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Chiropractic medical system : the making of a clientelle Eni, Godwin Onuoha 1987

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CHIROPRACTIC MEDICAL SYSTEM: THE MAKING OF A CLIENTELE By GODWIN ONUOHA ENI B.Sc. (Hons.), The University of Ibadan, 1969 M.Sc, The University of British Columbia, 1981 A DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY IN THE FACULTY OF GRADUATE STUDIES (Department of Anthropology and Sociology) We accept this dissertation as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA April, 1987 @ Godwin Onuoha Eni, 1987 In presenting this thesis in partial fulfillment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the Head of my Department or his representatives. It is understood that copying or publication of this thesis for financial gain shall not be 1 allowed without my written permission. Department of Anthropology and Sociology The University of British Columbia 2075 Wesbrook Mall Vancouver, Canada (i i) ABSTRACT Most sociological explanations for the success of chiropractic in attracting and maintaining its clientele have failed to consider the clinical context and the nature of the interaction between chiropractors and clients. Rather, most studies have focussed on leadership qualities, the professionaliza-tion process, and the ancillary role of chiropractic in health care to account for its success with clients. This study argues that chiropractic in British Columbia is successful in making its clientele because: (1) it is able to persuade new clients toward chiropractic health care by using strategies that are designed to minimize the polit ical , social and economic constraints upon i t ; (2) chiropractors are able to negotiate successfully, the differences in the health and illness beliefs [HMs] that are held by new clients and chiropractors as well as differences in explanations [EMs] for "present" health problems; and (c) chiropractors are able to provide potential patients with "positive" experiences in chiropractic clinics, which are different, in some respects, from experiences they have had elsewhere, for example, in their relationships with allopathic medicine. This study, therefore, describes how new clients are socialized in chiropractic clinical relationships and subsequently become chiropractic patients. 20 randomly selected chiropractors and a total of 60 new clients were interviewed for their impressions of chiropractic as well as their health beliefs and explanations for "present" health problems prior to encountering each other in the clinical setting. Their interactions were observed in the twenty clinical settings, with special focus on the negotiation of explanatory models. The patients were interviewed again, regarding their experiences and ( i i i ) impressions, following their fourth visit to the clinic after their initial encounter. 20 "regular" or long-term chiropractic patients, one from each cl inic , were also interviewed regarding their experiences. Data were analyzed by comparing pre- and post-interview results and by describing the nature of clinical interactions, relationships, and negotiation of explanatory models in the context of Kleinman's ethno-medical perspective and Goffman's social ethnographic perspective on interactions in everyday l i fe . It was found that chiropractors (1) provide potential patients with "adequate" information and the opportunity to ask questions; (2) express non-judgemental views on the health problems of clients, which provides new clients with the opportunity to fully explain their health concerns; (3) utilize persuasive interaction structures and processes to minimize both the constraints upon chiropractic and the effects of deviancy and marginality labels, and to manage the impressions of potential patients; and-(4) negotiate with potential patients over explanations for the causes of their health problems, which enables the delivery of chiropractic treatment by integrating, "shifting" and modifying clients' explanatory models and, to some extent, their own. These techniques for 'making' the chiropractic clientele appear to be successful. In this study, 53 of the 60 new clients were retained beyond the fifth vis it . More generally, chiropractic is now the second largest primary health care provider-group in B.C., next to allopathy, and is attracting an increasing number of patients. (iv) TABLE OF CONTENTS PAGE Abstract i i List of Tables vii List of Figures ix Acknowledgement x CHAPTER 1.0 INTRODUCTION 1 1.1 Society and the Healing Process 7 1.2. History and Development of Chiropractic as a Medical Specialty 9 1.2.1 Chiropractic Philosophy 15 1.2.2 Chiropractic Model of Health Care 17 1.2.3 Contemporary Chiropractic 20 1.2.4 Chiropractic in British Columbia 22 1.3 Constraints and Issues Relating to Chiropractic 26 1.3.1 Politico-Legal Constraints 28 1.3.2 Social Constraints 35 1.3.3 Economic Constraints 37 1.3.4 Self-imposed Constraints 38 1.3.5 Constraints on Practice 40 1.4 Sociological Studies on Chiropractic 44 1.5 Purpose of Study 53 1.6 Summary 62 Notes 65 2.0 SOCIOCULTURAL CONTEXT OF HEALING ACTIVITIES 70 2.1 Health Model [HM] 73 2.1.1 Conceptions of the Structure and Function of the Human Body 78 2.1.2 Lay Theories of Illness Causation 81 2.2 Explanatory Model [EM] 82 2.2.1 Elicitation of Explanatory Model 90 2.3 The Social Organization of Medical Care 93 2.3.1 Practitioner-Client Interactions 100 2.4 Summary 111 3.0 THE SOCIALIZATION PERSPECTIVE 115 3.1 Socialization Processes 115 3.1.1 Education of Clients 117 3.1.2 Managing Impressions 119 3.2 Socialization via Negotiation 123 (v) CHAPTER PAGE 4.0 METHOD OF STUDY 138 4.1 Methodological Orientation 140 4.2 Study Design 145 4.2.1 Construction of Interview Questions 149 4.2.2 The Setting 152 4.2.3 Selection of Chiropractic Clinics 153 4.2.4 Selection and Recruitment of Chiropractors 153 4.2.5 Selection and Recruitment of New Clients 154 4.2.6 Selection and Recruitment of Regular Patients 155 4.2.7 Procedure 157 4.3 Data Collection 159 4.4 Methodological Problems 164 Notes 169 5.0 ' HEALTH BELIEFS AND EXPLANATORY MODELS OF NEW CLIENTS AND CHIROPRACTORS 170 5.1 General Characteristics: Chiropractors and New CIients 171 5.2 Constraints on Chiropractic: Views of New Clients and Chiropractors 175 5.3 Impressions About Chiropractic: New Clients and Chiropractors 184 5.4 Beliefs About the Human Body and its Functions 190 5.5 Beliefs About Illness and Disease 197 5.6 Beliefs About Signs and Symptoms 204 5.7 Health Habits 206 5.8 Beliefs About Treatment Systems and Healers 213 5.9 Explanatory Models of New Clients and Chiropractors 217 5.10 Summary 237 Notes 240 6.0 . STRATEGIES FOR MODIFYING CLIENT PERCEPTIONS 241 6.1 Persuasive Interaction Structures 242 6.1.1 Physical Layout and External Characteristics 243 6.1.2 The Waiting Rooms 244 6.1.3 Treatment Rooms and Other Subsettings 254 6.1.4 Sociopolitical Linkages 257 6.2 Persuasive Interaction Strategies 260 6.2.1 Admission to Clinic 261 6.2.2 The Treatment Area 270 6.3 Summary 275 (vi) CHAPTER PAGE 7.0 MANAGING IMPRESSIONS AND NEGOTIATING EXPLANATORY MODELS 278 7.1 Chiropractic Self-Presentation 284 7.2 Negotiating Explanatory Models 305 7.2.1 Negotiating Functions of the Human Body 306 7.2.2 Negotiating Causes of Illness, Signs and Symptoms 309 7.2.3 Negotiating Health Habits 314 7.2.4 Negotiating Treatment 316 7.3 From Client to Patient 326 7.3.1 Communication and Language in Chiropractic-New Client Negotiation 342 7.4 Summary 347 Notes 352 8.0 CONCLUSION 353 8.1 Findings and Discussion 354 8.2 Implications of Study for Health Care 363 8.3 Suggestions for Future Studies and for the Sociology of Health Care 368 BIBLIOGRAPHY 373 APPENDICES 400 (vii) LIST OF TABLES TABLES PAGE 1. Knowledge of Chiropractic: New Clients 176 Health Care Practitioner Groups from 1973 to 1983 2. Channels for Chiropractic Information 177 3. General Impressions about Chiropractic: Views of New Clients 185 4. General Impressions about Chiropractic: Views of Chiropractors 186 5. The Human Body's Ability to Remain Healthy 191 6. Maintenance of a Healthy Body 192 7. Mechanisms for the Maintenance of "Own" Healthy Body: Chiropractors 195 8. Ability of the Human Body to Care for Itself 196 9. Cause(s) of Illness 198 10. Internal Effects of the Cause(s) of Illness: New Clients 200 11. Avoidance of Illness 201 12. Internal Effects of the Cause(s) of Illness: Chiropractors 203 13. Signs and Symptoms 205 14. Beliefs about Good and Bad Health Habits 207 15. Adherence to "Good Health Habits" 208 16. Reasons for Good Health Habits: New Clients 209 17. Reasons for Good Health Habits: Chiropractors 211 18. Preferences for Treatment Types 214 19. Reason for Most Preferred Type of Treatment 216 20. Behaviours Relating to "Present" Health Problem 219 (vii i) TABLES PAGE 21. Help-Seeking for "Present" Illness 220 22. Concerns About Chiropractic Treatment 222 23. Health Complaints of New Clients 224 24. Cause of Present Illness 225 25. Reason for the Onset of Illness(es) 227 26. The Working of Illness(es) in the Body 229 27. Effects of Illness in the Body 231 28. Severity and Duration of Illness 233 29. Expected Treatment for Present Illness 234 30. Expected Results from Treatment 236 31. Preferred Healer Characteristics: Views of New Clients and Chiropractors 291 32. Impressions of New Clients about Chiropractors 293 33. Impressions of Regular Chiropractic Patients about Chiropractic 297 34. Post-Interaction Views of New Clients and Chiropractors 298 35. Chiropractors' Views about the Explanatory Model of New Clients 332 36. Post-Interaction Impressions of Chiropractic: Views of New Clients 334 37. Differences of Opinion: New Clients and Chiropractors 336 38. Chiropractic Treatment: Views of New Clients 337 39. Evaluation of Chiropractic Treatment: Views of New Clients 338 40. Evaluation of Chiropractic Treatment: Views of Chiropractors 340 41. Communication Characteristics in 18 Two-Party Chiropractor-Client Conversations 345 (ix) LIST OF FIGURES FIGURE PAGE 1. The Relationship of Health and Explanatory Models of 57 Clients and Chiropractors for Healing Activities 2. Design of Study 147 3. The Relationship Between Data Files 160 (x) ACKNOWLEDGEMENTS This study would not have been possible in its present form but for the encouragement and support of many individuals during some very trying periods. I would like to thank the members of my Thesis Committee for their help, patience and encouragement: Professor Nancy Waxier-Morrison for "kindling" my interest in Medical Sociology, Professor Adrian Marriage for providing me with initial guidance during my search for a "home" within sociology, and Professor R.S. (Bob) Ratner for "sharpening" my academic mind beyond biomedicine and for chairing my Thesis Committee through years of personal tragedy. I am grateful to Professor Arthur Kleinman for his comments and advice. I would also like to express my special thanks to my family for their support, and to Miss Irene Korosec for the many hours she spent deciphering my handwriting and typing the various copies of this thesis. This Thesis is dedicated to my daughter PEARL (CHI-CHI) CHINYERE whose courageous battles with bone cancer and the seemingly unending hospitalizations and therapies during the process of this study, have taught me more about the Sociology of Medicine than I wanted to know. CHAPTER 1 1.0 INTRODUCTION This study is about how persons who seek help from chiropractic''' during illness are socialized into chiropractic care, and subsequently become chiropractic patients. It describes what goes on before and during the clinical encounter and the healing process, especially the symbolic and expressive aspects of the encounter which lead to client socialization. I have taken the view, after Kleinman (1980), and Kleinman et al . (1978), that the clinical art is essentially a negotiative process in which individual practitioner and client negotiate explanation and treatment for an illness problem. I also take the view that chiropractors have refined the "clinical art" in a manner that has helped sustain the success of chiropractic in the face of social, political and legal constraints as well as dramatic improvements in biomedical theory and treatment. Because the individual chiropractor, moreso than a doctor of medicine, faces greater constraints in his clinical practice, he not only negotiates common grounds for the treatment of illness, he also uses various "persuasive interaction strategies" to socialize new clients. This study, therefore, describes socialization aspects of persuasive interaction strategies used by twenty chiropractors in the three municipalities of Vancouver, British Columbia, in socializing sixty new clients into becoming chiropractic clientele. It examines the way chiropractors interact with potential clients in clinical settings, how new clients are "convinced" of chiropractic care, and, in - 2 -particular, the manner in which treatment is negotiated to enable ongoing care. In recent years, chiropractic has emerged as a visible feature of health care delivery in Canada. This is evident from the growing number of chiroprac-tors in Canada, the number of persons who seek and receive chiropractic treatment for their health problems, the continuing public debate regarding the nature of chiropractic care, and the kind of limitations that surround the 2 practice of chiropractic. In spite of constraints under which chiroprac-tors must legally practice in different Canadian provinces, a large number of Canadians have continued to subscribe to chiropractic care (Kelner et al . 1980). Consequently, more chiropractors are being trained every year, and chiropractic as a system of medical care has continued to grow and attract public 3 attention . Of all the health care professions which function as an initial portal of 4 5 entry in the Canadian primary health care system , chiropractic has shown the most increase in manpower in recent times. From 1973 to 1983 the number of chiropractors in Canada increased by 59% from 1269 to 2019. The corresponding increase for medical doctors [M.Ds] during the same ten-year g period is 36% while the number of osteopaths decreased nationally by 44% from 87 to 43. The rate of growth for chiropractors is more visible in the province of British Columbia where during the same ten-year period, the number of chiropractors increased by 86%, from 182 in 1973 to 330 in 1983, or 27% above the national growth trend. In the same period, the number of allopathic^ physicians [M.Ds] in the province increased by 45% while the number of osteopaths decreased by 75% (Health and Welfare Canada, 1984). - 3 -As the ranks of chiropractors grew, so did the number of persons who received chiropractic care. It has been estimated that about 1.8 million Canadians subscribe to chiropractic treatment in any given year (Kelner et al , 1980). In 1986, the number of Canadians who will seek and receive chiropractic treatment will likely exceed 2.0 million. The 339 chiropractors in British Columbia in 1983 accounted for 342,222 treatments in the province and 20% of all back-injury treatments for the Workmen's Compensation Board. It is estimated that at the end of 1985, 353 chiropractors in British Columbia would have accounted for more than 400,000 treatments for different kinds of illness g problems . Nationally, it has been found that 34% of consultations in Canada for musculoskeletal and related disorders are carried out by chiroprac-tors (Lee et a l . , 1985). The emergence of chiropractic as a visible feature of health care delivery is not limited to the Canadian scene. In the United States, over 7.5 million Americans have been estimated to receive chiropractic treatment each year (U.S. DHEW, 1978). It has also been suggested that from 10% to 15% of all Americans will at some time in their lives, seek chiropractic care (Inglis, 1969). This development has prompted some authors to view chiropractic as a profession which has achieved social and political acceptance despite opposition from "orthodox g medicine" (Silver, 1980) . In general, opposition to chiropractic has, for many years, been based on the contention that it is an unscientific healing cult which makes unsubstantiated, "grandiose" claims in conflict with medical science (Wolinsky, 1980; Relman, 1979; Ballantine, 1972). In 1979, allopathic opposition to chiropractic led the Government of New Zealand to appoint a Royal Commission of Inquiry on chiropractic to examine the reasons behind chiropractic - 4 -claims of success with certain remedies. The Commission found that "Chiroprac-tic is a branch of healing arts specializing in the correction of the spine by spinal manual therapy " but that "the precise nature of the biochemical dysfunction which chiropractors claim to treat has not yet been demonstrated scientifically. . ." (New Zealand Report of the Royal Commission, 1979:3-4). In British Columbia, as in all of Canada, chiropractors have not been granted the same rights of general clinical practice as allopathic physicians. They do not have hospital privileges for their clients and medical doctors are prohibited by their organization from referring patients to chiropractors (Kelner et al , 1980). The British Columbia College of Physicians and Surgeons prohibits the renting of offices to chiropractors in office buildings that are owned by physicians. Reimbursement for chiropractic services under the provin-cial health insurance scheme is limited to twelve visits per person per year, or fifteen visits for persons over 65 years old. Officially, chiropractors in British Columbia are permitted to use only their hands in the treatment of patients, unlike in the province of Ontario where chiropractors may use electri-cal and mechanical devices in treatment. It was not until 1982 in British Columbia that chiropractors were legally allowed to work on body extremities. In the face of these limitations, chiropractors must find ways by which to transmit positive information about chiropractic health care. They must, of necessity, elevate the valuation of chiropractic as a profession in the public mind i f they are to further the course of their profession. They must, there-fore, develop strategies, individually and collectively, for convincing sceptical and wary individuals and the public about the merits of the chiropractic healing system. - 5 -As I have noted earlier, constraints on chiropractic healing have not retarded growth in the number of chiropractors nor have they led to fewer persons seeking chiropractic care. Rather, evidence suggests that increasingly more persons continue to seek chiropractic care and are satisfied by the care they receive (Kelner et al , 1980, Kane et al , 1974). Consequently, chiropractic has emerged in Canada and the United States as the largest alternate healing profession to allopathy (Coulehan, 1985; Kelner et a l . , 1980). How, therefore, has chiropractic been able to negate its opposition, overcome limitations on its practice and emerge as a visible feature of health care delivery? In particu-lar, what features of chiropractic healing have enabled it to succeed with persons who seek chiropractic help for their health problems? How is the chiropractic clientele made? Early writers have described chiropractic patients as rural, unsophisti-cated folk with l i t t l e access to conventional medical treatment (McCorkle, 1961). Consequently, these patients are said to have l i t t l e choice but to remain chiropractic patients. However, recent studies have shown that chiro-practic serves patients of all ages, occupations, and socio-economic groups (Yesalis et a l , 1980; Cleary, 1985; Breen, 1977; Kelner et al , 1980). Yesalis et al . (1980) have found that despite the addition of 14 new medical doctors [M.Ds] in rural Iowa, the number of persons who visited a chiropractor in 1972 increased by 2% in 1977. Kelner et al (1980) have also noted that in Canada, 56% of chiropractic patients had previously sought help from medical doctors for their current problems and 85% had a family physician with whom they were satisfied. - 6 -Unlike the United States, Canada has a universally funded public health insurance scheme. More than 90% of all Canadians are covered for medical treatment under universal health insurance plan. Therefore, socio-economic factors, especially regarding ability to pay for treatment, are not as important as they could be in the United States where there is no universal insurance for health care. Therefore, the success of chiropractic with their clients in Canada and the United States should be understood not in terms of the reimburse-ment characteristics of different health care systems, but in relation to the clinical process, especially at the level of individual interactions when the chiropractor and the client address a particular health problem. I argue that although the socialization of chiropractic clients may begin much earlier during the help-seeking process, it is during personal, individu-alized encounters with the chiropractor in a clinical setting that socialization is maximized. It is during the healing process, especially during the initial encounter with new clients that chiropractors are presented with the opportunity to remedy whatever "negative image" or perception they encounter individually or as a group. This includes not only the tangible aspects of allopathic opposi-tion to chiropractic, but also the fears or concerns clients may have about chiropractic. The clinical encounter, therefore, presents an opportunity for a chiropractor to educate the client as well as learn about the client's most cherished beliefs and values with a view to negotiating common grounds from which chiropractic care can be effected. It also provides a potential patient with the opportunity to acquire first-hand and direct information about chiro-practic care, its philosophy, and its treatment methods. - 7 -1.1 Society and the Healing Process It has been argued that the process of healing the sick occurs in, and creates particular social worlds which in themselves are culturally constructed (Mishler et al , 1981; Kleinman, 1980). Clients and healers bring to the healing encounter a set of beliefs, values, and orientations about sickness which have become major aspects of individual l i fe experiences. What a person believes about his sickness, how he behaves as a sick person, and how his family, friends and healers respond to his sickness behaviour constitute social as well as cultural rea l i t i e s 1 0 . These realities are distinctly shaped in different societies and in different social settings within societies (Kleinman, 1980). One domain in which the conception and management of sickness episodes have become social as well as cultural realities is the professional approach to healing 1 1 . Located in the professional sector of health care are health-services professions and bureaucracies which base healing and clinical practice on highly developed and complex professional health cultures. For example, medical doctors or allopaths believe in "scientific medicine", the germ theory of disease causation, the use of drugs as therapy, and bodily intrusive measures in the treatment of diseases. Naturopaths believe in the use of naturally occurring substances in combating disease and in promoting health. Although different health services professions co-exist in different societies, very often there is competition among distinctive health care providers for access to limited resources, reimbursement for care, choice of treatment techniques, and in particular, competition for patients and clients (Unschuld, 1979). These types of competition have been known to occur, for - 8 -example, in the field of mental health between psychiatrists, psychologists and social workers (Chrisman and Kleinman, 1980). In societies where there are plural systems of professional medical care, governments have tended to recognize one system of care as the "official" system by granting that system greater authority in matters affecting the health of citizens (Kunstadler, 1978). In western societies such as Canada and the United States one group of health services providers comprised of allopathic physicians with a particular set of beliefs regarding the healing process, has been granted the right, through legislation, to claim disease and illness as social objects (Denzin, 1968). They claim, as a legal right, a licence to cure, control, and eliminate disease and illness and to define what is proper conduct for other medical workers towards their own work (Friedson, 1970a; 1970b). The main problem has been that the authority and power to "create" and treat illness as social phenomena, and to legitimate a particular construction of reality as the only socially-based reality have not been equally distributed among different healing groups. Because social power is , to some extent, a function of institutionalization, the professional sector of health care becomes important especially when the state has chosen to grant greater control and authority in healing activities to one group of care providers and not to the others. In Canada, the United States, and most of the western world, the profes-sional sector of health care has been heavily institutionalized (Lee, 1976). This institutionalization has favoured allopathic medicine. Consequently, it - 9 -has used its state legitimated authority and control over all types of health problems to further its dominance over other healing groups. Friedson (1970b) has described how modern medicine or allopathy has used legal and political means to gain professional dominance in health care by forcing other healing 12 traditions such as homeopathy to disband, submit to its professional control, or retreat into marginal health care. In the United States, osteopathy has been absorbed by allopathic medicine. In Canada, osteopathic healing tradition does not have legal status in a majority of the provinces and the number of its practitioners in British Columbia have declined by 75% in the ten-year period from 1973 to 1983. A healing tradition which has continued to survive in both the United States and Canada is chiropractic. Chiropractic has probably survived simply because it has too many adherents to be abolished, and because its clientele has continued to grow in the face of opposition from allopathy and institutional constraints on its practice. It is the making of chiropractic clientele as part of the "survival" or "success" of chiropractic as a medical system in British Columbia that is addressed in this study. 