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An Ethnography
of a Chiropractic Clinic

Chapter 5: A Chiropractic Patient Typology

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

The main concern of this chapter is the elucidation of the practitioner's typing of virtually all patients who entered his Clinic. His reasons for doing so are seen through the labeling approach to social deviance, this approach being based on and a direct outgrowth of the symbolic interactionist tradition. The practitioner is viewed not as a passive recipient of a deviant label, but rather as a possessor of a considerable degree of power within the behavior setting

The labeling perspective has recently been criticized for its failure to adequately take into account the labelee's power to effectively handle the deviant label accorded him by society at large. Schervish [1] (1973) has extended this criticism on two grounds: the assumed passivity of the labelee [2-11], and a tendency to focus upon the individual rather than on the group as the unit being labeled [2,4,12-15]. Traditionally, the sociology of deviance (and the labeling perspective may be included) has focused upon the pariahs of society, i.e., those persons whom obviously violate the norms of the social order and are handled accordingly. Although the notion of secondary deviance (the process by which the labeled person begins to take on as part of his self-conception those attributes of the label) has been introduced [16], the individual, even in this context, is seen as a passive recipient, responding in a more or less deterministic way. Schervish views this tendency in the labeling approach as being antithetical to the Meadian heritage upon which the perspective is founded:

The Meadian perspective enables sociologists to designate the process of becoming deviant (cf. Matza [9]) rather than merely to assert that "mind" or "personality" or some other intervening unknown or "black box" acts as deterministic transmitter or forces, impinging upon the actor and making him deviant [1:47 ].

The present study of a chiropractor as a marginally deviant individual affords the chance to assess the assertively active performance of the labelee in a behavior setting of his own design and control, i.e., the setting allows him the maximum freedom to structure the ongoing interaction which takes place within it. The chiropractor is viewed not as a passive agent in the Clinic, blindly responding to the social forces which surround him, but as a volitional actor in the sense of having, a considerable command over the situation.

Furthermore, the practitioner, having had a body of formal training, in his vocation was supplied with a highly significant professional reference group by which he was enabled to critically assess, modify, and rationalize his performance in a variety of situations. Whenever difficulties or doubts arose concerning practical problems in the Clinic, help was readily available from this reference group.

The association to which he belonged, the ICA, would supply him with philosophical, financial, and legal support if the need arose. Thus, the chiropractor was further viewed as possessing a considerable degree of power-in the sense that he was not powerless to negotiate the social reality within the Clinic's setting.

THE DEVIANT (CHIROPRACTOR) AS LABELER

A second major source providing impetus to the development of the labeling perspective (in addition to Mead's contribution) is the work of Alfred Schutz. (For a succinct discussion of the theoretical convergences giving rise to the habeling perspective, see reference 17, pp 115-158.)

A predominant theme in his work is that social reality for all human beings is a matter of classification of everything that one comes into contact. Indeed, this is the basic notion underlying the term label in that it allows social groups to classify, and therefore make understandable, various forms of behavior which violate certain values. By labeling inappropriate forms of behavior and thus placing them in some definitive context, plans of action become possible providing orientation in problematic situations.

Previous studies utilizing this perspective have focused almost entirely upon the phenomenon of labeling as it is carried out by those persons who represent powerful elements in the social order. However, the possibility of viewing the labelee as participating in the saine sort of activity has been neglected.

The practitioner engaged in a form of social psychological activity that is rendered understandable when viewed in the labeling, context. In other words, the practitioner as labelee, may now, quite properly, be viewed as labeler.

Certain forms of behavior occurred in the Clinic which the practitioner deerned inappropriate or deviant; accordingly, persons engaged in these behavior patterns were labeled (typified), thus allowing the practitioner various plans of action. The question of his power to apply the labels will be discussed in the sections that follow.

Although it was not discussed in this context, Becker's analysis of the professional dance musician suggests the same phenomenon: musicians type some audience members as "squares." As a symbolic expression. "such words enable musicians to discuss problems . . . for which ordinary language provides no adequate terminology." [18:143].

