James W. Parker's Practice Building and Office Procedure, "prepared especially for the Chiropractic Profession," Although the chiropractor was familiar with this and similar methodographic source material, he insisted repeatedly that the best procedure is that procedure which works for him (behavioral elements are unique to each behavior setting, as we have said above) and to follow a rigid plan in handling patients was construed by him to be "unnatural."

PRACTITIONER: You see, Mrs. M [pointing to a specific area on the X ray], here is the source of a lot of your difficulty. A lot of that indigestion you have had stems from subluxations here . . . and here.

MRS. M: Well, what about the arthritis in my hip? That's why I came here, you know.

PRACTITIONER: Please remember, chiropractic doesn't treat symptoms. Your spine [again pointing to the patient's X-ray] can suffer distortions at almost any point. Subluxation here between the second and third cervical [neck area] can bring about distortion even in the low back area.

MRS. M: You mean indigestion can cause arthritis'?

PRACTITIONER: Well, not exactly. All the unpleasant symptoms you feel are related since they all are produced by spinal distortion. Our job, over the next few weeks -- with your cooperation, of course -- will be to correct this "dis-ease." After we have adjusted you on a regular basis, we'll take another series of X rays and you can see the progress we've made.

At this point the patient was instructed to return to the adjustment table. During the actual adjustment, the practitioner directly discussed with the patient various specific spinal locations which he had previously identified on the X ray. The practitioner would systematically adjust the "subluxations," each being accompanied by an explanation of possible symptoms produced by each. A significant and unmistakable snap would be similar in effect to a popping of one's knuckles. Again, this reinforced the claims of the practitioner that there was indeed something there.

On occasion, some pain would be experienced, although this was rare for most patients of this practitioner. In the event of pain, the practitioner was quick to observe:

Say, that must have hurt a little. This is a little more serious than I thought. It means that you've suffered from this impingement a good while. Sometimes a fall or an accident in childhood can go unnoticed, but the longer the condition is left untreated the more troublesome it can be to correct it, not to mention your increased susceptibility to illness.

In order to allay any fears the patient would have of pain, the practitioner would note that it would be possible to work on other parts of the spine, easier to adjust, the effect being to ease other more difficult parts. "We'll return to that spot later, after a few other easier adjustments, and you'll be surprised at how easy it will move."

Face Disengagement. Although the time spent on the actual adjustment could be quite brief ("A good chiropractor can adjust a known patient in two minutes)", the new patient spent on the average forty-five minutes in the adjustment area of the Clinic. Most of the time was spent familiarizing him with basic procedure and situational expectations, "dipping" him in chiropractic.

A significant part of the dipping procedure involved the rest period immediately following the actual adjustment. The rest period was significant in that it revealed the practitioner's concern for the quality of interaction which he sought to control:

It's a rest period in two ways. It is good for the patient to relax after the adjustment, but it also lets him just take a break, and think about things.

The following exchange took place between the practitioner and a young girl, Miss V, who, up to that time, had shown great anxiety and apprehension.

PRACTITIONER: Please stay in that position [prone, lying on her front with arms outstretched and her face placed between the two supportive cushions] and try to relax the body after an adjustment in order to let the spine respond.

MISS V: I certainly feel relaxed. I could almost go to sleep.

PRACTITIONER: Well, don't do that, although most patients feel that way. Do you know what you're feeling? That's the natural strength which has been blocked for a long, long time. You're going to feel better when you leave here today, better than you've felt for a good while.

At times during this rest period the practitioner might have actually left the adjustment area, allowing the anxious patient a respite from the pressures of an uncertain social situation. But whether the practitioner was absent or present, the patient was allowed to break face contact and, in a sense, was permitted to be away from the necessity of what might have been uncomfortable, reciprocal, face-to-face interaction.

ENCOUNTER TERMINATION: THE PATIENT'S "BURDEN OF PROOF"

As a preparatory gesture to terminate the adjustment area encounter, the practitioner would instruct the patient to "turn over now and relax for a minute while I get your file card and make some notes."

Upon his return to the adjustment area, the interaction pattern shifted abruptly. At this point the patient was given the responsibility of directing the flow of conversation. (Again, I am not assuming intentionality here. The practitioner made it quite clear that this was part of his standard procedure. At times, when he was picking up an appointment card in his office, he would jokingly predict to me how a particular patient would react when given this burden of interactional responsibility.)