1.2 History and Development of Chiropractic as a Medical Specialty Hildebrandt (1978) has observed that therapeutic manipulation began to evolve as an indentifiable form of health care during the time of Hippocrates at about 400 B.C. Over the centuries, the concepts and methods of manipulation as a form of treatment became well known and comprised the primary method of - 10 -health care. Formal knowledge of the beneficial effects of manipulation gradually became known through its initial use to satisfy the instinctive sensory urge of the sick to experience feelings of comfort and well-being. From the knowledge gained from these initial experiences, there gradually emerged the development of organized systems of application, the most notable of which was bonesetting, a manipulative art passed on through families for centuries, especially in Great Britain and Europe. Later, bonesetters emigrated to North America where their procedures became popular during the early part of the 19th century. Osteopathy and chiropractic have been seen as direct descendants from bone-setters, the latter becoming primarily concerned with the human spine. In 1895, in Davenport, Iowa, a Canadian born immigrant, David Palmer, announced the formal beginning of chiropractic as a separate form of health care following a case in which he claimed to have alleviated a condition of deafness with a manipulative technique he called "adjustment". In his book, "The Chiropractor's Adjuster", published in 1910, Palmer reported on his historic encounter with a man who had been deaf for seventeen years. According to Palmer, he was told that the apparently healthy man became deaf as a result of something giving way in his back as he stooped in a cramped position. On examination, Palmer is said to have found a vertebrae that was dislodged from its normal position. He reasoned that replacement of the vertebrae would restore the man's hearing. Palmer claims that by using the spinous process as a - 11 -lever in replacing the displaced vertebrae, he was able to restore the man's hearing. Since the result he expected was realized, Palmer concluded that the restoration of hearing was not an accident (Lomax, 1975). Within three years, Palmer began a school of chiropractic in Davenport, Iowa to produce practi-tioners of the new method of healing. This occured during a very stormy period in the history of health care in North America. Consequently, early relations between chiropractic and organized medicine, the dominant part of the health care system, became acrimonious and have remained so ever since. By the end of the 19th century, medical care in the United States was not a flourishing enterprise. Hospitals were poorly equipped to handle illness and medical staff were selected in a haphazard manner. Dogmatic struggles between the allopaths or the dominant group, and homeopaths, the insurgent group, divided the medical profession. Homeopaths challenged the heavy dosages of drugs in vogue at that time, pointing out that more modest doses reduced death rates. It was during this period of meagre hospital care, heroic surgery, poor medical evaluation and heavy dosages of drugs, that chiropractic emerged as an alternative system of healing. Palmer was opposed to the practices of medical doctors of the times, as he was convinced of both the uselessness of most drugs administered and of the .dangers of surgery. But he remained in almost complete obscurity until he had the opportunity to practice spinal manipulation. Palmer's revelation as to the value of chiropractic ostensibly occurred with his first patient whose deafness he claimed to have cured by pushing a misaligned vertebra back into place. - 12 -It is doubtful that the appeal of chiropractic could be attributed solely to Palmer's discovery. Conditions were already ripe for the emergence of a variety of new forms of medical practice. Some prevailing popular sentiments in the middle and latter part of the nineteenth century were fear and distrust of the heroic surgeries of orthodox medicine and resentment of high fees charged by medical doctors. A shortage of physicians, especially in rural areas, also paved the way for the development of chiropractic and other alternative medical sects (Inglis, 1964). Chiropractic bears strong similarities to the Thomsonian movement, which had sprung up in reaction to the excesses and incompetencies of the regular medical practitioners. In the 1830's and 1840's, the Thomsonian movement acquired a large following, especially among the lower classes of the Mid-west-and South. Thomsonian practitioners relied on relatively harmless botanical remedies, as opposed to the frightening employment of cathartics, bloodletting, and blistering characteristic of the regular medical practitioners. The success of the movement can also be attributed to the encouragement given to patient self-education and patient participation in the treatment process. Thomsonian-ism gave the patient a greater sense of control over his own fate. The remedies advocated were easily available and easily applied. In contrast to orthodox medicine, which was becoming increasingly formalized and specialized, Thomsonianism was based on practices and precepts familiar and comprehensible to the general populace. In 1832, Samuel Thomson published his New Guide to  Health: or Botanic Family Physicians, containing a Complete System of Practice,  on a Plan Entirely New; with a Description of the Vegetables made use of, and - 13 -Directions for Preparing and Administering Them, to Cure Disease, to which is  refixed, a Narrative of the Life and Medical Discoveries of the Author. With the aid of Thomson's book, each man was to be "his own physician", capable of activating the healing forces within his body through the appropriate botanical remedies. The widespread use of all types of patent medicines reflects the same spirit of lay self-sufficiency characterizing the nineteenth century (Rothstein, 1972: 125-150). In similar fashion, chiropractic theory asserts that the ministrations of the chiropractor serve primarily as a catalyst; chiropractic adjustment merely sets the healing forces within the individual into motion. Thus, the patient is not reduced to the level of a passive object. It is also likely that chiropractic borrowed from the newly emergent osteopathic theory, with only minor modifications. Osteopathy exercised popular appeal for the same reason that Thomsonianism did. In that it posited a relatively straightforward, monocausal theory of disease, osteopathy was easily comprehensible to the average person. By way of contrast, orthodox medical practice was characterized by an el i t ist mystification of diagnosis and treatment, with the patient effectively precluded from any informed decision-making (Rothstein, 1972). According to osteopathic theory of the late nineteenth century, all disease was due to impeded circulation. In similar fashion, Palmer posited that all disease resulted from obstruction of the "nerve force", Both schools of healing advocated manipulation as a means of cure. Interestingly, Davenport, Iowa was only 150 miles removed from Kirksville, Missouri, where osteopathy originated, - 14 -just prior to chiropractic. An excerpt from the August, 1897 Journal of Osteopathy follows: "There is one fake magnetic healer in Iowa who issued a paper devoted to his alleged new system, and who, until recently, made up his entire publication from the contents of the Journal of Osteopathy, changing it only to insert the name of his own practice." (Reed, 1932: 18) Both chiropractic and osteopathy are closely related to the bone-setting tradition. Bonesetters were simply individuals who had demonstrated a knack for setting broken bones. Often bonesetting was merely a sideline or hobby and not a major source of income. Interestingly, bonesetting incurred l i t t l e opposition from orthodox medicine, at least in the first half of the nineteenth century, because "doctors rarely attempted to practice i t , because they regarded it as a knack, rather than as a craft and a vulgar knack at that" (Inglis, 1964: 94-95). The manipulative techniques employed by the bonesetters were never incorporated into the mainstream of orthodox medicine, although orthopedists later assumed responsibility for bonesetting. Thus, chiropractic combines a number of antecedent treatment modalities, all of which represented alternatives to the el i t ist character of orthodoxy and its practitioners. Today, in the United States and in some Canadian provinces, allopathy has absorbed osteopathy and, to some extent, homeopathy, into the mainstream of organized medicine - a scheme of treatment which consists mainly of drugs and surgery to be carried out primarily in hospitals. By contrast, chiropractic has maintained its identity and has allowed medical work to continue in individual - 15 -offices rather than in hospitals. The principal method of chiropractic care has been the use of hands which requires a great deal of personal attention to the person and body structures of their patients. 1.2.1 Chiropractic Philosophy Chiropractic philosophy is based primarily on the notion that "Each individual possesses an intrinsic, biological dynamic that interacts with and greatly modifies the external forces with which it comes in contact" (Strang, 1984:22). The human body, therefore, is conceptualized as a "structural and functional unit - a living, metabolizing, self-perpetuating composite being - which, under appropriate circumstances, has an inborn capacity to sustain itself while fulf i l l ing its objectives (whatever they might be for an individual) for a predestined span of years, and during that time reproduce itself for perpetuation of the species". (Hildebrandt, 1980). According to chiropractic theory, almost all diseases result from the vertebrae impinging on a nerve. The primary challenge is to locate the deranged vertebrae impinging on the nerve and push them back into proper position using mainly the process of "adjustment" (Strang, 1984; Haldeman, 1980; Kelner et a l , 1980; New Zealand Royal Commission on Chiropractic, 1979). The philosophical underpinning of chiropractic is based on the notion that disease arises from spinal misalignment. Through adjustment of body structures, primarily the spine, by manipulation, normal nerve function is restored and pain in the affected part or organ relieved (Pollack, 1972). Unlike orthodox - 16 -medicine, diagnosis is not a prominent feature of chiropractic because according to its theory, almost all disease results from vertebrae impinging on a nerve. The primary challenge is to locate the deranged vertebrae and push them back into proper position (Reed, 1932). Thus, diagnosis is unambiguous and treatment strategy fundamentally the same for all symptoms. Allopathic physicians [M.Ds] have traditionally scoffed at the notion that organ dysfunction could be attributed to spinal misalignment and they have also doubted that most back pain can be traced to vertebra impinging on nerves (Crelin, 1973). Chiropractic also maintains that health is expressed through the nervous system with the brain as the control station. Normal health, therefore, is a state in which there is no disturbance to nerve-energy flow channels. This vital nerve-energy must flow freely from brain cells to tissue cells in order that glands, muscles, and organs may function normally (British Columbia Chiropractic Association publication, undated). Until 1930, the National Chiropractic Association in the United States did not acknowledge the role of germs in disease causation. In recent times, some chiropractors have modified their views to accommodate the germ theory of disease as well as the role of genetic factors in the aetiology of disease. Lack of clear articulation and uniformity of views regarding causes of biological health problems among chiropractors has become problematic for the profession. The New Zealand Royal Commission (1979:43) which probed into chiropractic in that country finds that "A general theory of chiropractic is not easy to dis t i l l from the evidence we received....In the Commission's view, - 17 -chiropractic theories have only just begun to evolve on a scientific basis " Nevertheless, the Commission finds that "Spinal manual therapy can be effective in relieving musculoskeletal symptoms such as back pain and other symptoms known to respond to such therapy such as migraine" (p.3). 1.2.2 Chiropractic Model of Health Care In order to understand the logic and distinctiveness of chiropractic model of health care, it is necessary to contrast it with its major alternative, the medical model of health care. Chiropractic developed in response to allopathic medicine and its entire history has been marked by conflict and debate between followers of the two health care models. The success of allopathic medicine began with the emergence of the germ theory in the 19th century which brought medicine and science together. Consequently, the nature of medical practice was transformed from guess-work and heroic surgery to application of reductionist, scientific paradigms, thus establishing medicine as a dominant force in matters of health. The importance of the germ theory is that it enabled the treatment of kil ler diseases. Coulter (1983a, 1983b) argues, however, that it was the articulation of treatment methodology rather than the germ theory that provided the roots of scientific medicine. Increasingly, scientific medicine became less of a purely clinical endeavour and more a matter of scientific research and quest for wonder drugs. - 18 -Along with the scientific approach to health care and reductionism came specialization and consequent "atomization" of the human body into parts. Diagnosis became a complex exercise as more and more functions were relegated to dependent occupations such as radiographers and laboratory technologists, and some clinical functions to physiotherapists, respiratory technologists and occupational therapists, among others. What the germ theory seem to have achieved is the introduction of a methodology, an approach to isolating the 13 causes and treatment of "disease" and not of "illness" . This transforma-tion has not only transformed the social settings of medicine, it has also fundamentally altered the relationship between the practitioner and the patient, at great cost in terms of human relationships. Society at large, by becoming enamoured of things scientific encouraged by 14 advances in medicine, has chosen to grant "organized medicine" a special controlling role in health care. Other medical systems, therefore, became marginal to the "official" system which jealously guarded its powerful position against intruders and alternative healing systems. More importantly, the focus in healing is no longer located primarily in human relationships, but in the identification of causes of disease symptoms and their scientific remediation. In contrast, chiropractic as a profession did not, in i t ia l ly , and some chiropractors s t i l l do not, subscribe to the germ theory of disease. However, the fundamental aspect of the chiropractic model of health care has remained the same. That is, the body when functioning normally is able to combat disease processes naturally. According to the model, when disease occurs, it is because of a failure in the body's natural restorative power. The seat of this power is - 19 -the nervous system, which when functioning normally, is able to help the body combat disease. In general, the body is an integral unit which is capable of maintaining its own health (Strang, 1984). Sometimes disease occurs because of lowered resistance which therefore allows micro-organisms to be effective. For chiropractors, traditional "organized" medicine combats the symptoms of illnesses and not the predisposing factor or cause of illnesses. Chiropractors claim that they do not, in the strict sense, treat diseases. Rather, they treat the patient, the object being to restore the body to a normal state which will enable it to combat disease. In this model, disease is interpreted as symptom, not cause. Chiropractic did not develop from reliance on pure science as medicine did, nor was its treatment derived from science in the manner in which drug treat-ment was derived. It is primarily at the level of conceptual theories that treatment rationale developed. Chiropractic treatment was derived almost entirely from clinical experience or experience which was based on human interaction and relationships. As a consequence, it did not adopt the technical jargon of science, rather, it developed its own distinct language and concepts which appear to have been more accessible to the patient than those of medicine. For example, "adjustment", the primary method of chiropractic care, conjures an image of an auto mechanic adjusting a valve in an automobile engine to get it working properly. It appears that in general, organized medicine is located on the extreme end of the health-illness-disease continuum while chiropractic appears to locate - 20 -in the middle. Most of the models of health care espoused by family medicine practitioners bear some resemblance to the chiropractic model of health care. Each group of practitioners has its own definition and classification of health problems (Webster, 1984). Family medicine practitioners recoqnize that health care is holistic and that at their point on the health-illness-disease continuum, the cause-effect research models of the disease paradigm do not always suffice. Sacks (1977) has called for a new type of community practitioner. He envisaged a primary contact practitioner who, while competent to treat manifest disease, would actively promote health and prevent disease by client-patient education. The quality of this new practitioner's work would be assessed in terms not only of technical skills but also in terms of compassion, humanity and patient satisfaction. Practitioners in the illness sector of the health-illness-disease continu-um, therefore, have a model of health care which is characterized by a holistic or comprehensive approach to patient care, a person-oriented approach to clinical practice, sustained continuity of care, and a disease prevention and health promotion focus (Jamison, 1985). 1.2.3 Contemporary Chiropractic In recent times, some chiropractors believe in supplementing chiropractic adjustment techniques with other kinds of treatment modalities such as heat therapy, diet regulation, electrotherapy, and so on. Thus, conflict has - 21 -developed between those who follow this view, otherwise known as the "mixers", and those who adhere to the traditional view that spinal adjustment is the only permissable method of treatment, otherwise known as "straights" (Kelner et a l . , 1980; Baer, 1984; New Zealand Royal Commission, 1979). In the United States, as the new movement grows, it attracts "more and more members who are interested in making a good living and in raising their status in the outerworld. This means that they become more concerned with obtaining respectable credentials and providing services that more closely follow the medical model, and eventually even developing working relationships with the orthodox medical world" (Roth, 1976:40-41). Because of the views of the "mixers", the body of treatment procedures taught in chiropractic schools has been expanded to include adjustments of a much greater range of joints, and a device introduced to measure variation in body temperatures. Also, the range of biological studies and diagnostic procedures has widened. More importantly, most contemporary chiropractors use auxill iary equipments such as X-rays, ultrasound and other devices and treatment methods. In British Columbia, chiropractors are not legally allowed to use most of these equipments and different methods of treatment in treating patients. In the words of one chiropractor, "B.C. is a straight country. Some of us explore the margins of straights and mixers, but never admit it." - 22 -1.2.4 Chiropractic in British Columbia Chiropractic, as a system of health care was formally recognized in British Columbia via the Chiropractic Act in 1934. At that time, the few chiropractors in the province did not constitute a significant threat to organized medicine since their number was less than a dozen. There were no major developments until 1950 when the Workers' Compensation Board of British Columbia included chiropractic care among approved health care services for injured workers. This development did not occur without quiet and persistent lobbying of politicians and bureaucrats by few leaders of chiropractic. It was not until fifteen years later in 1965, after extensive lobbying by chiropractors, that the Province's Medical Services Plan included minimum coverage for chiropractic care to eight weeks. Presently, coverage has been extended to twelve visits per person, or fifteen visits for persons over sixty-five years old. The Workers' Compensation Act of 1968 deemed chiropractors as "Qualified Practitioners", and employees covered under the Act are free to select their own "qualified pracititioner" whether chiropractic or "medical". In 1960, the British Columbia Chiropractic Act defined chiropractic as follows: "'Chiropractic' means the science of palpating and adjusting the articulations of the human spinal column by hand only, and includes the manipulation and adjustment by hand of the ribs and articulations thereof for the purpose of adjusting the articulations of the human spinal column". The definition as stated, effectively limits chiropractors to only the use of their hands in providing treatment to the spinal column and its articula-tions, notably the ribs. Chiropractors, unlike their colleagues in the Province - 23 -of Ontario, are limited to the technique of "adjustment" as a modality of treatment. In Ontario, under the Drugless Practitioners' Act, chiropractors are free to utilize electrotherapeutic devices such as Short Wave Diathermy, 15 Ultrasound and mechanical devices in treating clients In 1972, Chiropractic Services were included in the British Columbia Automobile Insurance Act. Following quiet, non-confrontive lobbying of pol i t i -cians and bureaucrats in government by the Chiropractic Association, the Chiropractic Act was twice amended in the last three years to allow for adjust-ment of all articulations by hand only and a technical change to permit chiropractors to use the prefix "Dr." with their names. Because of opposition from organized medicine in British Columbia, polit ical , social and economic changes in the lot of chiropractors in British Columbia have been slow in coming about. The context of opposition is reflected in the following newspaper headlines and reports in the past few years. "City Chiropractors Shut Out" Vancouver Sun, March 14, 1984. The report discusses the decision by the British Columbia College of Physicians and Surgeons not to rent office space to chiropractors in buildings owned by college members. The Register of the College at the time defended the decision in the "Medical News" by stating a concern that the public may perceive the two health care professions in association with each other. "It tends to - 24 -give credence to their philosophy" adding that the philosophies of the two professions are different. "Handout pays for helping Hand" Vancouver Sun, August 4, 1984. In this account, a paralyzed client who was unable to pay for chiropractic services beyond the allowable twelve visits received free care from his chiro-practor. The report called attention to limits placed on public insurance reimbursement for chiropractic services. "Chiropractors Want Fair Shake from M.D's" The Province, March 27, 1983 This report by a journalist details a number of constraints on chiropractic services and the role played by organized medicine in British Columbia in fostering limitations on chiropractic. "Ruling Gets M.D's Back Up" The Province, April 3, 1983 The case of an allopathic physician who was denied permission to start a "centre for manipulative therapy" was discussed. The College of Physicians and Surgeons had denied him permission because of his intention to associate with one or more chiropractors. The irony here is that the allopathic physician is also a chiropractor, having been trained init ia l ly in chiropractic. He was interviewed for this study with respect to his views and experiences. "Medical Outsiders Seek Recognition" The Province, March 27, 1983 -a -- 25 -In this report, a number of non-allopathic medical systems in British Columbia were discussed with regard to the lack of adequate recognition by organized medicine and by political decision-makers of the role non-traditional health care systems play in British Columbia society. Among featured groups are Acupuncturists, Midwives and Homeopathic physicians who technically do not exist in the province. Chiropractors were also discussed with respect to their struggles to obtain cooperation from organized medicine and their plea for the removal of barriers to chiropractic professional services by the state. "Chiropractors Win" The Vancouver Sun, March 26, 1983 The case of a chiropractor who had been charged in the court with using the t i t le "Dr." as prefix to his name was dismissed by a provincial court. The College of Physicians and Surgeons had prosecuted the chiropractor in court before the change in the Chiropractic Act which allowed chiropractors to use the word "Doctor" in describing themselves. From time to time, public debate about chiropractic emerges to engage the attention of the public in British Columbia (The Vancouver Sun, August 25, 1975; Nanaimo Times, October 13, October 25, 1984; Nanaimo Free Press, December 10, 1984; Kamloops News, December 13, 1984; The Province, March 9, 1984; Vancouver North Shore News, April 8, 1984; Trail Daily Times, August 23, 1984; The Elder Statesman, 1985). Bureaucrats in the provincial Ministry of Health and leaders of the Chiropractic Association whom I interviewed noted the continuing - 26 -existence of political and professional opposition to chiropractic and the slow rate of change in improving relationships or removing barriers to change. 1.3 Constraints and Issues Relating to Chiropractic Differences in perceptions of chiropractic as a deviant, marginal or stig-matized professional group may have been, in large measure, due to particular issues and types of constraints chiropractors are faced with in different communities and political environments (McCorkle, 1961; Cowie & Roebuck, 1975; Gardner, 1975). When issues are not embedded in prevailing ideological values of the society, such as scientism in medicine, they are, to a large extent, mediated or influenced by polit ical , social and economic activities of organized medicine or local associations of allopathic practitioners. These activities often find strength in the official recognition that allopathy enjoys from the state or in structured regulations in medical acts which provide allopathic practitioners with diverse sources of power, prestige and political influence. In the United States, the competitive free-market ideological orientation is a strongly held value system. Consequently, unlike in Canada, health care is regarded as -a market commodity, subject to requirements of free-market competi-tion. Providers of health care are therefore in competition for clientele as well as for maximization of economic benefits. Because chiropractic emerged in the United States at a time when "organized" medicine was facing competition from osteopaths, among others, an adversary relationship developed first on philosophical grounds and later, for the survival of each healing orientation. - 27 -This adversary relationship has been championed by successive leaders of each health care orientation, especially since allopathy has assimmilated many rival competing health care groups, such as osteopathy, to the exclusion of chiropractic. The situation is somewhat different in Great Britain. In that country, there are fewer chiropractors compared to tens of thousands of allopathic physicians (Baer, 1984). The second largest group of primary health care practitioners in Great Britain are osteopaths, unlike in Canada and the United States where chiropractors constitute the second largest group to allopaths. Consequently, chiropractors are not seen as posing great threats to the powerful role of organized medicine in Great Britain. Unlike Canada and the United States, issues relating to chiropractic do not seem to make headlines, nor do they engage public attention to the degree such issues are discussed in North American media. In Canada, "socialized medicine", defined to mean state-sponsored universal health care, appears to have lessened the sort of competiveness that character-izes relationships among health care providers in the United States. Even so, one may view the reaction of allopathic medicine towards chiropractic in Canada as systematic erection of structural and political barriers on chiropractic. Many of the constraints on chiropractic in Canada reflect the level of political and professional activities of provincial medical associations as well as the degree of success each provincial medical asociation has attained in placing limitations on the healing activities of local chiropractors. One reason why organized medicine may view chiropractic as problematic may be partly due to its - 28 -inability to exert professional control over chiropractors, unlike allied health occupations whose work must be legitimated by allopathy (Friedson, 1970b). For example, in Canadian hospitals, physiotherapists treat patients only on referral from allopaths. In general, all health care activities in hospitals come under the control of allopaths directly or indirectly since only allopaths are legally allowed to admit patients. In order to understand chiropractic clinical and healing practices, it will be necessary to take into consideration the nature of issues and constraints which the individual chiropractor must deal with locally in order to maximize professional worth and output. In British Columbia, local issues and constraints can be categorized into five areas, namely: politico-legal, social, economic, self-imposed, and cl inical . 