THE CHIROPRACTOR AS MARTYR

The preceding chapters have dealt almost exclusively with the presentation of the chiropractor's self-image in a situation which has been shown to be at least marginally deviant. The practitioner himself readily admitted his deviant status and, in a very real sense, took pride in it in the same sense that a religious martyr takes pride in and consoles himself with his martyrdom. The practitioner confided in me one day during a backstage conversation:

You know, if chiropractic wasn't considered a kind of "far out" thing, it wouldn't be half so much fun. I really think that if everyone thought chiropractic was O.K., it would be just, another way to get well. A lot of us through the years have suffered because of the law and a bad name and things like that, but that's the reason why a lot of us keep working so hard to bring people the truth.

The practitioner encountered daily information, both through the media and personal relationships, which defined his profession as a deviant health care practice. He recognized and readily admitted his deviance, and yet, in the face of all opposition, maintained that he was right in the sense of possessing "the truth about the natural way of the body."

He saw himself as deviant in a formal sense in that he knew he violated established health care practices. Yet, by appealing to "higher loyalties" [12], namely the natural and Eternal Truths of chiropractic philosophy and those who espouse it, he sought to neutralize the label in order to present himself a consistent and acceptable self-image. Thus, he was free to engage in a form of behavior that was manifestly deviant yet did little daniage to his self-esteem.

Any self-image, deviant or otherwise, has as its ultimate source the perceived reflected intentions of significant others. As described below, the practitioner had the ability, to a considerable extent, to manipulate the quality of his clientele in order to create for himself the most favorable audience for his professional activity.

THE PROBLEM OF PATIENT RESPONSE

During the course of his practice, the practitioner encountered a range of patients who responded to chiropractic in various ways, from more or less open receptivity (these were rare) to overt hostility. Both the practitioner and his patients usually experienced -an incomplete biographical sketch of each other, especially in the initial encounter. As Glaser and Strauss [19:669-679] have noted, this situation necessitates the "bracketing, of the encounter into an immediate situational awareness context out of which biographical knowledge of each other is constructed relative to that point in time and space.

Ideally, this allows each actor (in this case, both the practitioner and the patient) to determine the latitudes of permissible behavior, provides a basis for determining the actions of the other towards himself, and also provides a set of more or less acceptable responses to those actions.

THE CRITERIA OF PATIENT ACCEPTABILITY

These criteria, as summarized here, have not been assumed but were elicited from the practitioner in the course of numerous backstage conversations. Their significance was validated by direct observation, nondirective commentary by the practitioner, and by the subsequent interviews with him during the last days of the study.

As indicated in the previous chapter, the practitioner perpetuated a front designed to accomplish two ends: (1) it presented to patients and to others a situational orientation within the setting, and (2) it provided a means of systematically assessing patients' response and receptivity to that setting. Among the criteria which the practitioner utilized in accomplishing the latter objective were:

Admittedly these criteria may overlap, but for the most part, according to the practitioner, they supported and complemented each other in tile sense that taken together, they provided a means of assessing the overall expressions "given" and off" [20:2] by the patient toward the practitioner, the Clinic's setting, and chiropractic in general.

THE TYPOLOGY

As indicated above, the following typology was based primarily upon the interpretations of the practitioner. It should be noted, however, that the categories were not completely his own, in that a chiropractic publishing company (operated by Dr. Sid in conjunction with the ICA) had printed a brochure describing three patient types. Dispensed to patients in the Clinic, this one-page foldout was entitled, "There Are 3 Types of Patients: Which Type Will You Be." The brochure was illustrated by caricatures which were supposed to show, by means of facial expressions (frown, half-smile, grin), the typical responses of patients. The first type, because lie feels so improved after the initial treatment, stops going to the chiropractor before lie has been totally cured. The second type discontinues chiropractic treatment because he does not feel better after the first few treatments. The third type is restored to good health because, although he may feel better, he continues treatments until "the chronic nerve interference is removed."

The practitioner did not merely adopt this simple classification, but embellished and modified it in a fashion relative to his own practice and patient experience. The categorical names, with the exception of the regular patient, were not normally used in the presence of patients, but were used extensively in backstage conversation, thus enabling the performance team to share a common set of definitions and orientation to patients.

The One-Timer or the One-Shot Patient

The practitioner prided himself on his ability to type a patient "five minutes after he walks in the door," and this ability was most evident with those patients labeled as one-timers.