At times during this rest period, patients were overheard talking to the practitioner about personal matters, e.g., a recent divorce, troubles at work or with children, and so forth. The practitioner would always listen sympathetically -- sometimes taking notes for future reference and occasionally making comments, not unlike the exchange which takes place in the office of a professional analyst. Some patients, it might be speculated, seek this kind of relationship with the chiropractor: a "poor man's therapy." A need for this kind of help, particularly for persons of the lower classes, has been suggested by Hollingshead and Redlich [6].

Although the practitioner had attempted to anticipate the usual problems, questions, and concerns of the patient, he nevertheless encouraged the patient to express himself fully.

The specific content of this interaction was, of course, problematic and varied from patient to patient. Questions concerning fees and appointment dates were frequently forestalled "until we check with my assistant and the appointment book." Of central concern to the practitioner was the patient's general impression of chiropractic and his potential for future adjustments. Questions were answered and concerns countered with care and precision, the practitioner relying upon stock answers which would emphasize chiropractic philosophy.

As will be seen in the following chapter, the practitioner's "reading" of the patient's receptivity and willingness to empathize with chiropractic philosophy was essential to his procedure of typing patients. In some cases, patients were reluctant to pursue certain lines of discussion, and when this was the case, the practitioner, at times, would approach the topic from a different direction. For example, when attempting to elicit the patient's response to the notion of the Innate Intelligence within the human body, questions would be couched in terms either of the Deity or of Nerve Impulses -- depending upon prior conversation.

It will be seen that the practitioner was not necessarily discouraged by a lack of response; some of his best regular patients -- one of his patient types -- were essentially noncommunicative. Of greatest importance for the practitioner was the patient who responded negatively. Negative responses could center around a variety of subjects, although the most frequent objections were related to the practice of drugless therapy and the necessity of frequent and continuous appointments. These objections will be discussed in the chapter on patient typology that follows.

Fees and Appointments

The patient was led to the doorway of the private office where the assistant was waiting with the appointment book. The most immediate and practical concern for the practitioner at this time was convincing the patient of the necessity of regular and systematic appointments. If the patient had been X-rayed, the practitioner had learned from experience that in most cases the patient would return for at least one more visit. Again, depending upon the practitioner's reading of patient receptivity, various approaches to the problem of adjustment scheduling were suggested. Although the practitioner would have liked to have seen each patient two to three times a week, he realized the danger of losing certain patients if it was insisted upon. For the most part, the patients themselves ultimately determined the frequency and duration of the adjustment schedule.

Fee collection was routine. Most patients responded favorably to the relatively low cost per visit. The advantages of the prepay and family plans were pointed out as well as the possibility of insurance and medicare benefits. Once again the practitioner was aware of the patient's willingness to cooperate.

Although routine, the matter of fee collection was noteworthy since it clearly pointed out an example of the practitioner's methodographic technique. Drawing heavily upon suggestions for fee collection found in Parker's manual on office procedure [7], the practitioner modified his collection methodology according to patient type.

As an example of the explicit instructions recommended by Parker, he suggests:

Don't be reluctant to say, "The examination, including all the pictures necessary, will be thirty-five (not dollars) and this will include (list the pictures individually) in addition to (some " extras" such as any X rays necessary under concentrated care you might find essential)." Incidentally, when quoting fees, mention the fee and then keep talking to enumerate what they will get for the fee [7:61]

The practitioner was observed using this approach almost verbatim on occasion, and other approaches were similarly employed as the situation demanded. The selection of methods depended primarily upon his prior methodographic training and past experience.

BACKSTAGE INTERACTION

In this section I am using a conceptual modification of Goffman's logical division of behavior settings into "front" (those features of the setting which were presented to the audience as part of the overall rhetoric), and "back" (that region which is inaccessible to the audience where persons can be off-guard with other actors and prepare for "front" performances), Earlier studies focusing upon this "front-back" dichotomy [1] have laid heavy emphasis upon the structural, spacial characteristics of behavioral regions while, for the most part, ignoring the temporal qualities of those regions.

As noted in Chapter 3, the backstage region of the Clinic was located primarily in the practitioner's private office. However, the main point here is that this region came into existence only at certain times, and to varying degrees. The implication is that, contrary to what the ecologists would emphasize, regions must be defined primarily in social rather than physical terms [8]. (MacCannel [9], in his study of tourism and social space -- one of the most insightful works dealing with back regions to date -- makes note of the social nature of regions. But even here, his treatment of them, particularly backstage regions, is worded primarily in physical terms.)