1.3.1 Politico-Legal Constraints In British Columbia, problems of health and illness must be legitimated under the Medical Act by a licenced member of the College of Physicians and Surgeons. This legal authority puts individual members of the College in positions of influence with persons who interact with the official healing system. A special relationship may develop between practitioner and patient, thus helping to foster positive attitude towards organized medicine. The intimate, close and personal relationship developed during moments of illness provides an important avenue for influencing the behaviour of politicians via the perceptions of members of the society. The doctor-patient relationship has often been characterized as a "private" relationship. - 29 -Allopathic physicians have high social prestige which may help in influencing the political attitude of voters. Because institutional arrange-ments have been set up to support this high prestige, such as exclusive use of publicly funded hospitals, it is problematic for other medical systems, for example, chiropractic, naturopathy and homeopathy to influence political behaviour in the same manner possible for allopaths. This places chiropractors and other healing systems at some disadvantage. One leader of chiropractic whom I interviewed has called these exclusionary institutional structures "discriminatory practices". Other interviewed leaders of chiropractic are of the general view that political and legal issues relating to chiropractic are located within the historical context and in the political activities of organized medicine. Opposition from organized medicine is seen as the major contributor to the nature of polit ical , legal and professional constraints on chiropractic in Canada, and in particular, in British Columbia. Local and national medical associations are viewed as powerful organizations which have not hesitated to use their social prestige and power in influencing the direction of change within Canadian health care, or to impede progress directed at maximizing the role of chiropractors in health care. A major issue is the various differences regarding the definition and scope of chiropractic medical care in Canadian provinces. One leader of chiropractic interviewed comments: "Every Chiropractic Act in the land is different. In British Columbia, chiropractors are limited to only the use of.their hands in treatment, at f irst , of the spine, - 30 -and more recently including extremities. In Ontario, chiropractors have wider scope of practice but no Act. There, they can use different treatment modalities and are grouped together with allied health professions under the Drugless Practitioners Act. I can tell you that differences in provincial Chiropractic Acts are reflections of varying degrees of political activities by provincial medical associations and the measure of success in the struggle by us to achieve recognition and acceptance." Although chiropractic has, over the years, gradually been included in various provincial health insurance reimbursement plans for services, unlike the case for organized medicine, these provisions are disparate and lack uniformity across Canada. Provincial policy makers have either placed dollar limits, visit limits, or no limits for reimbursing chiropractic services. For example, in the Province of Saskatchewan, public insurance coverage for chiropractic services is unlimited. In British Columbia, insurance coverage is limited by the number of treatment visits a person is allowed to make to a chiropractic clinic: twelve visits for persons under sixty-five years and fifteen visits for persons over sixty-five years old. In the Province of Ontario, chiropractic services are covered for all procedures to a limit of $185 including electrotherapy services, although there is no separate Chiropractic Act in the province. In British Columbia, chiropractic services do not legally include electrotherapy, 'and only treatments that are delivered by hand are covered by the provincial public health insurance scheme. One leader of chiropractic comments: "Chiropractors are so limited by variations in the scope of practice in Canadian provinces that they are susceptible to infringement of the laws of trespass. Various local medical associations have consistently opposed improving provincial Acts and Statutes to accommodate chiropractors." - 31 -In British Columbia, where the relationship between leaders of chiropractic and bureaucrats in the provincial Ministry of Health is said to be cordial and responsible, there have been some changes in some aspects of chiropractic services. Chiropractors can now call themselves "Doctors" - a right they won in a court of law. The definition and scope of practice has been extended to include extremities. The number of visits a sick person can make to a chiropractor for treatment to be paid out of public funds has now been extended from nine visits to twelve visits per citizen per year. One highly placed bureaucrat whom I interviewed has described the relationship chiropractors have cultivated with the Ministry of Health as "responsible, and of low vis ibi l i ty , a low key approach, not confrontative and a classical lobbying technique...". Both the Minister of Health and the Deputy Minister of Health in the province are said to have received chiropractic care. In spite of the "good" relationship between the leaders of chiropractic and bureaucrats in British Columbia, chiropractic is s t i l l officially regarded as a treatment modality, much like massage, surgery, or tonsillectomy, and not as a comprehensive medical system. Bureaucrats in the Ministry admit that the Chiropractic Act is very old and in need of amendment, but they are powerless to initiate changes because of the views of organized medicine in the province. Officially, the provincial College of Physicians and Surgeons does not allow allopathic physicians to refer patients to chiropractors although privately, some individual allopaths have cross-referral arrangements with some chiropractors. One allopath, who is also a chiropractor, was prevented from - 32 -hiring or going into partnership with a chiropractor, but can only make such an arrangement with the wife of the chiropractor, who happens to be an allopathic physician^. The president of the only chiropractic college in Canada comments that there are three allopaths in the college faculty with teaching responsibilities but there are no chiropractors in medical schools in any recognized position. Officials in the provincial government and leaders of chiropractic agree that chiropractors have limited or no access to public health faci l i t ies . Federal and provincial governments do not fund the training of chiropractors, nor do chiropractors have access to universities and research funding. The President of the Canadian Chiropractic Association calls these practices "discriminatory, exclusionary practices" aimed at "further minimizing the part chiropractic plays in the health care of Canadians". In a significant way, structures have been set up to prevent access to public resources and facilities by chiropractors. No chiropractors work for the government even though the government spent about twenty-five million dollars for chiropractic services in 1985. The provincial Medical Advisory Committee has no chiropractor sitting as a member, ostensibly because chiropractors do not work in hospitals. According to one leader of chiropractic, the Medical Advisory Committee "advises on health care matters outside of the hospital environment, and chiropractors, like allopaths, are primary health care providers". The Workers' Compensation Board reimburses chiropractors for services, but "allopathic physicians sit in judgement as to what is proper service by a chiropractor". - 33 -Legal and political constraints on chiropractic are evident in the recent refusals by all one hundred and fifteen provincial hospitals to allow chiroprac-tors to visit their hospitalized patients even when such visits are requested by the patients (The Vancouver Sun, September 16, 1986). According to the Executive Director of the Provincial Chiropractic Association, it is the provincial College of Physicians and Surgeons that has determined that medical doctors not practice "in conjunction or in association with Chiropractors". He continues: "This has more to do with politics than it does with health" (The Vancouver Sun, September 16, 1986). It is illegal under the Hospital Act to allow anyone who is not a member of the College of Phyisicans and Surgeons or the College of Dental Surgeons to admit and treat patients in hospitals. Although the provincial Minister of Health publicly supports the idea of chiropractors being allowed into hospitals at the request of patients, he stipulates that such requests must have "the support of the medical doctor treating the patient" (The Vancouver Sun, September 17, 1986). Mike Tytherleigh, a journalist, comments that not allowing his chiropractor to visit him in hospital is: "discrimination...a denial of my right to health care in a public faci l i ty paid for with my. tax money. That denial is because the College of Physicians and Surgeons has told doctors thou shalt not cooperate with chiropractors... The problem is basically emotional prejudice that has nothing to do with delivery of health care...The solution is for the provincial government to show some moral responsibility, amending the Hospital Act to allow chiropractic care in hospitals." (The Province, September 18, 1986) - 34 -The legal and political dilemma facing chiropractic is perhaps, best reflected in a recent amendment to the Federal Medical Act which bans extra-billing for medical services. Under the previous Medical Act, medical practi-tioners are prohibited from extra-billing patients for their services. The new act refers to health practitioners rather than medical practitioners prompting one leader of chiropractic to ask "What are we?". It is not certain whether the new act has been intended to include chiropractors although the problem with extra-billing of patients for services is located primarily among allopathic physicians. The depth of emotional feelings among chiropractors regarding the political and legal constraints on them is reflected in the following comment by a chiropractic educator: "For 90 years, the group has faced every major trick in the books...from quackery accusations to unethical relationships with M.Ds...a chiropractor cannot rent space from an M.D. but can only marry her. We have to be aware of political and legal matters at all times. What is legal in Ontario is not legal in British slip, then you provide a reason for organized medicine to say to the public 'we told you so'." Regardless of political and legal constraints, leaders of chiropractic admit that there have been some ethical concerns. One leader interviewed describes the case of a chiropractor who treats painful knees by wrapping them in cabbage leaves over-night. Another leader of chiropractic knows of the use of acupuncture procedures among "a few chiropractors". A more serious observation describes one chiropractor who was "so enamoured of vibrators that - 35 -rather than buy an expensive one, he wrapped a saber (electric) with foam rubber and used it". Leaders of chiropractic emphasize that they do not condone these unethical practices and note that every profession contends with a few of their members who stretch the margins of ethical conduct. 1.3.2 Social Constraints Since its beginning in Davenport, Iowa in 1895, through the seminal works of Wardwell (1952) and McCorkle (1961), chiropractors have faced long-term stigmatization as a deviant group. Consequently, public knowledge of chiroprac-tic has been limited and the role of chiropractors in healing systems in Canada and North America has been treated with scepticism, apprehension and doubt. The President of the Canadian Chiropractic Association comments: "Chiropractors have to work much harder. People do not know what a chiropractor does even when they see him on television. Most chiropractic patients do not usually make a decision to visit a chiropractor themselves. The family or a friend qets tired of hearing about 'bad backs' or pain and asks them to visit a chiropractor." The perception of chiropractors as "medical outsiders" seeking recognition (The Vancouver Province, March 27, 1983) has been fostered, not only in popular culture but also by the way the public media reports about chiropractic. Quite often, the media in British Columbia continually reminds people about the plight of chiropractic and its struggles for social recognition and acceptance. The President of the Provincial Chiropractic Association puts it this way: - 36 -"When you call yourself a doctor, people think of Allopathy. In the minds of people, allopathy is the only healing group, all others are fake or guesswork. In spite of the work we have done in the last 15 years, people are s t i l l skeptical about us. Sure we've made some progress, but it doesn't help when allopaths tell them (patients) before they come to us that chiropractic is unscientific and not beneficial. We see people become fearful of condemnation from their peers, family or friends because they are seeing a chiropractor. Most patients do not want their family doctors to know they are receiving treatment from a chiropractor." The social constraint on chiropractic is further supported by clients' responses in this study. When asked to compare chiropractic with other professions, only 3% of new clients rate chiropractors high amongst health professions, and a few clients view chiropractic and physiotherapy as similar. It is well known that physiotherapy, as a paramedical occupation is dependent on allopathy for legitimation of its role, especially in health institutions such as hospitals. Only 11.7% of new clients think chiropractors are similar to their own family doctors once they have encountered chiropractic. 60% of new clients say it was difficult for them to "come to see a chiropractor" because "they don't know enough" about i t , because they are "scared", or because their family doctors discouraged them. The lower social prestige of chiropractors compared to that of allopathic physicians as well as the labels of marginality and deviancy conferred on chiro-practic by early writers contribute to the public's unfavourable view of chiropractic. To overcome social constraints, chiropractors need to re-orient the public at large through image-enhancing strategies which will put them in good stead socially, professionally and economically. - 37 -1.3.3 Economic Constraints Provincial regulations relating to payment for professional health care services by the government allows each citizen under sixty-five years of age to twelve visits a year to a chiropractor which may be paid for by the government. Persons over sixty-five years old are allowed fifteen visits a year. Thus, regardless of the nature of illness, a chiropractor must provide twelve treatments during twelve visits in order to be reimbursed from public funds under the provincial health insurance plan. Allopathic physicians are under no such constraint, as they may provide any number of treatments as long as a "medical condition" exists and the client continues to visit the clinic or hospital. Other healing groups with similar restrictions in the province are naturopaths and physiotherapists in private practice outside of hospitals. All chiropractors interviewed experience outstanding debts in their practices, yet none of them enforces debt-collection because of the possibility of "bad professional image". It seems, therefore, that chiropractors in British Columbia would be compelled to treat a large number of clients in order to maximize their incomes. A majority of chiropractors rent office space and employ receptionists or attendants. Much like the allopathic family doctor, the chiropractor must provide for those assisting him in his practice as well as earn enough overhead to make it worthwhile to remain in practice. Consequently, chiropractors in British Columbia extend their services beyond twelve allowable client visits in order to receive private reimbursement for services. The difficulty is that not - 38 -all clients will readily pay for services beyond the allowable twelve visits. One implication of state sponsored health insurance plan for citizens is that people get used to it and expect all of their medical expenses to be covered through public funds. For the chiropractor, income maximization beyond twelve client visits would mean some uncollected debts, and any effort to collect same would further alienate the clients. The chiropractor must, therefore, absorb some of these losses as well as keep up with image-enhancing strategies in order to attract new clientele. One example of economic constraint on chiropractors in British Columbia is that the state will pay lower fees to an orthopaedist whose patient has been referred to him by a chiropractor but a much higher fee if the patient has been referred by a family doctor. Thus, orthopaedic medical specialists would be encouraged to reroute their patients through family physicians if they are to maximize their claims under the provincial public health insurance scheme. 1.3.4 Self-imposed Constraints Some leaders of chiropractic in Canada and in British Columbia consider some constraints on chiropractic, "self-imposed" constraints. One chiropractor educator comments as follows: "Having been rejected or not wanting to be rejected again, chiropractors are shy of participating in policy making bodies". For example, chiropractors did not take part in discussions leading to universal health insurance plans in Canada and in Canadian provinces. Consequently, health insurance plans are silent on chiropractic and had to be negotiated - 39 -through bureaucratic channels. Chiropractic associations neither participated in nor presented briefs at the Hall Commission of Inquiry in 1982 which re-examined the Canadian health care system. For some leaders of chiropractic, "these are signs of lack of self-confidence" resulting from decades of marginality at the edges of organized allopathic medicine. It seems that many chiropractors are reluctant to explore avenues for ongoing relationships with allopathic physicians within the locale of their clinics. There are a few instances where some chiropractors have successfully established rapport with neighbourhood allopaths to the extent of engaging in cross-referral of patients (Kelner et a l . , 1980). Perhaps, many chiropractors have been reluctant to initiate such relationships with allopaths because they have come to view the adversarial relationship between the two professions as a major block to the establishment of individual relationships. Some of the gains chiropractors have made professionally and economically, for example, the inclusion of chiropractic in the provincial health insurance scheme, have been achieved in spite of opposition from allopathy. These gains tend to reflect the view that perhaps chiropractors feel that they can be more successful in lobbying the provincial government than in building lasting relationships with allopathy. By not participating in public discussions relating to the future of health services such as the Royal Commissions of Inquiry, and by not increasing its effort in encouraging individual relationships between allopaths and chiroprac-tors to enable cooperation in patient care, chiropractic in British Columbia - 40 -appears to have imposed a measure of self-constraint on its ability to improve public relations. 1.3.5 Constraints on Practice When asked about his views regarding the constraints chiropractors are faced with in their clinical practice, the President of the only chiropractic college in Canada commented as follows: "The hostility of medicine has not harmed chiropractors professionally in some ways. Rather, it has made chiropractic more cohesive, and more united against a common problem, but it hurts when it comes to what a chiropractor can do cl inically, how he diagnoses a problem, what he uses in doing so and his contacts in trying to help a sick person." One of the major constraints on chiropractic care is the inability of chiropractors to function as a primary care, first contact health care providers. Officially, chiropractic is seen as a "treatment modality" such as a massage, an amputation, or bed rest, rather than as a medical system with its own theory of disease and treatment rationale. Consequently, chiropractors are unable to take full advantage of procedures normally available to primary health care allopathic practitioners such as access to hospital X-rays, laboratory tests, and referrals to other specialists, without incurring economic and clinical penalties. Allopathic practitioners do not share X-ray or other pertinent patient-related information with chiropractors. Chiropractors do not have access to hospital medical records, and according to one chiropractic leader, "they cannot send clients to Worker's Compensation Board X-ray labora-- 41 -tories because radiology technicians will not assist them". The implication is that para-medical occupations such as radiographers and physiotherapists may not be free to act contrary to the wishes of organized medicine in their relationship with chiropractors. In British Columbia, chiropractors are legally limited to using 'only' their hands in treating clients. Unlike their counterparts in Ontario who may use different treatment modalities such as electrotherapy and mechanical devices, chiropractors in British Columbia may not treat client problems for which these modalities are indicated, although they have received training in their use. This limitation puts more pressure on a chiropractor in British Columbia than in Ontario to succeed in clinical practice. His range of treatment options and modalities is limited. Of necessity, he must find ways to compensate for this limitation, probably moreso than his counterpart in other Canadian provinces. The President of the Canadian training college for chiropractors puts it this way: "Chiropractic graduates have to work hard in terms of building up a network....al1 kinds of community services will tell you how to get patients, but will not tell you how to keep them. At the College we teach good clinical organization and practice development. Because every Canadian province is different regarding regulations on Chiropractic, we tell them to make the best use of the situation, especially what they've got or are allowed to do clinically (they) must know how to operate a business and get patients otherwise, unlike M.D.'s, they cannot do something else". Economic, social and political limitations on professional conduct and practice do not pertain only to chiropractors. All healing groups in bureau-- 42 -cratic societies contend with varying degrees of legal, social, political and economic limitations, moreso in societies such as British Columbia where, much as in other Canadian provinces, the state not only controls resources, but also is responsible for the health care of citizens. From time to time, the public is made aware of demands from allopathic physicians regarding the right to extra-bill patients beyond what they have negotiated with the provincial government under various public health insurance schemes. Recent fiscal restraint in the health care system in British Columbia has led to complaints from hospital-based allopaths that the quality of their work is being compromised. More importantly, the argument is generally made by leaders of the "official" medical association that reimbursement fees for their services are too low compared to other Canadian provinces. Although allopathy is the official medical system in the province, like other medical systems, it also contends with some constraints resulting from the nature of institutional, bureaucratic and political structures in place in the society, but not to the same extent as are faced by chiropractors in British Columbia. Naturopaths, although few in number compared to allopaths and chiroprac-tors, are also constrained in their work. Much like chiropractors, they are reimbursed for twelve visits a year per client by the state regardless of the nature of the health problem and the need to continue therapy beyond twelve visits. Like chiropractors, they must find ways to supplement their income by finding ways to increase the number of clients in need of naturopathic services. However, the fourteen naturopaths in the province are too few to command public attention. Moreover, it appears that they have not been the subject of vigorous - 43 -opposition from the dominant allopathic group of healers partly because their disease theory does not threaten the scientific rationale of biomedicine, and also because their numbers are too small to pose threats to allopathy. Chiropractors have more reasons for wanting to thrive, survive and succeed as a profession than either the offical medical system or any other "marginal" group of health care providers in British Columbia. From the beginning in its history, chiropractic has been opposed by allopathy (New Zealand Royal Commission 1979). Other rival groups to allopathy such as osteopathy have been absorbed over the years by allopathic professional organizations, especially in the United States. Also, some research studies seem to have, from the beginning, labelled chiropractic with deviant and marginal status, thus helping to foster negative social valuation in the minds of the public at large. In spite of recent studies which appear to support the professional status of chiropractic (Leis, 1971; Lin, 1972), the public at large continues to view chiropractic as a deviant or marginal occupational group (Appendix XIX). As the second largest healing group in the province of British Columbia, as well as in North America, chiropractic may be said to threaten the continuing domination of the health care arena by allopathy, especially now that governments are seeking ways to reduce the escalating cost of health care. In the first place, chiropractic may opt for cheaper ways to deliver care without the highly priced medical technology of modern hospitals. In the second place, the growing number of chiropractors in the province could result in large numbers of chiropractors competing with family [M.D.] doctors for the treatment of "minor" health complaints. Yet it appears that the effects of legal, polit ical , social and - 44 -economic constraints on chiropractic as well as vigorous opposition from organized medicine have not led to fewer persons seeking chiropractic services. Rather, recent evidence indicates that Canadians are not only going to chiropractors in increasing numbers, but they are also satisfied with the care they receive (Kelner et a l . , 1980). Since the late nineteenth century, no other healing group has been subject to such high levels of opposition and structural limitations in their work. Chiropractors have been "inferiorized" by state officialdom, while allopathy has been accorded far more respect and responsibility. Even so, the popularity of chiropractic has increased markedly. 