The practitioner was quick to respond to the opening remarks given voluntarily or through questioning which would indicate the patient's prejudices toward chiropractic. Often a patient would enter the Clinic with a specific complaint and seek quick recovery on a short-term basis of two or three visits. This type of patient often had seen a chiropractor before and for one reason or another, had experienced some degree of success. For example, a member of the coaching staff of a local team entered the office one afternoon holding his back and walking, in a stooped position. He was shown into the adjustment area, as in the case of all emergency patients. Walking immediately to the adjustment table, he demanded, "Let's get this over with quick. I've got to be back in twenty minutes. I sure as hell can't run around in this position."

The practitioner began the adjustment process immediately. Although several attempts were made to engage the coach in conversation, all failed, except for noncommittal statements. After the adjustment was completed, the patient arose and handed the practitioner a five-dollar bill and departed with a hurried promise to return "when I have the time to do it right." (In McCorkle's study of chiropractic in rural Iowa [21] this patient response was typified its the norm, since persons in that geographic area were defined its "practical people who seek an immediate. simple solution to their problems." This observation is obviously an oversimplified one, its is demonstrated in the sections that follow.)

After he had left, the practitioner commented to me "Sure I straightened him out, but I didn't really help him. He might be back in a few months when it goes out again. You can't count on his kind at all."

Also included in the one-shot category are those patients who, for the most part, failed to significantly respond to the practitioner's rhetoric. Most persons would listen with courtesy to the practitioner's presentation from beginning to end. Some patients offered little response in an observable fashion except in the everyday pleasantries of any formal encounter between unacquainted persons. The practitioner would approach such patients during the encounter with a variety of performances, seeking what he referred to as an opening, sometimes with little success.

At times the practitioner expressed frustration ("Sometimes I get so damn mad I feel like telling them to stop wasting my time and theirs, but of course you can't do that"), although he considered his time well spent if for no other reason than that of income. "When they don't respond . . . it's both bad and good, depending on how you look at it. They don't usually kick when I bring up the X ray and the fees . . . and you know the money isn't bad for an hour's work even though I might not see them again."

If a patient refused to respond overtly, the criteria for patient acceptability was for the most part inapplicable in that the reaction was neutral. The patient presented no opportunity for biographical construction; he remained a nonentity, indicating neither positive nor negative attitudes toward chiropractic, the behavior setting, or the practitioner himself.

Since the one-shot patient provided little basis from which the practitioner could evaluate his behavior in the setting, he had a tendency to lapse into a standard presentational routine. At the termination point, for example, he would assume what might be described as a quite formal, even brusk, attitude toward the patient. He was never impolite, but he would dismiss the patient with tact and little or no attempt to persuade the patient to continue treatment.

Once the researcher became aware of the practitioner's conception of the one-timer as a patient type, the practitioner was timed by stopwatch technique in the initial encounter with the patient. After two or three minutes, he would sometimes return for a file card or some other reason and would indicate to me his perceptions concerning the patient. It was noted that although the average time spent with all other new patients was approximately forty minutes, the time spent with the one-shot patient was approximately twenty-five minutes.

During the course of this study, every attempt was made to initiate conversations with patients who had clearly been designated as falling into one category or another.

This was done in order to assess their differential responses to the treatment they received during their session in the adjustment area. A typical one-timer patient response was reflected in the comments of Mr. Y, a retired worker who had come in to "see about my health." At no time did he voice a specific complaint, enter into sympathetic interaction with the practitioner, or elaborate extensively upon his experiences in the adjustment area except for the following observations:\

ASSISTANT (MYSELF): Well, what do you think of chiropractic?

MR. Y: I learned a lot about it, I guess..

ASSISTANT: I see the Doctor has You down for mother appointment.

MR. Y: Yeah, well, if I'm not feeling any better I guess I'll be back; but if it clears up I probably won't.

ASSISTANT: You know, it's like the Doctor says, if you feel better then that's the time to continue adjustments. It means you're responding to the treatments and it's a good way to stay well. [While participating in the role of assistant the researcher was careful at all times to present to patients the verbal rhetoric specified by the practitioner as "part of your job."]

MR. Y: Well, I guess that's right. We'll see . . . .

Mr. Y never returned. Some weeks later, the practitioner was asked why.

PRACTITIONER: I told you lie wouldn't be back. I could see that right away. When lie came in, I ran him through the procedure and got some X rays, but I'll never use them.