The temporal relativity of regions"' (subsettings) may be illustrated by the following observations made in the Clinic's backstage setting. (As used in this context, the term "region" is a misnomer in that as normally defined it refers to a portion of territory or space. However, since the term has been used repeatedly and has become standard in the literature, to suggest an alternative would only serve to confuse more central issues.) First, patients, as a rule, were permitted into the private office at the termination point in the practitioner-patient encounter. (It will be recalled that the patient entered the office with the practitioner to discuss the matters of fees and appointment scheduling.) At this point in time, this region was not thought of as a backstage area; it constituted part of the front. Only at those times at which patients were not present -- either no patients were in the Clinic or they were beyond bearing distance -- did this region become backstage. Thus, this region existed only periodically.

Furthermore, there was a transitional quality of the backstage region. As will be seen in the chapter which follows, certain patients became regulars in their visits over a period of time. Depending upon the practitioner's reading of the patient's honest sympathy toward chiropractic, he was allowed to participate to a greater or lesser extent in backstage activity. My own personal experience as participant observer was illustrative.

Originally, as a patient, I was totally unaware of backstage activity in the Clinic, although as a student of dramaturgical sociology, I recognized the probability of such interaction. Gradually as I became accepted by the practitioner and his assistant as good material for chiropractic training, more and more was revealed to me concerning his private (nonpublic) statements concerning his methodological and methodographical activities.

As MacCannel has indicated (although in a different context), it is useful to view the "front-back" dichotomy as ideal poles on a continuum. His continuum is discussed primarily in terms of physical (spacial) objects. Similarly, in the Clinic, regular patients (including the writer) gradually moved through time from a position primarily "in front" of the performance to a privileged position "in back." Furthermore, it should be stated that although backstage, as defined here, existed periodically and transitionally, the following observations were recorded during those times at which the practitioner and his staff were confident of their privacy and my sincerity. "Insight, in the everyday, and in some ethnological senses of the term, is what is gotten from one of these peeks into a back region" [9:598]

Backstage Methodography

One of the most significant observations to be stated concerning backstage conversation is the preponderance of time spent on the topic of chiropractic. Reviewing the field notes, rarely does there appear any record of subjects discussed other than this.

Above, I have indicated that the practitioner was a "true believer" in Eric Hoffer's sense of the term [10]. That the topics of chiropractic history and philosophy were of intensely personal, immediate, and practical (methodographical) concern for the practitioner was indicative of this.

It must be admitted that my presence in the Clinic as a trainee might have caused, at least in part, a disruption in the normal conversational routine. However, for several reasons, I felt this was not so. First, the practitioner was engaged in similar conversations with several other sympathetic others, including his wife, other practitioners, regular patients, and even casual acquaintances. "You never know who you can turn on to chiropractic. If I live it, people are impressed, I talk about it all the time to anybody who will listen." Often these conversations were overheard by me; the practitioner was either unaware of or unconcerned with my presence.

Second, the practitioner, on two occasions during the course of study, had invited fellow practitioners to his home. These visiting chiropractors were accompanied by their wives and children. When asked what they talked about, the practitioner replied:

What else? Some of these guys I went to school with. This is what we do for a living. It's our lives. Sometimes we have study sessions and talk about lessons we had in school. We even review our old textbooks. It's a real party, everybody sleeping oil the floor and all. It's a great life.

Third, when visiting other practitioners as a sympathetic patient (while seeking supportive data for this study), similar topics of conversation were not uncommon.

It was from the conversations that took place in the Clinic between the practitioner and myself (in many cases they resembled lectures with question-and-answer periods), initiated and sustained by the practitioner, that the material for the second chapter in this study was gathered. Little effort on my part was needed to elicit historical and philosophical information, it was an integral part of backstage conversation.

Performance Disruptions and Remedial Methodography

The practitioner was beset with numerous difficulties in the Clinic. He earned a modest income, and felt it did not reflect his actual professional potential. Moreover, the chiropractor who had formerly occupied the building and was now leasing the office space, the adjustment table, and X ray equipment to the practitioner, was having financial troubles of his own. On several occasions they quarreled over rental payments, and threats were made to evict the practitioner.

Consequently, the practitioner was sensitive to the responses of some of his problem patients and often expressed uncertainty as to his capabilities as a professional. These and other problems were discussed and analyzed during those periods of backstage privacy.