1.4 Sociological Studies on Chiropractic It has been through the early works of Walter Wardwell that interest in the sociological study of chiropractic was introduced. In his original article, Wardwell (1952:340) adopted the concept of "marginality" which had been used previously to describe the marginal man or a person who was marginal to two cultures. However, Wardwell did not use the concept in that sense. For him it meant simply that the chiropractor's role, vis-a-vis allopathy, was marginal. He writes: "The role of the Chiropractor is structurally comparable to that of the Negro for it is marginal to the wel1-institutionalized role of the doctor." The importance of the concept for Wardwell was that it indicated a role that was imperfectly institutionalized, and therefore, created ambiguity over legitimate behaviour for those who occupied i t . Such roles usually resulted in personality - 45 -strain for the role occupant. The areas in which the chiropractic role is considered marginal include: the degree of technical competence which chiro-practors possess, the scope of practice, its legal status, the income of chiro-practors, and prestige. In all of these areas, the chiropractor is said to be inferior to the allopathic physician. In his first study, Wardwell focused on marginality and social structure. He dealt with the adjustment problems of the role player in his subsequent article (Wardwell, 1955). Wardwell (1963) moved from writing about the marginal role to the marginal profession and he presents a scheme for classifying health related practitioners as follows: ancilliary, limited medical practitioners, quasi-practitioners, and marginal practitioners. It can be argued that including chiropractic under any of these categories or even as "alternate practitioners" is problematic, since chiropractic has its own theory of health, disease and illness. Although ini t ia l ly , Wardwell (1972) characterized chiropractic as a limited, marginal, quasi-practitioner group, he later attempted to delineate the social factors which have allowed chiropractic to evolve as a separate, distinct, health care profession. He argues that critical factors in its survival and growth include charismatic leadership and a distinctive focus on spinal manipulation. One may, however, argue that there are few charismatic leaders of chiropractic beyond its founder, B.J. Palmer. It is doubtful whether chiropractic clients are aware of who B.J. Palmer was, or that they make their decision to seek chiropractic care on the basis of charismatic leadership rather than particular health concerns. Also, manipulation as a distinctive focus of - 46 -chiropractic treatment has not only been labelled "a lethal device" but also it has been subjected to a number of state-sponsored public enquiries (Lacroix, 1965; New Zealand Royal Commission on Chiropractic, 1979). It is doubtful, therefore, whether the success of chiropractic with its clientele, can be attributed to either its leadership or to its treatment methodology. McCorkle (1961) is the first sociologist to characterize chiropractic theory of health and illness as "deviant" theory, although he fails to state his reasons for such a characterization. A likely explanation for his characteriza-tion would be that chiropractic theory is "deviant" compared to the theory of the "official" allopathic theory of health and disease. In seeking to explain the survival of chiropractic, McCorkle attempts to establish an affinity between the rural culture of Iowa, the beliefs of chiropractic, and its development within Iowa. He maintains that chiropractic is especially wel1-designed to appeal to the thrifty, down-to-earth Iowan in that it offers to rapidly normalize a sick person, allowing him to go right back to work. This argument no longer holds in view of more recent findings that demonstrate the appeal of chiropractic to all levels of social, economic and political classes, including city dwellers (Gardner, 1975; Kelner et a l . , 1980; Coulter, 1984). Cowie and Roebuck (1975:4) draw from labelling theory in defining deviant "behaviour as behaviour that people so label" and proceed to isolate labelling bodies within the health care field in the United States. Statements are produced from five labelling bodies including a private interest group, which label chiropractic as deviant. They conclude that these statements illustrate - 47 -that chiropractors suffer a deviant or at least marginal role-identity in the United States. The study by Cowie and Roebuck is limited in the sense that generalizations cannot be made regarding chiropractors and chiropractic clinics because their study is limited to one clinic; but, as a descriptive study, it lays the foundation for future studies of chiropractic clinics. Some have argued, after Friedson (1970a) that the autonomy of a profession to be self-directive and self-regulative is the key to its success (Evans, 1973, 1975). In general, a profession should have control over its governance, be able to determine the features of its education and practice, and be able to self-regulate its members. It is this form of autonomy that has been regarded as important for full-fledged professionalization. The professionalization issue interests sociologists because chiropractic has elements of professionalism combined with elements of stigma. Leis (1971) and Lin (1972) have focused on chiropractic from the standpoint of professional-ization. Although neither researcher explicitly refers to the concept of "deviancy", that concept is implicit in their work. While Leis explores the extent to which chiropractic has struggled to acquire the characteristics of a profession, Lin argues that chiropractic has already acquired those characteristics. Mills and Larsen (1981) have found that a combination of characteristics contribute to the success of chiropractic. They have noted that the label "chiropractic" provides a unique identity compared to the identity of most healing occupations. The professional role of chiropractic is distinctive in - 48 -that the unique and contentious knowledge-base allows its practitioners to deliver a unique service. Moreover, Mills and Larsen note that chiropractors have gained occupational autonomy and have been given the right to self-regulation by provincial legislative acts. All of these characteristics have enabled chiropractic to provide a specialized service to clients and to the larger community, a service which would be otherwise unavailable. In their view, the result is the enhancement of professional status. Mills and Larsen note that the status of chiropractors appears to be rising in recent years (Blishen and McRoberts, 1976). Sternberg (1969) has provided a descriptive analysis of the socialization of chiropractic students. His analysis deals with how chiropractic students confront the stigma that some groups apply to the chiropractor and he notes that the chiropractic role is one of the few roles in society that is both profes-sional and stigmatized at the same time. Firman and Goldstein (1975:640-641) try to explain the appeal of chiroprac-tic by providing an analysis of its social functions. They argue as follows that: (a) chiropractic "fits well into the value system of the rural and poorer population" because, according to McCorkle (1961), chiropractors use a common sense approach to a single-cause theory of disease which is capable of being presented effectively by mechanical analogy: b) "Chiropractic features treatment modalities that are less time-consuming and expensive than those applied by physicians." In British Columbia, as in all of Canada, personal health expenditure for chiropractic treatment during the first - 49 -twelve visits to a chiropractic clinic is not a major factor due to the universal medical insurance scheme which covers about 98% of the citizens; (c) "The chiropractor functions to fu l f i l l a need by 'legitimizing' the sick status of patients with whom physicians can find nothing wrong." The authors do not provide evidence in support of this observation, but they note that a chiropractor may "fulfil l a patient's need by validating the patient's bel iefs. . . .by empathizing with the patient's idea how serious the condition is, and by impressing on the patient that the chiropractor will cure the disease by direct intervention"; (d) the chiropractor is successful because he succeeds "in treatment when other practitioners have failed". However, Firman and Goldstein are not certain whether this success is due to greater professional skill and knowledge, or more positive feeling engendered in the patient by the "illness orientation" of the chiropractor as opposed to the "disease orientation" of the allopathic physician, or to a placebo effect of the laying of hands (White and Skipper, 1971; Kane et a l . , 1974; Parsons, 1951a; Bloom, 1963). They note that "the practice of chiropractic is structured in such a way as to be considered along with many other techniques of 'persuasion' that have 'healing' as a goal"; (e) chiropractors offer alternative channels of therapeutic innovation such as manipulation and (f) that "they serve establishment medicine by providing an outlet for many potentially time-consuming and trouble-making patients". It has since been shown that clients simultaneously visit allopathic physicians and chiropractors (Kelner et a l . , 1980; Gardner, 1975). 78.4% of new chiropractic clients observed in clinics and interviewed in this study continued - 50 -to visit their allopathic physicians. It is doubtful whether the success of chiropractic can be explained simply on the basis of legitimation of the "sick role", or by chiropractic functioning as an outlet for "troublesome patients". Chiropractic is but one of many other healing groups in society. Other healing groups such as naturopathy and homeopathy among others have not been as successful as chiropractic in "making their clientele." They also may be said to function socially in the same manner Firman and Goldstein have attributed to chiropractic. Another explanation for the success of chiropractic with clients has been provided by Coulehan (1985). He argues that "specific 'clinical action1 is not a sufficient explanation for the success of chiropractic care. It is not even a necessary condition in individual cases because very often persons with aches and pains are not helped by manipulative technique but may benefit from clinical process..." (p.363). Rather, the attitude of the chiropractor and the immediacy of his therapeutic action are what is important in successful healing. Coulehan reasons that if a positive attitude or plan of action is helpful, then a negative or indifferent attitude is clearly harmful. The focus in his argument is that by projecting positive attitudes, chiropractors help their ailing clients. What remains to be explained is how the positive attitude is projected. What is it that the chiropractor does that helps to project a positive attitude? Is the projection of positive attitudes sufficient explana-tion for the success of chiropractic in clinical settings, considering the limitations and constraints chiropractors have faced in the historical develop-ment of the profession and in different social and political environments? - 51 -Coulehan (1985:353) finds that "the clinical art, as manifested in the chiropractor-patient interaction, contributes greatly to chiropractic healing. This process promotes patient acceptance and validation, fu l f i l l s expectations, provides explanations and engages the patient's commitment". Coulehan does not discuss how the patient is led to accept and validate chiropractic or how his expectations are fulfi l led or health problems explained. Rather he has based his reasoning on the works of Cowie and Roebuck (1975), and Luce (1978) among others in coming to the conclusion that "the attitude of the practitioner and the immediacy of his action are important in healing" (p.363). In Coulehan's view, chiropractic clinical interaction involves a scenario in which there is the acceptance and validation of the patients' illness problem; the fulfillment of his expectations by use of understandable explana-tions; the delivery of concrete clinical action; and the development of a plan which requires patients to commit themselves and to cooperate via frequent follow-up visits and telephone calls. Coulehan's views may partly hold in general terms, but they do not tell us how chiropractors and their patients reconcile individual "realities" of the clinical situation, especially the beliefs that each person holds about illness and its treatment, or how chiropractors overcome perceptions of deviancy in "convincing" new clients to become chiropractic patients. In another study, Parker and Tupling (1976:375) have speculated that "it is likely that a more complex interaction is occurring between the chiropractor and the patient than one which is restricted to a general concept of 'faith' in the therapist, and an 'expectation of therapeutic gain'". - 52 -Parker and Tupling (1976), like Coulehan (1985), do not describe how this "complex interaction" occurs. None of the sociological studies of recent knowledge including those discussed above examine the manner in which chiroprac-tors socialize new clients in trying to explain the success of chiropractic. One study, Cowie and Roebuck (1975) looked at one chiropractic clinic in an attempt to describe what chiropractors do. To generalize on the work of chiropractors from a study of one clinic in a specific social, political and economic environment would be, at best, rather inconclusive because chiroprac-tors face different professional and local obstacles in their work. This study adds to existing knowledge by examining the processual nature of successful chiropractic in a given locality. It does so by describing what goes on before and during individual interactions between new clients and chiropractors. It assumes that in order for chiropractors to be successful in the face of social, polit ical , economic and legal constraints, they must "convince" new clients to become patients of chiropractic. Individual chiro-practors, therefore, are assumed to act in ways that seek to overcome these constraints. In order to make a new client, it is assumed that a chiropractor tries to understand the "health beliefs" of the client and then attempts to negotiate some common ground for treatment and continuing utilization of chiropractic care. Unlike allopathic practitioners, chiropractors must promote their services for reasons discussed earlier. Unlike naturopaths and other healing groups, chiropractors face concerted opposition from allopathy. Particularly, in the province of British Columbia, chiropractors confront challenges and - 53 -problems which appear to place greater requirements on the need for socializing new clients than would be so even for chiropractors in other Canadian provinces (such as Ontario) where treatment modalities other than the use of hands are permitted. 1.5 Purpose of Study Broadly conceived, the purpose of this study is to contribute to existing knowledge regarding the "success" of chiropractic in British Columbia by describing how chiropractors in a particular political environment "convince" new clients to become their patients. Specifically, this study focuses on the nature of the relationship, or what Parker and Tupling (1976:374) have termed "the complex interaction" between a client and a chiropractor that enables the client to become a patient. "Successful socialization" of a new client is, therefore, considered to have been achieved when the client has continued in 20 chiropractic treatment for four or more visits to the chiropractor . In examining why chiropractors are successful with their clients, I argue that such factors as professionalism, charismatic leadership, and professional autonomy do not adequately account for the success of chiropractic in British Columbia, especially in the presence of the polit ical , economic, legal and social constraints on chiropractic care. I also argue, after Coulehan (1985), that specific clinical action as demonstrated by "manipulation" does not provide sufficient explanation for the success of chiropractic. These factors may, of course, contribute in various ways to the success of chiropractic, but client - 54 -satisfaction is achieved primarily in the relationship between individual chiropractors and their clients in clinical settings. These settings provide the key site for "socialization" of new clients, a process in which "persuasive interaction strategies" can be used to "negotiate" compliance to treatment. In these settings, all participants in the interaction exchange personal or professional beliefs and explanations for illness problems based on individual experiences, psychological profile, sociocultural factors, economic considera-tions, interpersonal relationships, and for chiropractors, professional culture and training. I argue that because of the relatively acute constraints on chiropractors in British Columbia, they, of necessity, develop "persuasive strategies", individually or collectively, for socializing sick persons who come to them for help. In other words, the fate of chiropractic, particularly in the one locality of the province of British Columbia, can be accounted for by examining and describing how individual chiropractors "convince" new clients to become their patients. Although client "socialization" often begins prior to the actual office contact, it is maximized during the clinical interaction between the chiropractor and the new client. It is during this encounter that treatment is "negotiated" in order to encourage continued utilization of chiropractic. Unlike any other healing group outside of the "official" allopathic group, chiropractors have more need to enhance their social image by devising different strategies for reorienting potential clients toward accepting chiropractic health care. - 55 -In recent years, a number of newspaper articles have commented on the restrictions chiropractors have faced in British Columbia. (The Vancouver Sun: Auqust 4, 1984, September 4, 1984, March 25, 1983, March 26, 1983; The Province: May 27, 1983, March 27, 1983). In one article captioned, "Chiropractors Want Fair Shake from MDs" (The Vancouver Sun, August 4, 1984), Nicole Parton, a popular consumer reporter observed that: (a) "Doctors who refer patients to chiropractors or who accept referrals from them face disciplinary action and fines. A 1972 resolution by the Canadian Medical Association concerning chiropractic and other forms of medical quackery also prevents doctors from passing patient information, laboratory results or X-rays." (b) The provincial "College of Physicians and Surgeons will not permit medical labs to release X-rays to chiropractors..." (c) "Hospital boards don't allow chiropractors to use hospital facilities or practice on hospital premises..." (d) "The College of Physicians and Surgeons bars its members from renting office space to chiropractors in buildings owned and occupied by medical doctors." (e) Until May 1984, when the provincial medical act was changed, "Chiropractors in the province were not legally allowed to call themselves 'doctors'." Regardless of these obstacles, persons with health problems have continued to seek help from chiropractors in increasing numbers. Consequently, chiroprac-tic has continued to experience growth in its ranks accompanied by increasing "official" acknowledgement of this healing group. Nowadays, chiropractic services are included in government sponsored insurance plans, and there is 19 legislative recognition of chiropractic in all but one Canadian province . Furthermore, two government commissions of inquiry that examined chiropractic - 56 -services, while not passing judgement on the merits of chiropractic theory of disease, found merit in the treatment of certain conditions by chiropractic methods. Over 75% of chiropractic patients reported that they were satisfied with treatments they received (New Zealand Royal Commission on Chiropractic, 1979; Lacroix, 1964; Kane et a l . , 1974; Kelner et a l . , 1980). What, therefore, accounts for the ability of chiropractors in British Columbia to satisfy their patients in spite of formidable restrictions? How do they interact with their clients in clinical settings so as to foster high levels of satisfaction? In short, how are chiropractic clients socialized towards becoming chiropractic patients? Figure 1 illustrates the conceptual relationships between a new client and a chiropractor prior to, during, and after both have interacted in clinical settings. The new client brings to the clinical setting his personally held "explanation" [Explanatory Model: EM] regarding the cause, course, reasons why a particular health problem has occurred, and the kind of treatment he should receive (Kleinman, 1980, 1976, 1974b; Kleinman et a l . , 1975, 1978). The "explanation" an individual holds for a particular health problem is based on characteristics such as psychological profile, sociocultural factors, past experiences with illness and treatment, economic adequacy, the social significance of the health problem, and relationships with family and friends. These factors provide an individual with a "health model" (HM) from which he derives the explanation for a specific or recent health problem (see Chanter 2). A Health Model [HM] is defined in this study as the general beliefs a person has about sickness and health care which exist prior to a given sickness THE RELATIONSHIP OF HEALTH AND EXPLANATORY MODELS OF CLIENTS AND CHIROPRACTORS FOR HEALING ACTIVITIES THE CLIENT HEALTH MODEL EXPLANATORY MODEL Individual Characteristics Psychological Profile Sociocultural Factors Past Experiences Economic Adequacy Health Problem Relationship with Friends and Family 1. Beliefs about: - Human Body and its Functions - Cause(s) of Illness Signs and Symptoms - Treatment Systems and Healers 2. Health Habits (For specific health prohlem) THE CLINICAL SETTING. (Negotiation of shared model) DROP OUT - Non-comoliance CN C i-S fD THE CHIROPRACTOR - Individual Characteristics - Psychological Profile - Sociocultural Factors - Past Experiences - Economic Adequacy - Health Problem - Professional Culture - Method of Healing HEALTH MODEL 1. Beliefs about: - Human Body and its Functions - Cause(s) of Illness - Treatment Systems and Healers 2. Health Habits EXPLANATORY MODEL (Professional and personal for specific health problem) PATIENT ROLE (Socialization complete) - Compliance - Increased , Uti1ization 3. .Professional Culture and Method of Treatment - 58 -episode. In this study, health model includes beliefs about the human body and how it functions, beliefs about causes of illness including signs and symptoms, and beliefs about treatment systems and healers including personal health habits. An Explanatory Model [EM] is the total understanding an individual has regarding the cause of a particular illness, its pathophysiology, the course it will take, and the assumed remedy (Kleinman, 1980, 1975; Kleinman et a l . , 1978). (For more discussion, see Chapter 2). Explanatory Models are derived from Health Models (Figure 1). Various factors can influence the extent to which an individual's explanatory model is a "true" reflection of his health model. For example, a person who believes in "natural" remedy for a particular illness episode may be "forced" to accept medication or surgery because of the prevailing orientation of the society at large and a general belief in "scientism", unless the person's EM is consistent with the EM of the physician. The acquisition of "medical" and related knowledge through education can mediate or change a person's HM, therefore leading to the alteration of his EM. The history of an illness such as the frequency with which the illness has occurred in a family over time can lead to the alteration of an EM. More importantly, the context in which a particular illness has occurred, influences the health and illness beliefs [HM] of an individual, and in turn, alter the explanation the person has for the reasons why the illness has occurred. For example, sudden and intermittent joint pains may be attributed to seasonal changes in weather conditions, especially i f pain - 59 -is experienced more often during cold weather following a hot spell (see Chapter 2 for more discussion). Generally, a chiropractor's health model is mediated by his professional training and culture, which in turn mediates the "explanation" (EM) he has for particular illness episodes. A new client's health model is mediated by his personal characteristics including past experiences, and social relationships which, in turn, mediate the explanation [EM] he has for his sickness. Both the new client and the chiropractor bring to the clinical setting their "explanatory models" [EMs] which become part of the definition of "clinical reality" (see Chapter 2). It is during interaction in the clinical setting that the chiropractor and the new client negotiate a "common understanding" or "shared explanatory model" which enables treatment and ongoing care, and it is during these clinical encounters that new chiropractic clients are "convinced" of and "socialized" towards accepting chiropractic care. Crucial to an understanding of this negotiative process is the fact that parties to this and any other negotiative process are rarely of equal strength so that the negotiative process is usually occurring in the context of asymmetrical power relationships which may be either overt and known to the parties or covert and veiled by hidden agendas. This is a crucial feature of negotiation and must be taken into account in trying to explain their outcomes. Also crucial to an understanding of the negotiative process in clinical interactive settings is how people, in general, behave in the course of their normal "life" activities, within which the interaction between a practitioner and a client is embedded. Goffman (1959, 1967, 1969) has made observations - 60 -about how people present themselves and interact in the course of their daily activities, in particular, the definition and structuring of situations. According to Goffman (1959), one way of creating an impression is through the use of specific techniques of interaction and "presentational" devices. In order to overcome the limitations that have constrained chiropractic care, chiropractors may use specific persuasive interaction structures and processes as well as presentational devices to "attract" and "impress" new clients. Of central importance in this study is how a new chiropractic client perceives his health problem, and whether his perception is consistent with that of the chiropractor. Because the decision has been made to seek chiropractic help, the new client has taken the first step towards interacting with chiropractic, and thus, is "open" to the acquisition of personal impressions about this type of healing. Central to the initial clinical interaction between the new client and the chiropractor are three factors, namely: the degree of prior knowlege the client has about chiropractic, what happens when he makes the first contact, especially with a medical system he knows l i t t l e about, and his beliefs, expectations and explanations regarding his present health problem. In conceptualizing the negotiation of health and explanatory models between a chiropractor and a new client, certain questions inevitably arise, such as whether clients and chiropractors have similar HMs and EMs, whether ethnic and cultural differences between the two groups affect the negotiation process, and whether changes in the negotiative process may be equated with changes in personal beliefs. Such questions are considered in the analysis of the study - 61 -data, bearing in mind, however, that the main thrust of the study is to identify commonalities in chiropractor responses to the problem of client socialization. This study, therefore, describes the socialization of persons who seek "help" for their health problems from chiropractic for the first time in the three municipalities of Vancouver, focusing on the processes by which they are converted from clients to patients. The following assumptions have been made: (a) that the health care of a society is a sociocultural system which comprises different medical systems; (b) that clients and healers have personal health habits and beliefs about health and illness from which they derive personal health models [HM]; (c) that clients and healers have individual explanations for specific illness episodes [EM] which are derived from individual health models; (d) that during the first encounter, clients and practitioners negotiate for common explanation and treatment for a particular illness complaint; (e) and that successful negotiations occur when clients adhere to suggested treatments for, at least, four visits to the cl inic . It is also assumed that client "socialization" begins earlier than the initial chiropractor-client encounter via different "presentational devices" and "office routines" that the client experiences just before his first encounter with the chiropractor. It is therefore argued that whether or not new clients will continue to receive chiropractic treatment for at least four visits to chiropractic clinics (a measure of "success"), will largely depend on their personal - 62 -impressions regarding the clinical settings, interactions with chiropractors, especially during initial visits, and how their health beliefs and explanations for their present health problems have been taken into consideration or satisfactorily negotiated to enable ongoing treatment. In this study, "socialization", broadly conceived, means the successful conversion of new clients from the statuses of potential patients to those of subscribing patients as determined by at least four visits to chiropractors. The process of negotiating explanatory models is considered a key aspect of the socialization process. Therefore, the successful negotiation of explanatory models is considered necessary for chiropractic treatments to occur, and is discussed in the context of Goffman's (1959, 1967) views regarding everyday behaviour and relationships. 1.6 Summary In this chapter, I have discussed the emergence of chiropractic as a visible feature of the Canadian health system. In doing so, I have character-ized its growth as the result of an increasing number of satisfied clientele who seek help from chiropractic for particular health problems. Chiropractors have more need than any other healing group in British Columbia to elevate their social valuation and to acquire new patients, given the opposition from allopathy as well as the polit ical , legal, social and economic limitations on chiropractic care. In British Columbia, public atten-tion has often been called by the media to issues and debates on chiropractic. - 63 -Unlike the situation in other Canadian provinces, chiropractors in British Columbia are limited to the use of hands in treatment. They have often gone to the courts to win certain rights, such as the right to call themselves "doctors". As the second largest healing group to allopathic [M.D.] physicians in British Columbia, chiropractors may be viewed as posing a threat to the domination of the health care system by the "official" medical system. I have argued that previous sociological explanations for the "success" of chiropractic are inadequate. These explanations fail to examine and describe "what goes on" during the interaction between a prospective patient and a chiropractor. I have also argued that in British Columbia, socialization of clients is dependent on the kinds of limitation chiropractic faces as a profession. Individual successes at client socialization depend on individual approaches to commonly held strategies - approaches which may have been devised because of constraints on chiropractic care. I have noted that beliefs individuals hold about health and illness [HM] are influenced by such factors as individual characteristics, psychological profile, sociocultural factors, past experiences, economic needs and relationships with family and friends, and for chiropractors, by professional culture and training. These beliefs help to provide explanations [EMs] for particular illness episodes, which may be altered because of the context in which the illness has occurred or is perceived. I have argued that the success of chiropractic in convincing new clients is determined by the ability of chiropractors to "convince" clients to continue in - 64 -treatment for at least four visits to the clinics via the successful negotiation of explanatory models that will enable treatments to occur, as well as via persuasive interaction strategies that are designed to convert new clients to become subscribing patients. This thesis is organized as follows: In Chapter 2, the sociocultural aspects of health care systems are discussed, in particular, Health and Explanatory Models. The notion of "clinical reality" is discussed in relation to its importance in practitioner-client interactions. In Chapter 3, practitioner-client interactions are discussed as well as socialization via negotiation. The method of study is presented in Chapter 4. Interview data are presented in Chapter 5. Observational data for modifying client perceptions and negotiation of Explanatory models are described in Chapters 6 and 7. Study results are analysed in Chapter 8 along with suggestions for future studies and for policy innovations in the sociology of health care. - 65 -NOTES Chiropractic has been defined variously as an art, a science, or both. It is "that branch of the healing arts concerned with the restoration and maintenance of health by the adjustment of the articulations and related structures of the body, more especially the spinal column, and is involved primarily with the relationship of the spinal column to the nervous system " Board of Directors: The British Columbia Chiropractic Association (1978:4). It has also been defined as "the science which concerns itself with the relationship between structure, primarily the spine, and function, primarily the nervous system, of the human body as that relationship may affect the restoration and preservation of health". British Columbia Chiropractic Association (Undated:6). Chiropractic has also been defined as "that science and art which utilizes the inherent recuperative powers of the body, and deals with the relationship between the nervous system and the spinal column, including its immediate articulations, and the role of this relation-ship in the maintenance of health". Palmer College of Chiropractic (1978:25). In this study, the word "Chiropractic" has been used both as an adjective and as a noun. The usage is consistent with its use in the literature on chiropractic as well as its use by chiropractors themselves. Chiropractors are faced with different limitations to their clinical practice in different environments. In the United States, chiropractors are licensed in forty-five states and they face different state regula-tions as they compete with "official" allopathic physicians for clients within the free-market system. In Canada, there is no uniform regulation for the practice of chiropractic. Provincial laws differ considerably and what is legal in the Province of Ontario may not be legal in the Province of British Columbia. The Province of British Columbia has the strictest laws regulating chiropractic. For example, while a chiroprac-tor in Ontario may use electrical and mechanical devices in treatment, a chiropractor in British Columbia is allowed to use his hands only in treatment. Therefore, differences in provincial regulations on chiro-practic treatment therefore necessitate the development of local strategies for client socialization. During the course of this study, especially during the twenty-two months of field observation, sixteen headlines and six full-length articles on issues related to chiropractic appeared in the two daily newspapers in Vancouver in addition to radio and television features. - 66 -The first points of contact by clients in the Canadian health care system are considered "Portals of Entry" into the system. These are primary health care providers who are in first contact with clients prior to referrals to specialists or secondary care providers. Initial Portals of Entry practitioners include family doctors, and chiropractors, among others (see Soderstrom, L . , 1978:4). Primary health care in Canada comprises health care services that are provided outside of health care institutions, such as hospitals, by health care providers. Officially, primary health care includes everything that the family doctor does in treating individuals' health problems in the community. Sociologically, primary health care would include the totality of all that every healer, such as family doctors, shamans, chiropractors and other individuals do in a given society in order to alleviate the social burden of illness. Osteopathy is treatment that is aimed at correcting supposed deformation of skeleton as a cause of many diseases. Skeletal deformations are thought to impede circulation. There are no schools of osteopathy in Canada. Unlike in the United States, where osteopathy has its own hospitals and collaborative clinical practices with "official" [M.D.] medicine, osteopathy in Canada is marginal and declining in numbers. New osteopathic physicians are not being licensed in Canada anymore. It is possible that by the end of this century, osteopathy, as a medical specialty in Canada, will have ceased to exist when the few remaining osteopaths are no longer able to practice. Allopathy is treatment of disease by inducing an opposite condition to that disease. For example, in a case of high body temperature, a drug may be administered to lower the temperature. Chiropractors generally refer to conventional physicians [M.Ds] as allopaths or allopathic physicians and to themselves, usually sometimes as chiropractors or as chiropractic physicians. These figures do not reflect the number of persons who have visited or will visit chiropractors in 1983 and 1985 respectively. Accordinq to published reports (THE VANCOUVER SUN, March 27, 1983), the total number of treatments by chiropractors in British Columbia include repeat visits by regular patients for any number of occasions. Chiropractic has variously been described as a "marginal", "quasi", or "deviant" profession compared to the more established medical [M.D.] profession. More recently, several authors have concluded that chiropractic has attained the full status of profession. See for example: Leis (1971); Lin (1972); and Mills and Larsen (1981). - 67 -10. The notion of social reality is based on the work of Peter Berger and Thomas Luckmann (1967) which itself is conceptually related to the work of Alfred Schutz (1970). Eliot Freidson (1970a) is most responsible for transposing the "social reality" concept to the health care field. 11. There are three different sectors in which healing activities occur in society, namely: the popular, the folk, and the professional sectors (Kleinman, 1980; Chrisman and Kleinman, 1980). The popular sector consists of diagnosis and care by sick persons themselves. The shared meanings of illness within this sector has been called "popular health care culture" by Polgar (1962:46). In the popular sector, illness is first perceived and labeled, treatment applied, and most sickness episodes receive care. Individual and collective beliefs about sickness result in the use of a variety of remedies such as herbs, diet, exercises, humidifiers and blankets, as well as off-the-counter patent medicines. Folk medicine is a mixture of many different components, some of which are closely related to popular and folk sectors of healing activities. It includes non-professional, non-bureaucratic, and often quasi-legal or sometimes illegal forms of health care which are based on various folk health cultures. Very often, these folk cultures shade imperceptibly into professional practice on the one side, and popular care on the other side. Examples of folk medicine are shamanism, herbalism, traditional surgical and manipulative treatments, special exercice systems such as yoga for health, and symbolic non-sacred healing activities. 12. Homeopathy is the treatment of disease using drugs that would, in a healthy person, produce symptoms like those of the disease. 13. The dichotomy between two aspects of sickness are disease and illness. Kleinman (1980:72-73) has defined disease as "a malfunctioning of biological and/or psychological processes". It affects single indivi-duals even when whole populations are attacked, unlike illness which most often affects others such as family members, and social networks. Illness is "the psychosocial experience and meaning of perceived disease...(including) secondary personal and social responses to a primary malfunctioning (disease) in the individual's physiological or psychological status (or both)". It is the experience of disease and suffering and involves "attention, perception, affective response, cognition, and valuation directed at the disease and its manifestations" such as symptoms and role impairment. Illness, therefore, is created by personal, social and cultural reactions to disease. The construction of - 68 -illness from disease has been called "a central function of health care systems (a coping function) at the first stage of healing (Kleinman, 1980:72). Disease and illness are explanatory concepts and not entities. Kleinman (1980:73) has observed that disease and illness exist as "constructs in particular configurations of social reality" and "can only be understood within defined contexts of meaning and social relationships". It is our explanatory models [EMs] which enable us "to identify, assemble and interpret the clinical evidence that confirms the relationships". Kleinman et al . (1978:251) have commented that "modern physicians diagnose and treat diseases (abnormalities in the structure and function of body organs and systems) whereas patients suffer illnesses (experiences of disvalued changes in states of being and in social function) the human experience of sickness...illness may occur in the absence of disease". 14. The terminologies "organized medicine", "official medicine", and "allopathic medicine" are used interchangeably to refer to the dominant group of healers [M.Ds] in the Western world whose members and organi-zations have been granted greater state sponsorship via legislation than members of any other group of healers. The group is organized in two separate units: One unit, the College of Physicians and Surgeons, is responsible for regulatory control of members through such activities as monitoring infringements relating to the Medical Act, licensing and discipline of members, as well as introduction of new regulations on practice. It is an autonomous boyd with delegated powers from the state. The second unit, such as local medical associa-tions, function more or less as labour unions for members. It negotiates reimbursement fees with provincial governments for services provided by members. Both units are strongly opposed to chiropractic in British Columbia as elsewhere in Canada. The terminology "official medicine" is used to denote the group of health care providers that is most favoured by the state through licensing, control and regulatory laws in matters affecting health and the treatment of disease. 15. Chiropractors in the Province of Ontario have greater freedom in their choice of treatment techiques and methods. Like hospital-based physiotherapists, they are allowed to use a variety of hospital-oriented treatment techniques such as electrical stimulation of muscles, traction devices, ultraviolet radiation, and so forth. Physiotherapists and chiropractors come under the same Provincial Act, and are similarly regulated. Chiropractors in Ontario have a much wider range of treatment options to use and they are not as constrained, in this regard, as their colleagues in the Province of British Columbia. - 69 -16. The physician in question had ini t ia l ly trained as a chiropractor prior to his medical education as an allopath. He has been involved on both sides of the debate. The provincial medical association has been cautious in dealing with him. On the other hand, the provincial Chiropractic Association is pleased to have him as an ally but also very cautious of his role. Disapproval from the College of Physicians and Surgeons in permitting him joint clinical practice with a chiropractor, but approval in allowing him to collaborate in such a venture with the allopathic wife of another chiropractor led one leader of chiropractic in the province to comment: "In British Columbia, a chiropractor is not allowed to establish joint practice with a medical doctor, but he can marry one". 17. The Canadian Memorial Chiropractic College [CMCC] in Toronto is the only training institution for chiropractors in Canada. There are half a dozen chiropractic schools in the United States. 75% of chiropractors in this study received their training at CMCC and 15% in U.S. colleges. 18. Freidson (1970b:48) defines "paramedical occupations" as "occupations organized around the work of healing which are ultimately controlled by physicians". Physiotherapy and nursing are examples of hospital-based para-medical occupations. 19. The Province of Nova Scotia has yet to legislate a chiropractic act or provide official recognition of chiropractic as a form of health care. 20. The criterion of four visits were determined on the basis of information from two chiropractors in the study area. They noted that new clients who wish to discontinue chiropractic treatments usually do so after the f irst , and no later than the second visit to their clinics, and that patients who continue treatment do so beyond the second visit . Therefore, it was assumed that a much higher number of visits, in this case, four visits, wil be used to ensure that new clients who will be dropping out of the relationship, have done so. - 70 -CHAPTER 2 2.0 S0CI0CULTURAL CONTEXT OF HEALING ACTIVITIES Sociological research has shown that the medical culture of patients and their families, including their medical understandings, theories and values, affect their evaluation, experience and method for expressing symptoms (Mechanic, 1972), their pattern of help-seeking (Chrisman, 1977; Lin et al , 1978; Mechanic, 1978), and their evaluation of the outcome of the treatment they receive for their suffering (Kleinman, 1980). A likely critical factor in assessing the social and cultural affects on an ill-person appear to be the meaning a symptom has for the individual and the "idiom" or language in which distress is experienced and communicated. Interpretive sociology involves conscious translation across meaning systems to arrive at understanding of the realities of others. For example, a new, "ethnic" chiropractic client living in Canada would draw the meaning of his illness from his ethnic background, merge it with the prevailing Canadian culture in terms of the meaning that is socially accepted for that particular problem, in coming to terms with what he should or should not convey to the chiropractor. Similarly, the chiropractor would, in order to successfully socialize the new client, understand the client's predicament and resolve his own response in relation to his own therapeutic beliefs. Thus, an interpretive approach to clinical practice is not a reflection of causal products of somatic and physical processes but a reflection of meaningful human realities. Healing, - 71 -therefore, is viewed as transaction across meaning systems which results in the construction of socioculturally specific illness realities and a treatment effort to transform these realities. Kleinman (1980:41) has coined the term "clinical reality" to designate the socially constructed contexts that influence illness and clinical care. His argument is that health care systems are not only socially and culturally constructed systems, but they are also forms of social reality. According to Kleinman (1980:35): "Social reality signifies the world of human interactions existing outside the individual and between individuals. It is the trans-actional world in which everyday l i fe is enacted, in which social roles are defined and performed and in which people negotiate with each other in established social relationships under a system of cultural rules." Viewed in this way, social reality is constituted from, and in turn, is part of the meanings and relationships between people and institutions. Social reality is absorbed and internalized by an individual as part of a system of symbolic meanings, norms and values which govern his behaviour, his view of the world, his communication with others and his understanding of the environment in which he finds himself. Thus, a person undergoes a process of socialization, not only within his family and among his friends, but also within other social groupings. There is a "bridging reality" that links social and cultural worlds with biological and psychological reality. Kleinman (1980:41-42) has referred to this bridging link as "symbolic reality". "Symbolic reality" is formed when an - 72 -individual acquires language and systems of meaning during the course of his l i fe . Although socialization through language acquisition and symbolic systems enables an individual to respond behaviorally to interpersonal relationships and to social institutions, the internalization of symbolic reality (Mead, 1934) also plays a key role in orienting the individual to his own inner world (Berger, 1973; Cicourel, 1973). In other words, symbolic reality helps an individual to make sense of his inner experience, especially in shaping his identity in accordance with sociocultural norms. Thus, basic psychological processes, such as state of consciousness, attention, cognition, motivation, memory and perception are influenced by symbolic meanings. Kleinman (1980) observes that clinical reality is mediated by symbolic reality, and that as much as language can be thought of as a cultural system linking thought and action, medical symbolic systems can be considered cultural systems linking illness and treatment. The two cultural systems are forms of symbolic reality. Both are situated in social roles, relationships, and cultural beliefs, as well as in individual experience and behaviour. A person who seeks help from a particular medical institution will have to contend with the clinical reality of that system. A new chiropractic client, therefore, brings to the clinical setting, not only his illness problem or the psychobiological reality underpinning his illness, but also his system of meaning or the symbolic reality which mediates his sickness and care. These realities then encounter the "reality" of chiropractic care or the social, structural and cultural contexts in which chiropractors offer help to sick persons. - 73 -I have argued, in Chapter 1, that several factors influence a person's health beliefs as well as his explanation regarding why a particular illness has occurred and the type of treatment that he expects (Figure 1). I have also argued that the "success" of chiropractic in converting new clients to patients can be understood by examining how chiropractors and new clients reconcile their health beliefs and explanations for specific illness problems. In this chapter, the concepts of health and explanatory models are elaborated upon and discussed. In order to understand, more fully, the nature of the relationship between healer and client, the institution of medicine is also discussed, especially how its organization relates to the experience of patients and to the relationships between healing groups. 