ASSISTANT: I noticed he didn't stay as long as some of the other new patients. Did he have to leave early?

PRACTITIONER: No, I don't think so, but I didn't waste much time with him either. I mean, why should I? He wasn't coming back.

According to W.I. Thomas, if actors define a situation as real in it specified manner, future events in the ongoing situation will refect those prior definitions [22]. Similarly, Merton has termed this phenomenon a "self-fulfilling prophecy." [23] If the practitioner in this case gives off the impression that lie doesn't expect to see the patient again. this expectation may become shared by the patient, thus fulfilling the one-shot prophecy. When the patient did indeed fail to return, this served to reinforce the practitioner's conviction that he had the ability to accurately read each patient typically. This notion of defining situations as real is just its applicable to other patient types.

The Problem Patient: Deviance within a Deviant Setting

Although the practitioner did seem to have the ability to predict the behavior of many patients, he was often wrong. Occasionally a patient who had been typified as a one-tirner did return to the Clinic, much to the surprise of the practitioner. Many patients who eventually were typed as problems followed this pattern. Quite often the patient, although he had missed the scheduled appointment, would return to seek relief from a recurring problem at various and unpredictable times.

Typically the patient would resist the practitioner's efforts (now renewed) to convince him of the benefits of regular chiropractic care. At one extreme, the patient would remain nonconininal, while at the other, open antagonism and even hostility might be expressed.

It was not possible to delineate a specific set of behavioral characteristics to describe the problem patient. A problem patient was identified as such due to his inability to meet the criteria of patient acceptability as defined by the practitioner. Whereas the one-timer typically remained passive in his non-acceptance of chiropractic and/or the practitioner, the problem patient responded negatively.

One conversation that was recorded extensively in the field notes exemplifies the negative and disruptive comments of patients labeled extremely problematic. Miss A, a middle-aged teacher who had seen the practitioner irregularly four times over a six-month period prior to this visit, complained of a backache and general fatigue. When the practitioner saw her name on the waiting list, he grimaced, rolled his eyes toward the ceiling, and said to me, "Well dammit, here we go again!" The following are excerpts from their conversation in the adjustment area:

PRACTITIONER: Here are the X rays we took, let's see . . . uh . . . five weeks ago. It's been a long time. All we can do is hope for the best. Why don't we check it [indicating the adjustment couch]?

MISS A: Well, You certainly don't sound very encouraging.

PRACTITIONER: Miss A, I'm going to be very honest with you. There isn't very much I can do for anybody unless they take my advice and begin a series of regular appointments. We really don't work miracles here -- although some people are convinced we do -- but we do allow the body to correct itself over a period of time the way God intended it.

MISS A: Let's leave God out of it if you don't mind. I don't think we speak the same language. [Placing herself on the adjustment table, she insisted:] Well, let's get this over with. I'm in a hurry.

At this point the practitioner commenced his technique of suggesting possible symptoms of dis-ease while carefully examining her spine. Several attempts were made to this end, all of which were responded to negatively.

MISS A [quite exasperated]: No, no! None of those things. I feel fine. It's my back that hurts, not my head! Why don't you work on my back and leave the rest of me to a doctor who knows what he's doing.

PRACTITIONER: Did you read any of the material I gave you the last time you were in'? . . . Well, I wish you had. It would make things a lot easier.

The practitioner began the adjustment accompanied by standard, under-the-breath comments to himself.

MISS A: What? What's that you said?

PRACTITIONER: Oh, nothing. It just helps me to concentrate on your condition. It wouldn't mean much to you anyway. . . .

When the adjustment was completed, the practitioner motioned to Miss A. to be seated at the small table.

MISS A: No, I'm late as it is, How much do I owe you this time?

PRACTITIONER: The standard fee. Five dollars.

MISS A: You must be a millionaire. Your adjustment didn't take live minutes.

Without pausing at the door of his private office, Miss A. hurriedly handed him the fee as she was leaving, giving him no chance to pursue the possibility of a future appointment. Said the practitioner to me, after she had left, "That's that! Good riddance."

The above example illustrates the failure to meet most, if not all, of the criteria for patient acceptability. Although most problem patients did not exhibit such an extreme negative reaction, this pessimistic and antagonistic attitude was not uncommon.