Advice from Supportive Others. Being alone in the Clinic except for his staff and not having immediate recourse to the council and advice of mother nearby professional ally the practitioner felt it necessary, at times, to place long distance telephone calls to Dr. Sid (see Chapter 2). He had met this chiropractor while attending Palmer College and knew him personally. Unfortunately, I was never able to witness these conversations and must rely solely upon what the practitioner related to me concerning the subjects discussed; however, there is no reason to believe that any information was altered or deleted.

When attempting to support and encourage the practitioner, Dr. Sid would cite examples of other chiropractors, including the early forefathers, who experienced "tremendous difficulties when trying to carry the [chiropractic] message to the people." The practitioner was urged to recall the basic principles of chiropractic, which deal with the positives and negatives of human existence as they become manifest in the human body. Chiropractic, he was reminded, has as its immediate purpose the elimination of physical negatives. This principle can and must be applied to the matter of daily living:

He told me to "eliminate the negatives from my practice." I've got to locate the sources of trouble in the Clinic and do something about them. These trouble spots can cause negative attitudes for me and when I have it bad attitude it can cause more troubles. He [Williams] said that we [himself and the staff] have to figure out where things might be going wrong and do something about then,. . . . We've got to learn from the experience and mistakes of others who've been through this before.

This kind of advice, coming from a prominent spokesman of chiropractic, supports the contention that history and philosophy are of paramount inethodographic importance for many if not most chiropractors.

To use the practitioner's term, these conversations were "pep talks" and presumably would apply to any chiropractor. "Of course, he [Dr. Sid] has never been in this Clinic and doesn't know exactly what's wrong, but he gives good advice just the same."

Dr. Sid, along with other spokesmen of chiropractic, sponsored several meetings around the country during which they offered advice concerning the practicalities of running a clinic. Practitioners spent hundreds of dollars to attend these meetings and, according to editorials in chiropractic journals, most meetings realized high attendance. Thus, the practitioner had avallable to him explicit methodographic techniques designed to ameliorate various difficullties as they might occur.

Flexibility in one's procedural method was often emphasized. According to a passage, pointed out to me by the practitioner, from Parker's Manual:

Look for successful methods, not a retirement plan. Be, ambitious, not ultraconservative. Develop growth-potential, not self-depreciation. Make a list of your strengths. . . . Possess a BIG-THINKER'S vocabulary, not a defeatist's slang. . . . GO FIRST CLASS. Pick your environment.

Analysis of the Physical Setting. From time to time, the practitioner would consider making changes in the arrangement of the waiting-room furniture, his private office, or the adjustment area. For example, new stage props were considered. "You know, maybe we ought to put a Bible in the waiting room. We could turn it to a passage on 'the laying on of hands,' or something like that." This idea was eventually rejected, the practitioner explaining that he didn't feel competent to cope with theological questions that might possibly arise from the presence of a Bible.

Although few changes were actually made during the time of the study (except for the handwritten signs), the topic arose on numerous occasions. New ideas were sought by examining pictures of other chiropractic clinics as depicted in the practitioner's trade magazines, which he regularly received. Following a basic plan learned while a student at Palmer, the practitioner had rearranged the furniture of the office during his first days in the Clinic. Accordingly, he fell reluctant to risk major changes which might have unexpected results or be viewed unfavorably by his professional superiors. As an example of this last point, the practitioner at one time seriously considered selling health foods as a sideline in the waiting room. He intended to let his wife or myself be in charge of sales. This idea was also rejected since he was unsure of how Dr. Sid would respond. "He's a 'Straight,' you know, and he doesn't believe in mixing anything with the truth of chiropractic."

Analysis of Standing Behavior Patterns. As in the case of physical arrangements in the Clinic, the practitioner expressed reluctance to alter, in any substantial way, those patterns which were recommended that he use in his training in office procedure.

Predominant standing behavior patterns (e.g., the "first come, first served" method of receiving patients, the method of introducing patients Into the adjustment area, the X-ray procedure, fee collection and appointment scheduling, and encounter termination techniques) underwent slight modification, if any, during the time of the study. However, as in the former instance, several alternative procedures were considered from time to time. (Virtually all aspects of the behavior setting at one time or another were methodographically examined with the hope of uncovering some hidden difficulty.)

Analysis of the Performance Team. One of the most obvious examples of methodographical activity involved the analysis of the cooperative teamwork of the staff. The practitioner was especially aware of and concerned with the coordination of his staff and the manner in which they (himself included) presented and sustained a consistent front through their personal actions toward their patients. Once again, my experience as assistant-in-training is illustrative.