2.1 HEALTH MODEL [H.M.] Health Model, is defined in Chapter 1 to mean the general beliefs a person has about sickness and health care which exist prior to a given sickness episode. A health model is specific for an individual and several factors which influence it were identified in Figure 1. These factors are discussed in the context of the beliefs individuals hold about health, illness and treatment systems. In this study, the Health Model is defined to include health habits, beliefs about the human body and its functions, beliefs about the causes of illness and disease including signs and symptoms, and beliefs about treatment systems and healers. One often hears the statement "A person lives what he - 74 -preaches". In other words, i f a person holds certain beliefs about good health care, he will be expected to demonstrate these beliefs through his health habits. A person who believes cigarette smoking is dangerous to good health is not expected to smoke cigarettes. Moreover, a person may develop personal explanations about why a particular health problem has occurred by organizing his health and illness beliefs in a way that makes sense to him. His health model acts as reference points in his search regarding why the problem has occurred, its cause and outcome, and the type of remedy he feels he should receive. Individual and psychological characteristics and the way a person thinks of his health and his personal beliefs about l ife and living influence his health and illness beliefs. People have opinions on a number of things that go on in l i fe , from politics to food additives and lifestyle. According to Becker (1974), a person's ideological stance contributes to whether or not he will comply with a particular form of treatment. Similarly, it has been shown that psychological characteristics, namely, characteristics that are not personality traits but rather characteristics which relate more to the way people think and what they believe, have some relationship to whether or not they will comply with recommended treatment (Rosenstock, 1974; Becker, 1974; Becker et a l . , 1979). For example, it has been found that patients who do not cooperate with their medical treatment believe themselves to be less susceptible to and less threatened by their illness or possible future illness (Becker et a l . , 1979). To these people, the physician's assessment of the danger of their illness does not matter very much. Rather, to them, it is their own perception of the severity of the illness that is important. - 75 -Social and cultural factors influence views about health and illness and about the type of treatment that is acceptable. For example, Davitz and his colleagues (1976) have shown that cultural factors have an enormous influence upon people's interpretation of symptoms and their responses to these symptoms. Moreover, anthropological work has shown that conceptions of illness in any culture are part of a learned cultural complex and that responses to symptoms are culturally conditioned as are responses to any other environmental threat (Clark, 1970; Saunders, 1954). In comparing Anglo- and Spanish-speaking cultures, these authors find that the "Anglos" tend to prefer medical sciences and hospitalization for dealing with illness, while many Mexican-Americans tend to rely more heavily upon folk medicine and family care as important aspects of treatment. It has been shown that to many Mexican-Americans, illness relates to their l i fe , to their community, and to their family and interpersonal relation-ships (Kiev, 1968). Furthermore, Mexican-Americans traditionally believe that illness exists only when there is pain or visible symptoms (Clark, 1970). Zola (1966) and Zborowski (1958) suggest that among certain Caucasian ethnic groups, the complaint of pain may be used to communicate personal and interpersonal distress in a culturally acceptable way. Zola has found that illness behaviours can influence how health care professionals evaluate the medical conditions of patients. In his study of patients who voluntarily went to the ear, nose, and throat clinics for symptoms for which no medical disease could be found, Zola found that the modes of cultural expression by the patient strongly influenced the way in which they expressed the symptoms, which in turn, strongly influenced the physicians' decision about their care. In other words, - 76 -patients' usual methods for expressing symptoms affect how they are viewed and evaluated by the physician, especially i f the methods of expression are primarily culturally based. In a study about how people respond to pain, Zborowski (1952) found that Jewish and Italian patients tended to exaggerate pain experiences by responding in an emotional manner, while patients of English or Irish descent were inclined to be more stoical and to deny pain. While the outward expressions of Jewish and Italian patients were usually similarly emotional, there was a difference in the meaning of pain to patients in these two ethnic groups. The Jewish patients were concerned with the cause of pain and its future significance, whereas the Italian patients tended to seek relief from the pain and were satisfied when they felt better regardless of future consequences (Zborowski, 1952). How pain is described is influenced by a number of other factors including language faci l i ty , familiarity with medical terms, individual experiences of pain, and lay beliefs about the structure and function of the body (Helman 1984). Once a person has made public his pain, there exists an implied social relationship of some duration between the sufferer and another person or persons. The nature of this relationship will determine whether the pain is revealed in the first place, how it is revealed, and the nature of response to i t . As Lewis (1981:153) has noted, the expectations of the sufferer are important here, particularly the likely response to his pain and the social costs and benefits of revealing i t . "Possibilities of care, of sympathy, the allocation of responsibl ity for sickness in others, affect how people show their illness". People will receive maximum attention and sympathy if their pain - 77 -behaviour matches the views of the society regarding how people in pain should draw attention to their suffering, whether by an extravagant display of emotions or by a quiet change in behaviour. As Zola (1966:622) puts i t , "It is the ' f i t ' of certain signs with a society's major values which accounts for the degree of attention they receive". Therefore, there is a certain kind of dynamic process between the individual and society whereby illness and pain behaviours as well as reactions to them influence each other over time or lead to help-seeking. Therefore, the ways in which people perceive, evaluate, and act upon their symptoms depend to a great extent upon their cultural and social backgrounds as well as early experiences. Very often, the presence of a particular health problem will limit that ability of an individual to fu l f i l l his social role. For example, an active player of the game of tennis will be prevented from undertaking this social activity with his friends if he has a nagging backache. Consequently, his main focus in treatment may concentrate on the relief of pain to enable him to meet his social obligation even when there could exist a more serious underlying health problem such as generalized rheumatoid arthritis. Similarly, in the United States where there is no universal health insurance for all citizens, a worker whose monthly earnings barely cover the expenses required for basic necessities is unlikely to readily define a symptom as needing medical attention or warranting a day off from work with the resultant loss of a day's pay. In this case, the decision about the seriousness of the symptom is made in the context of the resources of the individual or the entire family. - 78 -In many cultures, including the western culture to a lesser degree, the family is frequently involved in labeling and treatment of an illness. An i l l person may seek advice from a family member or vice versa. Martin (1981) has pointed out that in native American healing, the patient's sickness places a responsibility on both patient and family to participate in healing rites. The focus of attention is not only on the patient, as in Western medicine, but also the reaction of the family and others to the illness. Also, responses to childhood illnesses may influence a person's experience as an adult in ways which, over time, may lead him to favour specific types of remedies. Kleinman (1980) has noted that unpleasant emotional states such as depression, or the experience of social stresses, is often expressed in the form of physical symptoms. Kleinman refers to this observation as "somatization" (p.138). His studies in Taiwan led him to observe that because mental illness is heavily stigmatized, depression is often presented in the form of physical symptoms. Finally, the professional training, culture and healing activities of a healer influence his beliefs about health and illness and the kind of treatment that he will favour. 2.1.1 Conceptions of the Structure and Function of the Human Body In general, the beliefs people have about the structure and function of the human body, the causes, signs and symptoms of illnesses, professional healers and treatment systems as well as the health habits they observe, are therefore - 79 -derived from sociocultural factors, past experiences with illnesses, the influence of peers, family and friends as well as other l i fe events that may have contributed in shaping these beliefs (Figure 1). THe belief a person has about the structure, function and the inside of the body can influence his perception and presentation of bodily complaints as well as his response to treatment (Helman, 1984). Waddell and his colleagues (1980) have shown that the manner in which a person views his body may affect the clinical labeling of his condition, especially when physicians are considering non-organic and psychogenic signs and symptoms. The healthy working of the body is thought, by some people, to depend on the harmonious balance between two or more forces or elements within the body. To some extent, the balance is dependent upon external influences such as diet or supernatural agents as well as internal forces such as inherited weakness or state of mind. According to Ayurvedic medicine (Kleinman et a l . , 1974), the body contains four liquids or humours: blood, phlegm, yellow bile and black bile. Health is a result of the four humours being in optimal proportion to one another. Ill-health, therefore, results from an excess or deficiency of one of them. Diet and environment can affect this balance as can the seasons of the year. Treatment of the imbalance or disease consists of the restoration of optimal proportion of the humours by removing excess via bleeding, purging, vomiting or starvation, or by replacing the deficiency via special diets and medicines (Kleinman et al , 1975). - 80 -In the "plumbing-model" of body function (Boyle, 1970), the body is conceived of as a series of hollow cavities or chambers, connected with one another, and with the body's orifices, by a series of "pipes" or "tubes". The major cavities are usually the chest and the stomach which almost completely f i l l the thoracic and abdominal cavities respectively. The plumbing model deals mainly with the respiratory, cardiovascular, gastro-intestinal, and genito-urinary functions of the body and does not necessarily pertain to all aspects of anatomy and physiology of the body. It is usually a series of metaphors that are used to explain the function of the body. Very often, different physiologic systems are lumped together. One often hears the expression: "I always swallow a bit to loosen the cough". (Helman, 1978). From the point of view of scientific biomedicine, swallowing goes to the stomach and coughing relates to the chest. Sometimes the plumbing model is used to express emotional states, especially lay notions of "stress" or "pressure" via expressions such as: "I blew my top" "I have to let off some steam". The function of the body is also conceptualized as an internal combustion engine, or as a battery-driven engine. These machine or engine metaphors are often reinforced by doctors and nurses. It is common to hear a doctor or a nurse say to a patient: "Your right chamber is not pumping well", or "You have had a nervous breakdown". Central to the notion of the body as a machine is the idea of a renewable "fuel" or "battery-power" needed to provide energy for the smooth working of the body. Such "fuels" include different food-stuffs or beverages such as tea, coffee and vitamins. Alcohol may also be viewed as - 81 -"fuel". One often hears of the comment: "I need to rest because my batteries need recharging". The concept of the body as machine implies that individual parts of the body, like parts of an automobile, may "fail" or stop working and can sometimes be repaired or replaced. Recently accomplished heart and kidney transplants tend to reinforce this notion. 2.1.2 Lay Theories of Illness Causation Helman (1984) has identified four categories in which lay people locate the cause of i l l-health. These are: the individual person; the natural world; the social world; and the supernatural world. Helman observes that people in non-western societies tend to ascribe the causes of their health problems to social and supernatural causes. Person-centred lay theories generally locate the cause of illness within the individual. Sometimes the theories are about malfunctions within the body, changes in behaviour or dietary habits. Ill-health may be blamed on wrong diet, hygiene, life-style, social relationships, smoking, drinking habits, and physical exercise. Other causes of ill-health may be attributed to stigmatized personal conditions such as obesity, alcoholism, and venereal disease. Other lay causes of illness may include: hereditary proneness or the genetic transmission of a particular illness; degeneration in the structure and function of body tissues or organs such as occur in the aging process; invasion in which illness is due to either external invasion by a germ or other object, or internal spread from existing problems such as cancer; imbalance or a state - 82 -of disequilibrium, excess or depletion of, say, vitamins or blood; mechanical disorder such as abnormal functioning of organs or circulatory system; damage to parts of body; blockage of organ or vessels, and pressure in organs or particular parts of the body. In many non-Western societies, the most common causes of ill-health are located in the social world. The usual forms are witchcraft and sorcery. In all of these causes, illness and other forms of suffering and misfortune are ascribed to interpersonal malevolence, whether conscious or unconscious (Foster and Anderson, 1980). It is from the beliefs people hold about the functions of the human body, the causes, signs and symptoms of illness, treatment systems and professional healers as well as health habits that Health Models are derived. Health Models [HMs], in turn, give rise to the explanations people have about a particular illness (Fig.l) . 2.2 Explanatory Model [EM] Explanatory model pertains to a specific illness episode which is set in the context of the person's health model [HM]. In response to the miscommunications caused by the different professional and lay cultures as well as to the crucial psychological and social influences on sickness and care, Kleinman (1980) has suggested a useful way for examining the process by which illness is patterned, interpreted, and treated. Kleinman has termed this perspective "Explanatory Model" [EM] which he has defined as "the notions about an episode of sickness and its treatment that are employed by - 83 -all those engaged in the clinical process" (p.105). The explanatory model, therefore, contains a sick person's understanding of the cause of his illness, its pathophysiology, expected course and prognosis, and the treatment that he believes will be or should be administered. Kleinman (1980), based his notion of explanatory model on the following considerations: (a) That the institution of medicine is a social institution of which the manner of its organization has important influences on medical care and the experiences of clients and patients (see Section 2.3 for more detailed discussion). (b) That clinical practice occurs in and creates particular social worlds in which beliefs about sickness, the behaviours exhibited by sick persons, including their treatment expectations, and the ways in which sick persons are responded to by family and healers are all aspects of social reality. These, like the institution of medicine itself, are social and cultural constructions which are shaped distinctly in different social structural settings. (c) That each sector of the health care system (see Note 11, Chapter 1), or each healing profession, creates its own clinical reality. Kleinman (1980:52) comments: "Once people decide to enter the professional or folk sector, they encounter different beliefs and values in the cognitive structures of professional or folk practitioners. They make these encounters in the process of entering or exiting from healing agenices. The clinical realities of the different sectors and their components differ considerably." - 84 -(d) That there is a distinction between disease and illness. In the Western medical paradigm, disease is the malfunctioning or maladaptation of biologic and psychophysiologic processes in the individual whereas illness represents personal, interpersonal and sociocultural reactions to disease or discomfort. In other words, "illness is shaped by sociocultural factors governing perception, labeling, explanation, and valuation of the discomforting experience" (Kleinman et a l . , 1978:252). (e) That conflicting interpretations of clinical reality are partly the result of the social and cultural organization of medical institutions and partly due to discrepancies between the health beliefs and values held by members of different professions and sectors of health care. (f) That beliefs about illness are closely tied to beliefs about treatment. (g) That individuals are in contact with different belief and normative systems as they move from one sector of health care or one profession to the other. As they move between distinct clinical realities of health care they carry with them their own cognitive and value orientations and also encounter other cognitive and value frameworks. Contact with another system of meanings and norms may mean simply a shift between conceptual frameworks and behavioural styles via the process of "negotiation". Thus, contact with a different conceptual framework entails conflict between divergent orientations. Kleinman (1980:105) notes that EMs are held by both patients and practitioners. The EM of a practitioner tells us something about "how the practitioners understand and treat sickness". The study of patient and family EMs "tells us how they make sense of given episodes of illness and how they - 85 -choose and evaluate particular treatments" (p.105). EMs, therefore, "offer explanations of sickness and treatment to guide choices among available therapies and therapists and to cast personal and social meaning on the experience of sickness". Belief in holistic treatment for health problems might lead to the choice of holistic care from a holistic practitioner. Belief in scientific medicine might lead to the choice of modern allopathic care from allopathic physicians. An Explanatory Model, therefore, is a person's understanding of (a) the cause of his illness, (b) the timing and mode of the onset of symptoms, (c) the pathophysiological processes involved, (d) the natural history and severity of the illness, and (e) the appropriate treatment for the condition. EMs provide explanations for these five aspects of illness and they are marshalled in response to a particular illness episode and are not identical to the wider beliefs about illness that are held by society in general or by the individual, his [HM] in particular (Kleinman, 1980). Since EMs draw from the belief systems of the individual and the society, and are employed to cope with a specific health problem, Kleinman (1980) suggests that they need to be studied in clinical settings in order to analyse them more precisely. Client EMs are also influenced not only by "popular culture" EM, but also by the family EM. On the other hand, chiropractor EM may be influenced primari-ly by the professional EM which has a theoretical base. Client EMs tend to be idiosyncratic and changeable, and to be heavily influenced by both personality and cultural factors. They are partly conscious and partly outside of - 86 -awareness, and are characterized by "vagueness, multiplicity of meanings, frequent changes, and lack of sharp boundaries between ideas and experience" (Kleinman, 1980:107). By contrast, practitioner EMs which are also marshalled to deal with a particular illness episode, are "mostly based on single causal trains of scientific logic", and I would also add, work constraints, economic constraints and individual experiences, thus extending Kleinman's view. Clinical consultations and practitioner-client interactions are actually transactions between client and practitioner EMs. Explanatory models, therefore, are used by individuals to explain, organize, and manage particular episodes of impaired well-being, and can only be understood by examining the specific circumstances in which they are employed. One way of looking at this process according to Kleinman (1980), is to examine the sort of questions that people ask themselves when they perceive themselves to be i l l . These are: (a) What has happened? - which includes organizing the signs and symptoms into a recognizable pattern, and giving it a name or identity, (b) Why has it happened? - explaining the cause of the condition, (c) Why has it happened to me? - trying to relate the illness to aspects of the client or patient such as behaviour, diet, body-build, social and supernatural factors, personality or heredity, (d) Why now? - relating to the timing of the illness and its mode of onset, whether sudden or slow, (e) What would happen if nothing were done about it? - it's likely course, outcome, prognosis and dangers, and (f) What should I do about it? - strategies for treating the condition, including self-medication, consultation with friends and family, or going to seek help from a particular healing orientation or healer. - 87 -A person suffering from a "head-cold" might answer the questions as follows: "I have picked up a cold because I went out into the rain on a cold night directly after a hot bath when I was feeling low. If I leave it alone, it may go down to my chest and make me more i l l . I have tried some hot soup and some sleep. I better see a doctor in order to get some medicine for it." Before these questions can be answered, the client must have experienced certain signs and symptoms as abnormal such as "runny nose", shivering, and muscle aches and pains, before grouping them into the recognizable patterns of "a cold". This implies fairly widespread belief in the client's community about what a cold is and how it can be recognized, even though the EM of a particular cold is likely to have personal and idiosyncratic elements. Where many people in a culture or community agree about a pattern of symptoms and signs including its origin, significance and treatment, it becomes an illness entity with recurring identity. This identity is more loosely defined than biomedical diseases, and it is greatly influenced by the sociocultural context in which it appears. Kleinman (1980:106) argues that although EMs can be distinguished from general beliefs about sickness and health care, they draw upon these beliefs and belief systems as they are "marshalled in response to particular illness episodes". Thus, EMs "formed and employed to cope with a specific health problem", therefore need to be analyzed in "concrete settings". He further comments that in practice, people do not volunteer their EMs to health care professionals, and when they do, they report them as short single-phrase explanations because they are embarrassed about revealing their beliefs in "formal health care settings". Individual and family EMs often do not possess - 88 -single referrents but represent semantic networks that "closely link a variety of concepts and experiences" (p.107). In Kleinman's framework, EMs interrelate illness beliefs, norms, and experiences and they function as clinical guides to decisions that he has termed "hierarchies of resort" or "structures of relevance". It is "the EM and the semantic sickness network it constitutes and expresses for a given sickness episode that socially produce the natural history of illness and assure that i t , unlike the natural history of disease, will differ for different health care systems" (Kleinman, 1980:107). The metaphors that are used by people and practitioners to articulate their EMs disclose cultural patterning. For example, popular and professional EMs in western societies contain metaphors of war such as: "fighting", infection, "vanquishing" disease, "invasion" by pathogens, and immunological "defenses". Kleinman (1980:109) notes that Taiwanese popular EMs "frequently employ the metaphor of a person being "hit by ghosts and then becoming i l l " . Kleinman (1980:111) has conceptualized the patient-doctor relationship as a transaction between patient explanatory model [EMp] and doctor's or practi-tioner's explanatory model [EMd]. He has explicated four types of outcomes in the transaction as follows - outcomes meaning what the patient holds: (a) EMp + EMd - both the original patient model and the medical model together are held by the patient. (b) EMp > EMd - in this outcome, there is systematic distortion, usually in favour of the patient's original model. (c) EMp or EMd - either the original patient model or the medical model is held alone by the patient, and - 89 -(d) EMn - a totally new model is reported by the patient, usually based on a new source of information. A fifth outcome may also be considered, namely, EMd > EMp or transaction in which there is systematic distortion of outcome in favour of the practitioner. In other words, I envisage a transaction in which a doctor could modify his EM as a result of what he has learned from the patient's EM. Conceivably, there could emerge a sixth outcome in which the doctor's EMd changes to the patient's EMp. Admittedly, such an outcome may not be realizable in allopathic transaction but may be realized with non-allopathic transactions. A seventh outcome would require the practitioner to acquire a totally new EM which is based on a new source of information. It is also conceivable that both the doctor and the patient will continue to hold on to their original models when there is no common agreement. Kleinman (1980:113) suggests that by eliciting the patient EM before the doctor and the patient interact with each other and then comparing that EM [EMpj] with the EM the doctor transmits to the patient [EMd ]^ for the five major questions they concern (relating to cause, course, pathophysio-logy, expected outcome and expected treatment) it may be possible to estimate the initial cognitive distance between them - Distance A = EMp^  -EMd2» Similarly, the cognitive distance following patient-doctor interactions can be calculated by comparing the model the doctor communicates to the patient [EMd£] with the model the patient holds subsequent to the interaction [EMp9] - Distance B = EMd,, - EMp9. - 90 -According to Kleinman, the distance B is a rough measure of the communication between practitioner and patient. If distance A is compared to distance B, the efficacy of the communication between practitioner and patient will be revealed as to the degree to which the discrepancies are reduced or widened in clinical communication. Similarly, family EMs can be included in other combinations of the equation. In this study, there is no attempt to calculate cognitive distances by quantifiable means nor of the elicitation of family EMs. Rather, discrepancies in client and chiropractor EMs are described and tabulated as observed in percentage terms according to the frequency of occurrence. The primary goal is first to identify clients' and chiropractors' HMs and EMs and then to describe how discrepancies in EMs are negotiated in chiropractic-client interactions. 