Ironically, although the problem patient actually brought more business to the Clinic than, say, the one-timer, the practitioner frequently returned the antagonism, even to the point of open rejection. For example, one day he was overheard commenting, to a patient who had insisted on combining chiropractic and prescription medicine:

How do you expect me to get you well if You insist on poisoning yourself [with "drugs"]? If you feel that the medical doctor is doing more for you than I am, then you are wasting your time here. You might as well not come back.

In sum, the problem patient was disruptive in his behavior in three ways: (1) his attendance was irregular, thus violating one of the tenets of chiropractic philosophy and procedure; (2) his overt behavior within the behavior setting was unpredictable, thereby preventing the practitioner from constructing a systematic and reliable biography of the patient, and determining a course of action in the setting; and (3) his behavior served to threaten the practitioner's self-conception.

As Goffman has noted, "The individual may deeply involve his ego in his identification with a particular part, establishment, and group. . . . When a disruption occurs, then, we may find that the self-conceptions around which his personality has been built may become discredited" [20:243]

Rationalizations for Patient Rejection. After the author became aware of the practitioner's tendency to select his clientele in the fashion described above, the practitioner was asked, "How can you justify driving away patients when you repeatedly tell me of the difficulties of practice-building? It seems you are defeating yourself." The practitioner offered the following explanations:

1. Long range -- outside the Clinic: "A bad patient can really hurt your business. He may bring in a few dollars, but it's not worth it. When he goes home with bad attitudes and talks to friends and neighbors about it, it can really hurt. . . . I've even lost some regulars because they've been turned off by a friend of theirs."

2. Immediate -- inside the Clinic: "You've seen me take patients out of the waiting line? Well, those are usually problem patients who like to talk about their complaints about me. I can't let those troublemakers spread that gossip in the waiting room. I once had a fight going Out there between a problem and a regular. I haven't seen either one since."

3. Personal: "When I have a run-in with one of them [problem patients], it spoils my whole day. It's like Dr. Sid says, you've got to get rid of the negatives. If all my patients gave me trouble like some of them do, I don't think I could take it. . . . The regulars make it all worthwhile."

The Regular Patient

Whereas the problem patient was irregular in attendance, unpredictable in his behavior, and threatening to the practitioner's self-image, the regular patient, conversely and ideally, evidenced none of' these undesirable characteristics. The practitioner noted two principal sources of regular patients: transfer patients-patients who had been seeing another chiropractor-and converts.

Although a wide variety of patients may become regulars ("a 'regular' is made, not born"), at least half of the patients identified as such by the practitioner were either retired persons of either sex or housewives. Although it is not within the intended scope of this paper to assess the empirical characteristics or psychological attitudes of patients from an outsider's point of view, this clearly is an area for study [24].

Transfers usually presented little difficulty for the practitioner in that his situational rhetoric and adjustment procedure was representative of other straight chiropractors. Most entered the situation with a clear-cut set of definitions and experienced little difficulty in adjusting to the surroundings.

It will be recalled that there was another chiropractor in the same community, but he was of the mixer variety. Depending upon the patient's prior exposure to chiropractic, he would select one or the other, in many cases, by following the recommendation of his previous chiropractor. Straight chiropractors recommend other straights, and mixers, other mxers. Both have membership lists (ICA, ACA) for this purpose.

Those persons with whom the practitioner ultimately realized success in the conversion process were those persons whom in most cases he had identified previously, sometimes after only one or two sessions, as showing good potential. Occasionally, a one-timer who was misjudged would become fairly regular, but this was rare. Never once, during the course of the study in the Clinic, was it observed that a problem patient became a regular.

Supportive Others and the Regular Patient. Regulars were accompanied to the Clinic by supportive others much more often than either of the other two patient types discussed above. It was quite common for the supportive other (or others, in the case of families) to become converted, and become regular as well. These persons at times would request that their appointments be set up to coincide with each other.

Furthermore, persons previously unacquainted would sometimes establish friendships within the Clinic and would also arrange their appointments together. This was supported and encouraged by the practitioner who saw this as beneficial both to his patients and to his business.

Although no attempt is made to demonstrate the representativeness of the Clinic relative to other chiropractic offices, support for this statement is provided by (1) the practitioner's own testimony, (2) the author's own impressions based upon visits to other chiropractic clinics, and (3) the responses of patients who had previously been exposed to chiropractic elsewhere.