Part of my backstage training consisted of the appropriate use of "stage talk." "Don't come on too strong with words; You can scare people sometimes by talking over their heads; use words like 'honesty,' 'sincere,' 'love,' things like that. Leave the big stuff to me."

The specific meanings of chiropractic terms were discussed in great detail. "We've got to agree on things. If you tell a patient one thing and I tell him another, he gets the idea we don't know what we're talking about."

The problem of presenting a consistent front to the audience was a major concern for the practitioner. Of special importance for him was the manner in which his assistants prepared the patient for his entry into the adjustment area particularly for the first time. He discussed and rehearsed with us the manner in which we should defer to his knowledge and experience in matters directly pertaining to chiropractic. The matter of avoiding eliciting information from the patient concerning his overall health has already been discussed, and the examination for that technique made apparent. On this he commented backstage:

It's really impressive when I tell the patient what's wrong with him. It's not the kind of thing that happens when he goes to a medical doctor. Don't spoil the show for me by getting him to tell you his entire case history.

Audience Analysis: Treatment of the Absent. A fourth subject of methodographic activity, closely related to the last, dealt with the techniques of reading patients,

A major premise of interaction theory refers to the persistent and ongoing attempts of human social actors to determine the perceptions, conceptions, and intentions of all significant others. Although it is a basic human activity, persons are, most of the time, unaware of this process.

Conversely, the practitioner was not only intensely aware of this activity, but was quite concerned with his accuracy in determining patients' definitions of the situation and of himself. "It's very important for me to figure out how a person is going to respond to chiropractic and to me."

Much backstage conversation was directed toward various means of assessing patient responsiveness. The importance of engaging patients in conversation prior to and after his experience with the practitioner in the adjustment area was stressed. The practitioner, while forming his own impressions of patients as the result of his own contact with them, relied heavily upon the interpretations of his staff. We were told:

Watch carefully for any sign of [the patient's] confusion or trouble [dissatisfaction] and let me know about it right away so we can do something about it. Get friendly with them, but be careful. Some people don't like it when you get too personal, especially when they've got something to gripe about.

As Goffman has indicated:

When members of a team go backstage where the audience cannot see or hear them, they very regularly derogate the audience in a way that is inconsistent with the face-to-fact treatment that is given to the audience . . . . Sometimes, of course, the opposite of derogation occurs, and performers praise their audience." [11:170-171]

It was during periods of private backstage discussion in the Clinic that the practitioner and his staff exchanged views of patients and patients became typed or previous typifications were modified.

In the following chapter, several examples will be cited which pertain to the practitioner's reading of patients' definitions of the situation. Although the practitioner depended primarily upon his own interpretations of the responses of various patients, at times he would indicate some confusion. At these times he would seek our interpretations and we would discuss at length these persons. Ultimately, there would emerge a classification which would provide the practitioner with a plan of action toward that patient in future encounters,

A careful examination of the procedure involved in the typing of patients is discussed in the following chapter.

REFERENCES

1. Ball DW. An abortion clinic ethnography. Social Problems 14::293-30, 1967.
2. Goffman I. 1963. Behavior in Public Places. New York: Free Press, 1963.
3. Wardwell WI. Social Strain and Social Adjustment in the Marginal Role of the Chiropractor. Doctoral dissertation, Harvard University, Department of Social Relations, 1951.
4. Goode E. Marijuana and the politics of reality. Journal of Health and Social Behavior 10(2):83-94, 1969.
5. McCorkle T. Chiropractic: A deviant theory of disease and treatment in contemporary Western culture. Human Organization 20(1):46-62, 1961.
6. Hollingshead AB, Redlich FC. Social Class and Mental Illness. New York: Wiley, 1958.
7. Parker JW. Years of Articles on Practice Building and Office Procedure. Fort Worth, TX: SHARE International, 1965.
8. Barker RG. Ecological Psychology: Concepts and Methods for Studying the Environment of Human Behavior. Stanford, Calif.: Stanford University Press, 1968.
9. MacCannel D. Staged authenticity: Arrangements of social space in tourist settings. American Journal of Sociology 79:589-603, 1973.
10. Hoffer E. The True Believer. New York: Harper, 1951.
11. Goffman I. The Presentation of Self in Everyday Life. New York: Doubleday, 1959.

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