2.2.1 The Elicitation of Explanatory Models Kleinman (1980) and Kleinman et al . (1978) have commented that the explana-tory model outcomes are the result of a transactional process which, in theory, might be likened to a paradigm for translation between two languages, although, in practice, the actual translation rarely takes place. However, in principle, there is a process of elicitation, followed by processes of analysis, transfer restructuring (in the new language or EM) and feedback. Elicitation is the process by which client or practitioner may obtain the other's EM through questioning. Kleinman (1980:111) notes that in clinical transactions, "practitioners commonly do not el icit the patient's EM but - 91 -spontaneously transmit at least part of their EM". Perhaps Kleinman's comment is relevant when one considers the nature of allopathic medical transactions and the authority relationship that have been seen to characterize the way allopa-thic medicine is organized (see Chapter 3). Other health care practitioners who do not enjoy much authority relationships or who are constrained in one way or the another, may exhibit different forms of clinical transactions from that proposed by Kleinman. In this perspective, analysis is the process by which the patient's EM is analysed in terms of the doctor's EM, and transfer means that the analysed EM is transferred into the other EM, which as a consequence, is restructured. Katon and Kleinman (1980) have suggested that client's EM should be elicited by open-ended questions in layman's terms, or questions which do not contaminate the client's perspective with the practitioner's assumptions. They suggest that in order to e l ic i t such information, the practitioner must demonstrate warmth, empathy, and persistence, and he must be non-judgemental. The practitioner must have a genuine interest in the meaning the sickness has for the client and make explicit to the client his intention to draw on this information in "constructing an appropriate treatment plan" (p.259). The elicitation of the client's EM is followed by an assessment of the meaning of the illness for the client such as loss, gain, threat, opportunity for growth or no significance (Lipowski, 1969). Katon and Kleinman (1980) also suggest that the practitioner should determine the client's illness (as opposed to disease) problems such as the experiential, family, economic, interpersonal, occupational and daily l i fe - 92 -problems created by the disease and its treatment. The key to a successful clinical transaction, determined by compliance to treatment by the client, is measured by the ability to successfully negotiate between differing perceptions of illness goals of treatment and conflicts. "The objective is neither to dominate patients nor convert them to the physician's value orientation, but to enlist the patient as a therapeutic ally and provide care for problems patients regard as important in ways that patients desire" (p.262). The goal is to provide less "doctor-centred" transaction. Katon and Kleinman further comment: "Crucial to this shift in the structure of clinical relationships is the recognition that clinical care should involve a genuine negotiation between physicians and patients." (p.262) The implication of this enjoinder is that both the client and the practitioner would negotiate as "equals" for a satisfactory outcome. The significance of this observation is further discussed in Chapter 3 where nego-tiation is discussed as part of an overall strategy for client socialization. In this study, Explanatory Models [EMs] are taken to be derived from Health Models [HMs] (Figure 1). The practitioner and client bring to the clinical encounter, their respective EMs for negotiating a shared EM in order to enable treatment. Failure to successfully negotiate a shared EM would lead to non-compliance with treatment by the client, or dropping out, at least after the initial encounter and treatment. Failure to successfully negotiate a shared EM would also lead to the doctor referring the client to another doctor or in discouraging the patient from chiropractic care. Successful negotiation of a - 93 -shared EM would lead to the socialization of the client and the latter's trans-formation from client to patient as evidenced by adherence to treatment over a period of time (Table 1). In each instance, negotiation occurs in the clinical setting within the context of "individual meaning" for each participant, client and practitioner. According to Kleinman (1980:110), "EMs are the main vehicle for the clinical confirmation of reality, and they help to reveal the historicity and specificity of socially produced 'clinical reality 1 regardless of the form of knowledge on which the healing process is based". 2.3 The Social Organization of Medical Care Kleinman (1980:25) has commented that "the health care system is a concept, not an entity", hence, a conceptual model that is held by a society or an individual. Therefore, it is important to understand how actors in a particular social setting think about health care, how decisions are made, their beliefs about sickness, how responses to illness episodes are structured and what particular kinds of structures and processes are put together in the system. By examining the way the institution of medicine is organized and how it functions, it is possible to analyse the social and cultural rules and meanings which shape medical care in a society, at least certain of its key components. Janzen (1977) has argued that models of medical systems must deal with both micro- and macro-analysis. Thus, they should examine specific episodes of sickness and treatment, showing how small-scale events within healing systems relate to large-scale social structures and processes of change. - 94 -The following discussion relates principally to the institution, organiza-tion and processes of allopathic medicine. Because allopathy is the dominant group of health care providers in Canada and the western world, it provides the yardstick against which the performances of marginal healing groups are measured. More importantly, allopathy plays a much greater role in the social and cultural lives of the inhabitants of western societies. In these societies, as in the province of British Columbia, allopathy has been granted greater rights and autonomy, via legislation, over health and illness than any other healing group. As I have noted in Chapter 1, it is allopathic medical system that, in the view of chiropractors, has encouraged and fostered polit ical , legal and practice constraints on chiropractic health care. The focus of our discussion, however, relates primarily to the relationships and interactive behaviours in allopathic medical settings and institutions, as a way of under-standing what goes on in chiropractic clinical settings. Allopathic medical care is a social institution which is dominated by physicians [M.Ds] as a particular profession. The principal function of medicine is the regulation and control of one type of deviance, namely, sickness. In carrying out this function, allopathy has been granted, by society, the right to define criteria of sickness, to determine appropriate modes of treatment and management, and to engage in practices that are consistent with these definitions and determinations. However, the specific organizational forms and practices vary as a function of relationships between allopathy and other social institutions. For example, in British Columbia, only allopathic physicians can provide legal and acceptable medical evidence in the - 95 -law courts, legitimate the rights of disabled persons for access to guaranteed income for need (GAIN, 1978), admit patients to publicly-funded hospitals, and practice accupuncture to the exclusion of trained accupuncturists. Friedson (1970a) has reviewed the historical development of organized medicine and argues that its status as a profession depended on establishing a monopoly over the exercise of its work. Friedson observes that the profession of medicine is one of the most successful in achieving this autonomy and in establishing the freedom to work without outside regulation. It is perhaps, only allopaths [M.Ds] among health care professions who have been vested with the responsibility of monitoring one another's performance. In the United States, and to a certain degree in Canada, this organizational structure reinforces the performance of procedures for profit, prestige and control rather than the performance of procedures for health. The consumer of allopathic medical services, unlike the consumer of any other product of service, has a very small voice in determining health care practices and policies. There is a growing body of critical literature that outlines in great detail the flaws in the health-care-delivery system, their roots in the structure of society and their manifestation in the organizational arrangements of the field of medicine (Ehrenreich and Ehrenreich, 1971; Waitzkin and Waterman, 1974; I l l ich, 1977; and Navarro, 1976). Although the volumes of critical literature vary in their particulars, nevertheless, they share an orientation which is marked by their use of such key terms as "power" and "politics". These terms help to position health care as a topic within the structure of the political power in society and they reflect the central - 96 -question relating to "who gets what?" In this context, the referrent "what" is not restricted to the standard goals of health care such as the cure of illness and the remission of symptoms, but it is expanded to include, or to focus on such social and economic benefits as status and profits. It is the distribution of these benefits among various health professionals, such as allopathy and chiropractic, and between other groups in society that becomes the main focus of attention. Homowy (1981) has described how during the history and development of medicine in Canada, allopathy used political relationships, exclusionary tactics, and restricted entry to prevent the development and growth of competing medical systems such as Osteopathy, Homeopathy and Chiropractic. In recent times, these approaches have continued to be used by allopathy in British Columbia against chiropractic, the second largest healing group to allopathy, perhaps in an effort to minimize chiropractic role in the health care system of the province (see Chapter 1, Section 1.3). Critical literature has suggested that the allopathic profession has not only pursued its own special interest, but, at the same time it represents the dominant groups and classes in the society, therefore serving its special interest as well. In British Columbia, of all the primary health care groups in the province, only allopathic physicians sit in the highest level of state committees which adjudicates and evaluates the role of other primary health care groups. For example, whereas both allopaths and chiropractors are entitled to provide health care to injured workers and be compensated for their services by the Worker's Compensation Board, only allopathic physicians sit on the Ministry - 97 -of Health's committee that monitors, evaluates and approves all claims for payment for services. Asked why there is no chiropractor or any other primary health care group sitting on the committee, one senior official of the Ministry of Health interviewed for this study commented that the College of Physicians and Surgeons in the province would not allow i t . A leader of chiropractic in the province, also interviewed, noted that "a significant number of reimburse-ment claims from chiropractors are rejected each year", and that the stringent scrutiny with which chiropractic treatments are reviewed by the Ministry of Health's committee has necessitated the development of a "special claims manual" for chiropractors. The way medical care is organized also has social implications for society and for individual members of society. Illich (1977) has noted that one of the social consequences of the monopolistic control by the medical profession of so many important areas of l ife is the erosion of individual autonomy for self-care and of community processes for mutual care. Because of the increasing reliance on allopathic medicine and experts, individuals become less competent in taking care of themselves or of others without medical intervention. Otherwise such self-care and care of others may be treated as an illegal act by the courts. The recent struggle by midwives in British Columbia to obtain recognition as a socially and medically acceptable health care occupation has met with very strong opposition from allopathic medicine as well as legal intervention by the law courts (The Vancouver Sun, November 20, 1986). It is well known that, for centuries, the occupation of midwifery has been in existence, and that in many Western countries, for example, Holland and Denmark, midwives are part of the - 98 -health care system. Some people may consider the act of midwifery a natural occupation for a naturally occurring phenomenon, child-birth, even before the advent of organized medicine. Organizations and institutions which have been designed and developed for certain specific purposes, sometimes come to serve other aims and imperatives. Friedson (1970a, 1970b) has argued that the demand for monopoly control of the profession by the profession may have less to do with the corpus of specialized and technical knowledge of medicine, which is used to justify this demand, than with efforts to sustain the position of power and status of allopathic physicians, vis-a-vis other health professions and their patients. We have discussed in Chapter 1 how the allopathic profession in British Columbia has used its position of power to prevent chiropractic, and also midwifery, from making significant impact on the health-care-delivery system. According to the views of Friedson (1970a:350), "social policy is coming to be formulated on the basis of the profession's conception of need and to be embodied in support of the profession's institutions". The general values about health and health care about which Illich (1977) is concerned and the specific interests of medicine as a profession which is examined by Friedson (1970a), are actualized in the work settings through which health care is organized and "delivered" to patients. In discussing the labeling perspective on illness, Waxier (1980:294) has commented that the "ways in which the institution operates has an important and selective effect on the negotiation of illness". She noted how some hospitals which rely on "patient fees, may organize admission procedures in such a way as - 99 -to produce the numbers of ' i l l ' people that are required to keep the system" going. She went on to show how the organizational working of a hospital "produces illnesses that might not exist i f , for example, social workers did night duty" (p.295). Waxier (1980) uses the findings of several studies to argue that illness labels originate as a result of social negotiations between professionals and individuals within institutional and social contexts, and that "the ideologies and organizational procedures as well as the relative power and interests of the negotiating parties contribute to the label of illness" (p.296). The occurrence of initial labeling depends on the prevailing norms of the society, an individual's social position, and the characteristics of the organization. Waxier notes that alcoholism in the United States is no longer considered a crime but an illness, and that homosexuality is no longer regarded as an illness by the American Psychiatric Association but simply as the "lack of sexual desire" (p.289). On the role of knowledge and social position of individuals in the labeling of illness, Waxier (1980:293) states: " some individuals learn through experience with particular treatment systems how to state their case (regardless of symptoms) in order to get what they want, either hospital admission or discharge the social and economic position of the potentially ' i l l ' person along with his family or spokesmen may have a significant impact on the negotiation of the problem." The focus of Waxier's argument is that illness labels are the result of negotiation between physician, patient and significant others in the context of - 100 -an institution and organizational arrangements, and that illness labels have important implications for the individual. Allopathy "produces" illness labels. A person who is "uncomfortable" with a given label or whose health beliefs are inconsistent with the label may opt to seek an alternative explanation from another healing system such as chiropractic. In order to gain more understanding of what takes place in medical work settings, we shall use the practitioner-client interactions and studies that have examined these interactions to compare allopathic and chiropractic beliefs, norms and roles, especially aspects of their respective health models. The focus is on how allopathic practitioners conduct their relationships, some of the reasons why allopathic-client relationships are the way they are, how they are often perceived, and how chiropractic-client interactions might differ from that of allopathic interactions. 2.3.1 Practitioner-Client Interactions There are fundamental differences in the basic beliefs of modern allopathic and chiropractic treatment systems. Modern medicine is based on and dominated by concepts, methods, and principles of the biological sciences. As Engel (1977:130) has noted, "the dominant model of disease today is biomedical, with molecular biology its basic scientific discipline. It assumes disease to be fully accounted for by deviations from the norm of measurable biologic (somatic) variables". Coupled to the narrow biomedical definition of disease is the concept of specific cause for every disease and the assumption that disease has - 101 -specific and distinguishing features that are universal to the human species. In other words, the symptoms and processes of disease are expected to be the same in different historical periods and in different cultures and societies. Moreover, physician [M.Ds] tend to see themselves as, and often acquire the self-image of, bioscientists, therefore reflecting the view of medicine as a discipline that has adopted not only the rationality of the scientific method but also the concomitant values of the scientist, namely, objectivity and neutrality (Coulter, 1983; Mishler et a l . , 1981). The biomedical definition of disease ignores the importance of socio-cultural factors such as individual beliefs about health and disease, and the dichotomy between disease and illness, especially the role of institutional factors in the aetiology of illness and its remedy (Waxier, 1980: Kleinman, 1980). Balint (1957:40) also has suggested that the diagnosed disease is not simply "out there" in the patient, but is in the result of negotiation between physician and patient. Thus, diseases are not found; they are socially constructed. Coulter (1983) has commented that the scientific approach of biomedicine has necessitated a form of reductionism in treatment in which the germ theory has introduced an approach isolating the cause and treatment of specific diseases. Thus, rather than focus on the patient, allopaths tend to focus on the biological aspects of the body and disease, thus transforming the social setting of medicine. Consequently, this transformation has altered, in a fundamental way, the nature of practitioner-client relationship from one which takes human relationships into consideration to one which alienates individuals. - 102 -On the other hand, chiropractic philosophy is "holistic" and it considers the body an integral unit. According to the chiropractic orientation, the human body, when functioning normally, is able to combat disease processes naturally, and the occurrence of disease is the result of a failure in the body's natural restorative power. Chiropractic treatment, therefore, takes the whole body into consideration. In this regard, a person's physiological make-up, his state of mind, as well as intervening social problems such as unemployment or stressful marital relationships, are predisposing factors to illness (Strang, 1984; Haldeman, 1980; also see Chapter 1, Subsection 1.2.2). In the chiropractic model of treatment, disease is interpreted as symptom and chiropractors claim not to treat disease. Rather, they claim to treat the "cause" of the disease by treating the patient, "the object being to restore the body, including mental processes, to a normal state" (Coulter, 1983:153). Since the body has the natural ability to restore itself to normal function; it should, therefore, not be tampered with drugs which may affect the ailment but not remove the cause. Chiropractic, therefore, is conceived as a natural therapy without the use of drugs. The focus of the chiropractic-client interaction is on human relationships and the psychological and social factors which mediate the ability of the "whole" individual to restore his own body to normal health. The chiropractic model of care, therefore, encourages the mutual participation of the client in the discovery, explanation and treatment of illness, in contrast to the "activity-passitivity" model of allopathic-patient relationships in which the - 103 -patient is totally passive, or sometimes the guidance-cooperation model adopted by some allopaths in which the physician tells the patient what to do and the patient is expected to cooperate (Szasz and Hollender, 1956). It is conceivable that both the chiropractor and the client may not be operating from the same power-relationships that characterize allopathic care -one in which the physician [M.D.] has greater legislated power compared to the patient or the chiropractor. It goes without saying that in Western societies, the physician [M.D.] has come to be viewed as "powerful" in society and this perception of power is often actualized through the social control and gate-keeping functions of allopathy (Parsons, 1951; Ehrenreich and Ehrenreich, 1971). In relation to the client, the chiropractor may be viewed as relatively less powerful in view of the historic deviant perceptions chiropractic has faced over the years, its marginal status compared to allopathy, and especially the special constraints that have confronted the work of chiropractors in British Columbia. An important question in this study is whether chiropractors and their clients negotiate as equals in the chiropractic clinical settings or whether one of the partners in the negotiation is in a commanding position during the negotiation of explanatory models and treatment. The organization of chiropractic care is modelled along the lines of that of family [M.D.] practitioners in solo and group practices. There are no specialized subgroups in chiropractic, unlike allopathic care in which different specialists lay claim to the treatment of different parts of the body, and in some instances, different diseases such as rheumatoid arthritis or cancer. - 104 -Therefore, the need to consider all of the "presenting problems" of a client is enhanced for the chiropractor who is expected to provide total care and not depend on some other para-professionals to assist in treatment. Friedson (1970a) has noted how physicians [M.Ds] rely on and control the work of paramedical professions such as physiotherapists and nurses. Finally, unlike allopathic physicians, chiropractors do not, and are not, legally allowed to use treatment institutions such as hospitals. Physicians [M.Ds] often admit patients to hospitals for "observation", thus disrupting the social link and social support the person has depended upon in the community. A chiropractor provides treatment in the community, the client returns to his home and family and important social supports are maintained. It appears that chiropractic would be potentially appealing to patients because there is no hospitalization for the individual patient. People are treated in the community, therefore enabling them to continue to take advantage of support from their family members and friends. They can return to their work, especially when they have "minor" ailments for which a physician [M.D.] may have recommended hospitalization for "observation". The absence of such considerations in allopathic care has led Frankel (1983:19) to comment that "the organizational settings for recommending allopathic treatment are often more remote from the actions and treatments recommended". More importantly, the orientation of chiropractic seem to be person-centred with emphasis on human relationships. It is also possible that the absence of drugs and surgery in chiropractic treatment, together with the "soothing" and "comforting" effects of treatment by hand only, may encourage people to try chiropractic form of care. - 105 -Their subsequent experience of chiropractic, and whether or not they will continue in chiropractic treatment, would depend on the experience they acquire in coming in contact with chiropractors in chiropractic clinical settings. How, therefore, are chiropractic-client interactions different from those of allopathic medicine? What are the possible "occurrences" in allopathic-patient interactions that may lead subscribing patients of allopathic to consider chiropractic care? What significant factors influence the cognitive and affective aspects of physician-patient relationships? And what is the impact of the physician-patient relationship on treatment and its subsequent outcome? The answers to these questions may be found by discussing the results of some of the studies which have examined the processes of allopathic-patient interactions in order to assist our understanding of the chiropractic-client interactions. Studies of physician [M.D.]-patient relationships extend over a wide range of areas, in particular, the communication of medical information, distortions of understanding, patients' compliance with doctors' instructions, and affective behaviour. (a) Communication Problems between Doctors [M.D.] and Patients: Asking questions West (1983) examined the overall distribution of questions between physicians and patients engaged in 21 two-party exchanges in a family practice centre in the United States. She observed 773 questions in the 21 exchanges of which 91% or 705 questions were initiated by physicians and only 68 or 9% of the - 106 -total number of questions were initiated by patients. Neither the sex nor the race of physicians and patients seemed to influence the distribution of questions between the parties. Moreover, the proportion of physician-initiated questions answered by patients, 98%, and the proportion of patient-initiated questions answered by physicians, 87%, was not equal. West (1983), therefore, concluded that patient-initiated questions were dispreferred in physician-patient interactions, and that while questions do, in most cases, e l ic it answers from their recipients, patients answer doctors' questions more often than doctors answered theirs (p.89). West also found that "doctor-talk" (that is when doctors ask questions and engage in conversations) is more constrained by "utterance-type" and "speaker identity" than casual conversation. For example, physicians would chain questions together with no intervening slots for answers, therefore causing the patients to fail to answer some of the questions in the chain (p.89). Goffman (1981) has noted that the construction of multiple-question utterance-types can itself place constraints on opportunities for answers. Therefore, both the numbers of physician-initiated questions and the ways they are constructed display their orientation to a normative order of medical exchange in which physician-initiated questions are preferred. West (1983) also found that when physicians' "next" questions were posed over patients' attempted answers to their "last" questions, incomplete answers often appear within states of simultaneous speech, and "that doctors who were asked fewer questions also answered fewer of those they were asked" (pp. 90-99). - 107 -In another study, Wallen et al . (1979:145) found that "patients who ask the most questions are necessarily the ones to receive most explaining time". Korsch and Morris (1969); Korsch and Negrete (1972) and Freeman et al . (1970) investigated aspects of communication gaps in 800 pediatric emergency room visits using tape-recordings of medical consultations, follow-up interviews, and the review of medical records. The patients were children between the ages of 6 months and 10 years, but it was their mothers who were engaged in consultations with physicians. They found that sufficient information was not made available to the patients or mothers. 