Eliciting Testimonials. At times, when the practitioner would observe that several fairly regular patients (who may have been more or less acquainted) happened to be in the office at the same time, he would suggest that "we all get together in the adjustment area to get to know each other a little better."

During such a session (usually brief -- five to ten minutes -- and quite casual), the practitioner would attempt to elicit personal testimonies concerning success with chiropractic. Also, patients would be asked their opinion concerning articles appearing in chiropractic magazines and journals. Such give-and-take sessions were conducted with informality, each patient participating freely with little or no prompting by the practitioner. These discussions at times would focus upon a wide variety of topics, mostly dealing a with personal chiropractic success, chiropractic philosophy, the problems of everyday living, and the solutions to such problems. The practitioner was quick to emphasize the simple, natural logic of chiropractic, "which is really much more than Just a way of keeping healthy, it's a whole way of life."

Booster Patients. A regular patient who becomes convinced that he has experienced success ("It really seems to be doing, me some good"; "It's miraculous! I've never felt better.") would often voluntarily promote chiropractic. These boosters were encouraged to spread the word and bring in new patients. Quite often this was done despite the fact that no financial remuneration was offered.

(The term "booster" was not coined by the practitioner but is found throughout chiropractic publications. Parker, for example, in his practice-building manual discusses various techniques for utilizing the potential of boosters. For example . . . make certain to introduce and encourage conversation between regular and prospective patients if the regular is a booster-type patient." [25]

Ample supplies of free literature were provided for these patients, and the practitioner considered the money well spent. Indeed, several new patients were brought to the Clinic through these boosting efforts during the course of the study.

Before the state laws licensing chiropractic were put into effect. advertising in the various forms of mass media (now illegal) was a common means of acquiring new patients. Large advertisements promoting clinics were placed in town newspapers. These ads consisted primarily of testimonials from satisfied patients, a picture of the booster being predominant.

Recruits. Chiropractors occasionally encounter a patient (usually a regular) who expresses such interest in and commitment to chiropractic that he seeks to convince this individual of the advantages of chiropractic as a profession. This is not an uncommon practice for either straight or mixer chiropractors, Recruitment pamphlets and short application forms were observed in all chiropractic offices visited. As far as can be determined, the chiropractor receives no reward, either from his professional organizations or the colleges, for the recruitment of new persons into the profession. His efforts were apparently strictly voluntary.

One of the main reasons the researcher realized success in achieving a considerable involvement in the behavior setting and success as a participant observer was the practitioner's conviction that I was "choice material for Palmer College of Chiropractic." By showing enthusiasm and sympathetically supporting his excitement about his profession. I established and sustained a relationship with the practitioner not unlike that which existed between himself and several other strongly supportive patients.

This chapter has been devoted to processes by which the practitioner (1) perceived the varieties of patient response, (2) assessed these responses in light of his past experiences and the biographical source material he had gathered for each patient, (3) typified each patient, thus allowing him a course of action in future encounters, and, finally (4) adjusted his own behavior in light of these categorical definitions.

The ultimate consequence of this overall process was to eliminate those persons who persisted in responding unfavorably to the practitioner's efforts to present a satisfactory chiropractic front and to convert those others who had demonstrated sympathetic inclinations.

Thus, the notion of impression management and the techniques normally associated with it may be enlarged to include a technique which heretofore has received little recognition: one can present and sustain an image of oneself by adjusting both appearance and actions, and managing the composition and overall "quality" of the audience.

REFERENCES

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20. Goffman I. The Presentation of Self in Everyday Life. New York: Doubleday, 1959.
21. McCorkle T.. Chiropractic: A deviant theory of disease and treatment in contemporary Western culture. Human Organization 20(1):46-62, 1961.
22. Thomas WI. The Unadjusted Girl. Boston: Little, Brown, 1972.
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24. Schmitt MH. Who goes to chiropractors: Descriptive data on a sample of medicaid chiropractic utilizers in the Buffalo, New York Region. Working paper submitted to the American Sociological Association, August 27, Montreal, Canada, 1974.
25. Parker JW. Years of Articles on Practice Building and Office Procedure. Fort Worth, TX: SHARE International, 1965.
 

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