19% of the mothers did not receive a clear statement of what was "wrong" with their child. 50% were s t i l l wondering when they left the doctors what the cause of their child's illness was. The analysis of tape-recordings indicated that the doctors had failed to provide a clear statement of diagnosis and they often did not offer prognosis. Korsch and her colleagues (1969, 1972) also found that physicians were not attentive to the remarks of mothers, therefore disregarding their remarks about what worried them most about their children; that physicians gave almost all the instructions while the mothers asked few questions; that physicians did nothing to encourage mothers to take a more active role in solving the medical problems; and that mothers expressed more tension, disagreement and hostility than physicians because of a feeling of helplessness. - 108 -(b) Language Differences and Distortions of Meaning Hauser (1981) comments that an important aspect of communication problems between doctors and patients is that they include the dimension of the level of awareness. Plaja and Cohen (1968:161-162) analysed interviews between physicians and their patients in three out-patient clinics in Colombia and they found a range of distinct interaction styles associated with communication problems. They noted that, by far, the most common orientation of doctors was "bureaucratic task-oriented" - a style characterized by "efficiency" and "limited sensitivi-ty". They observed l i t t l e or no variation in the manner of questioning patients, and 80% of the patients interviewed by "bureaucratic task-oriented" physicians responded with a "matter of fact collaboration" style by answering questions in the exact order asked and expressing l i t t l e initiative or concern in the way the physician guided the interviews. The remaining patients interviewed by these physicians responded in ways that were "rambling and elusive; vague and difficult to pin down". Few of the physicians were classified as "amiable or person-oriented" (p.110). In another study, Shuy (1974) found that the largest portion of medical interviews are dominated by physicians' language and perspective. He also found that the most serious breakdown in communication between physicians and patients occurred "when patients would (or could) not speak the doctors' (medical) language and the doctors could (or would) not understand the patients' (everday) language" (p.5). Physician-patient communication problems are not limited to outpatient clinics. In a study of various medical and surgical services in a general - 109 -hospital, Golden and Johnson (1970) concluded that "the most dramatic finding related to the massive amounts of anxiety experienced by patients, and lamentably, the lack of recognition of their anxiety by the doctors" (p.137). (c) Following Doctors' Orders DiMatteo and Friedman (1982:38) have observed that "one-third of all patients fail to cooperate with their medical regimens according to the results of many studies. In some situations, the percentage of non-cooperation is as high as 50 percent". In their analysis of 165 studies, Dunbar and Stunkard (1979) report that clinicians should "expect to find between 20 and 82 percent of their patients are not following their regimens". Among the factors that influence compliance are medical setting, type of illness, characteristics of the patient, and characteristics of the treatment regimen. One other influence on compliance which has been identified in earlier studies is the nature of physician-patient relationships (Davis, 1968). Davis found that the patients with the lowest compliance scores had physicians who passively accepted the patients active participation in the interview, gathered information without feedback to the patient, and were highly formal and distant while with the patients. (d) Doctor-Patient Relationships: Affective Components Friedman (1979) has found that much of the communication, especially between doctors and patients, occur through non-verbal channels. A study of non-verbal cues in physician-patient relationships indicates that physicians' feelings about alcoholic patients may be expressed by "how" they speak rather - 110 -than "what" they say. Milmoe (1967) has found that when physicians' voices conveyed anger, patients did not follow through on referrals. (e) Doctor-Patient Relationships: The Social Context Mizrahi (1986:167) has examined the ways by which house officers (resident doctors) in the department of medicine at a university hospital "get rid of patients". Some of the ways they used to get rid of patients due to heavy work assignments included transferring patients to other hospitals, releasing patients as quickly as possible, passing along the unwanted patient-related task to another person or by using psychological means such as intimidation and avoidance. The social and psychological effects on the patient who is aware that his doctor is doing his best to get rid of him may be said to have devastating effects including feelings of alienation and rejection. Drawing on the observations of the communication between doctors and patients during medical appointments, Fisher (1986) has demonstrated that doctors work from a position of power and women from a position of vulnerabili-ty. She found that doctors rarely felt obliged to present women with all the information they needed to make informed choices about their health care, and that women rarely asserted their rights to know. Fisher found that a large number of hysterectomies recommended by physicians and agreed to by the patients were not necessary on medical grounds. She also noted an alarming number of cases where pap smears were needed but not performed. More importantly, she observed that doctors began and concluded conversational exchanges, asked the most questions, initiated most of the topics, and held the floor more success-- I l l -fully than their patients. The scenario was a replication of the mainstream of behaviours and relationships in a male-dominated society and male-dominated medical profession. To what degree is the relationship between chiropractors and their clients similar to those that have been shown to characterize allopathic care? As Freidl (1978) has speculated, the emotional distancing style of allopathic physicians is said to contrast strongly with the emotionally close, personal style of alternative practitioners. As alternative practitioners, chiropractors may deliberately promote close and personal interaction style as a collective way of relating to clients in view of the constraints on their practice and the emotionally distancing style of the "official" practitioners. In this study, the nature of chiropractic-client relationship is observed and described with respect to communication characteristics, language differences, and affective components (see Chapter 4). 2.4 Summary I have introduced some of the factors which influence the beliefs people have about health and illness by discussing how these factors help to shape their health models [HMs], which, in turn, are used as a basis for constructing explanations or explanatory models [EMs] for specific health problems. From personal factors such as individual characteristics, psychological profile, sociocultural factors, past experiences, economic adequacy, relation-ship with friends and family and the nature of a health problem, people - 112 -"acquire" personal beliefs about the structure and functions of the human body, the causes, signs and symptoms of illness, treatment systems and healers, and about personal health habits. Practitioners supplement these factors with their professional training and culture as well as the preferred method of treatment. The notion of clinical reality is used to designate the socioculturally constructed contexts that influence illness and care. Thus, different medical systems as well as individuals have different clinical realities which link illness to treatment. The clinical setting provides an opportunity for bringing together the EMs of the chiropractor and the new client. It is in the clinical arena that a common EM is negotiated which will enable treatment to occur. There are a number of possible outcomes resulting from the negotiation of chiropractor and client EMs. Each participant may hold on to his own EM, modify the EM by accepting aspects of the other's EM, acquire a new EM which is different from the previously held EM, or integrate both EMs as a compromise. One implication of Kleinman's (1980) perspective on the clinical negotia-tion of EMs is that it is doctor-centred. Another implication is that participants negotiate genuinely, yet one invariable outcome of the negotiation involves the shifting of the patient's EM in order to receive treatment. I have discussed how the institution of medicine and its organization have social implications for patients. In particular, I have contrasted allopathic and chiropractic models of medical care. The doctrine of scientific rationality of allopathy together with its assumption of generic diseases, scientific - 113 -neutrality and objectivity, contrasts with the "holistic" and relatively uncomplicated chiropractic view of the causes of disease, as well as its humanistic approach to the whole of the human body. While one model encourages detached reductionism to diagnoses and treatment, the other is person-centred. I have discussed problems with allopathic-patient relationships as a way to help us understand the chiropractic-client relationships. A number of problems have been identified, especially in the area of communication. For example, assymetry in questions and answers between the parties, non-disclosure of information by physicians, "bureaucratic" interaction style of allopathic physicians, the domination of medical interviews by doctors, and the use of non-verbal cues to show disapproval. More importantly, doctors work from a position of power and they tend to control the interaction in the clinical settings. Some of the effects of problems of physician-patient interaction has been shown to be non-compliance and dissatisfaction with treatment by patients. To what extent are the chiropractic-client interactions different from those of allopathic-patient interactions? I have taken the view in this study that because of the constraints faced by chiropractors in the study area, they would, of necessity, interact with new clients in ways that are different from those of "official" allopathic medicine in order to convert their new clients to patients. Chiropractors also espouse "holistic" health care which pushes them toward negotiations of a certain kind. I have also argued that one way in which chiropractors try to achieve their objective is to satisfactorily negotiate "common" explanatory models with new clients. In Chapter 3, socialization of clients via negotiation is discussed. Because the organization of health care is socially based, and all activities in - 114 -it have social implications as they are operated in the context of every day "life activities", socialization via negotiation is discussed in the context of Goffman's observations (1959,1963,1967,1969). What people do in face-to-face interactions is used to further discuss Kleinman's perspective on explanatory models, the purpose being to integrate Kleinman's perspective with Goffman's observations of face-to-face interactions and behaviour. Viewed in this way, we may gain a better understanding of how chiropractors interact with potential patients. - 115 -CHAPTER 3 3.0 THE SOCIALIZATION PERSPECTIVE DiRenzo (1977:266) has defined socialization as "the purely processual and/or structural dimension of social learning in which uniquely human attri-butes are developed and/or actualized". The particular concerns are how and what must be transmitted or acquired by the individual in terms of social learning, in order to permit him to assume and to maintain the social statuses that he will achieve or that will be ascribed to him in society and its sub-units. In this respect, socialization is primarily a matter of learning any social role (Goslin, 1969). Children are socialized into becoming adults (Inkeles and Levinson, 1969), medical students learn to become and behave like physicians (Mumford, 1970), and clients learn to become patients. In this study, "socialization" of a new chiropractic client is achieved when the client becomes a patient of chiropractic for not less than four treatment visits to the chiropractor. It is assumed that the chiropractor will direct his effort towards socializing the new client. The negotiation of explanatory models (Chapter 2) is considered an integral part of the chiroprac-tic socialization process. 3.1 Socialization Processes Processes of socialization can be found in most activities of daily living, from childhood to adulthood, student to professor, medical intern to medical - 116 -specialist. However, socialization in clinical settings, such as those structured for the purpose of providing help with illness, takes on special considerations. The relationship between the healer and the i l l person involves a professional power relationship. While one actor in the relationship is seeking help, the other is providing help. This kind of relationship has been studied in the allopathic clinical setting (Mishler et a l . , 1980; Eisenberg and Kleinman, 1981; Kleinman, 1980). One often hears about nurses in hospitals talking about "Doctor's orders" for "his patient". A legitimating sentence in a work situation to avoid strenuous duties often goes like this: "My doctor says I should not l i f t things". In other words, society members learn how to respect the professional power of the allopathic physician. The situation is somewhat different for the chiropractor, who for reasons discussed earlier, must find ways to attract professional respect due to historically conferred "professional" deviancy status and opposition from allopathic medicine. Thus, socialization of new chiropractic clients must take on some urgent as well as carefully structured processes although these processes may be largely tacit. Where there are existing social structures, chiropractors may seek to reinforce them towards positive valuation of their work. For example, people mostly rely on family and friends for advice. This relationship can be used as a socializing process. Also, primary care givers such as family doctors generally have waiting rooms and reception areas. Again, this first contact area can be effectively used in client socialization. More - 117 -importantly, the first contact or interaction a chiropractor has with a new client is rife with socialization potential. If he succeeds, the client's friend and family will hear about i t . If he fai ls , at least for the particular client, the professional deviancy label will be sustained. Allopathic physicians may also engage in these socialization practices if they are establishing new clinics. However, allopaths do not face the same constraints as chiropractors. The urgency or the desire to "succeed" in making their clientele is greater for chiropractors than for allopaths. For chiropractic in British Columbia, the crucial client socialization processes include education, the creation of positive impressions via situational interactions, and negotiation. 3.1.1 Education of Clients Clients, who, for the first time, visit a chiropractic c l inic , will expect to acquire necessary information about chiropractic to enable them to become informed. This is especially true of new clients who either have no previous knowledge of chiropractic or who have been somehow aware of its deviant label. Most clients of chiropractic have been to other healing systems (Kelner et a l . , 1980). Some clients may also have been cautioned against chiropractic either by practitioners belonging to the "official" medical assocation or by their friends and family who see chiropractic as deviant. Thus, there is a natural curiosity on the part of uninformed new clients to become informed. - 118 -The need to educate the client is recognized in the training of chiroprac-tic students. First , they are made aware of the deviant label that has been conferred on chiropractic as an impetus to correct such notions. As noted by Kelner et a l . , (1980:80) regarding the training of chiropractic students at the Canadian Memorial Chiropractic College [CMCC]: "By the time they are ready to leave chiropractic college, students have had a good deal of experience in coping with the negative attitudes expressed by the medical world and by some sections of the general public. They have begun to develop the defense mechanisms which wil serve them throughout their careers, and have managed to deal with disapproval they may have encountered from personal friends or family members. They have learned to respond to attacks in the media by dis-regarding accusations of incompetence and irresponsibility." Kelner and her colleagues go on to describe how, as interns, chiropractic students are "required to handle a specified number of patients, and are held responsible for attracting the required number are compelled to take an active role in bringing patients to treatment" (p.71). These requirements and responsibilities make it very necessary for chiropractic students, who later become chiropractors, to work very hard at "convincing" new and "curious" clients to become regular patients. As observed by Kelner and her associates (P.71): "They become adept at explaining to patients the value of the care they are getting, and at educating them in the importance of returning for regular treatment until their problem is resolved." - 119 -In learning to educate and to "convince" potential patients about chiro-practic care, chiropractic students also are learning the art of impression-management. Their success in obtaining sufficient numbers of clients for their clinics upon graduation will depend upon how "good" they are in impressing potential patients. 3.1.2 Managing Impressions Goffman (1959, 1963, 1967, 1969) has described how individuals or groups structure their interaction with others in public places, private encounters or in everyday l ife by using ritualized behaviours. Goffman (1967:5,12) uses the concept of "face" to designate "the positive values a person effectively claims for himself by the line others assume he has taken during a particular contact". He uses "face-work" to "designate actions taken by a person to make whatever he is doing consistent with "face", in order "to counteract "incidents' - that is, "events whose effective symbolic implications threaten face". In other words, "face" is the personal image a person has of himself or the type of image he wants to convey to others during interpersonal relationships. Thus, a person's actions, "face-work", will be largely directed at protecting his "face" and counteracting "incidents" which will tend to discredit, or give wrong impressions of his "face". Goffman (1967:13) notes that "face-saving actions" often become "habitual and standardized practices". He writes: "If a person is to employ his repertoire of face-saving practices, obviously he must first become aware of the interpretations that - 120 -others have placed upon his acts and the interpretations that he ought, perhaps, to place upon theirs. In other words, he must exercise perceptiveness". Perceptions of chiropractic as a deviant profession dictate that chiroprac-tors develop a collective "face" for chiropractic which should become the self-image of the chiropractic medical system. However, an individual chiro-practor may function within the collective face in ways that complement the collective face and at the same time respond to the local situation in which his clinic is located. New clients of chiropractic must, therefore, be presented with both the collective and individual "faces" depending on local circumstan-ces. It is through these presentations that new clients learn about the "images" that are important to chiropractic as a step towards their socializa-tion. Goffman (1967:12) further comments as follows: "To study face-saving is to study the traffic rules of social interaction; one learns about the code the person adheres to in his movement across paths and designs of others " "Face-work" also involves "expression games" (Goffman, 1959:2). This relates to the expression that a person "gives" and "gives off", involving symbols and a wide range of actions that "others can treat as symptomatic of the actor". Through these expressions, an individual undertakes "performances" or purposeful activities that occur during the period the person is in the "continuous presence of a set of observers" (p.22). Goffman uses the terminology "front" to describe "that part of the individual's performance which regularly functions in a general and fixed fashion to define the situation for - 121 -those who observe the performance". It involves a "setting" - decor, physical layout, background items "which supply the scenery and stage props for the spate of human action played out before, within and upon it" (Goffman, 1959:12). The setting, appearance and manner of a chiropractic clinic may be described, after Goffman (1959:29) as the "social front". The front comprises the waiting room, the reception area, the chiropractor's office and the location of the practice. The contents and appearance of these areas create the first impressions on a new client. These impressions may lead a client to infer to himself how professional the practitioner is and what kind of a person he is likely to be. A sparsely decorated office may lead a new client to think of a "struggling" and unsuccessful practitioner, meaning that not enough clients request his services. In other words, such a chiropractor appears to be a marginal professional which confirms attributions of deviance. On the other hand, a tastefully decorated office, especially one that is similar to that of an allopathic family physician, or one consistent with others in the same community, would help to convey an impression of medical and professional competence. The aim is to reduce the level of anxiety in a new client prior to the actual clinical encounter. Another setting which provides the chiropractor with the best opportunity for managing the impressions of clients is the clinical encounter. The first clinical interaction between the chiropractor and a new client provides the opportunity for mutual formation of impressions about the interactants and an opportunity to evaluate each other's acceptability. It is during the first encounter that "face-work" is first initiated in a personal way. In this context, the result of creating and "managing impressions" about chiropractic, - 122 -especially by the chiropractor, will either be successful or end in failure. By successful management of impression, I mean that the new client has been so positively influenced that he has decided to receive treatment and to continue in chiropractic treatment. The chiropractor would have succeeded in mobilizing his activity to express, "during interaction, what he wishes to convey" (Goffman, 1959:30). The social situation is one which has forced both the chiropractor and the new client to interact. The reward for the chiropractor will be to "convert" the new client towards positive views of his work and profession, that is to negate deviancy perceptions, and for the client, relief from pain. In general, the most significant outcome may be the learning of social coping strategies by client and chiropractor, that is , how to respond to social situations and exert some control over them (Goffman, 1959; Weinstein, 1969). Interaction between the new client and the chiropractor becomes complex in the sense that intended and unintended activities and symbols take on special meanings. As noted by Goffman (1969:5), in strategic interaction, "individuals offer more than expressions; they also offer communications" such as "the use of language - like signs, to transmit information". There is also "intentional effort" to produce expressions that the individual "thinks will improve his situation if they are gleaned by the observer". Goffman (1969:12) called this intentional effort "control move". The implication is that intentional production of expressions, "body language", and other signs and symbols, are specifically targeted for certain results. For example, a chiropractor may use concentrated listening attention to convey the impression that he is not only - 123 -listening to the client but also sympathetic to his troubles especially if the client has shopped around different treatment systems. A nod could mean agreement, a clasped hand could mean respect, and sitting very close to the client could mean caring or affection. Again, to quote Goffman (1969:85): "Individuals typically make observations of their situation in order to assess what is relevantly happening around them and what is likely to occur. Once this is done, they often go on to exercise another capacity of human intelligence, that of making a choice from among a set of possible lines of response". The decision by a new chiropractic client to receive and continue treatment is a positive response and testament of the ability of a particular chiroprac-tor to socialize the client given the social, polit ical , and economic environ-ment in which he practices his chosen calling. 3.2 Socialization via Negotiation People bring different beliefs and values to any social situation which significantly affects their lives. Political parties, and cultural systems are examples of human collectivities with like-minded beliefs and values. In Chapter 2, I discussed the importance of belief systems in the health care system of a society, and how people's beliefs help guide their "help-seeking" and illness behaviours. I also discussed notions of Health and Explanatory Models, [HM] and [EM] from which people make sense of their illness problems using their internalized beliefs about health, illness and treatment. These - 124 -models are located in individualized clinical realities when ill-people are situated in particular treatment environments. Because people are different in many respects, conflicts arise, especially when there are competing values. Nader and Todd (1978) l i s t several methods for dealing with conflict, ranging from avoidance, coercion, or negotiation, the latter being a bilateral arrangement in which two principal parties attempt to work out a solution. Others have defined negotiation in various ways. For example, Guralnik (1968) defines it simply as conferring, discussing or bargaining to reach an agreement. Johnson and Johnson (1975:171) view negotia-tion as a way to reduce conflict and promote cooperation. They comment that it is "a process in which people who want to come to an agreement but disagree on the nature of the agreement try to work out a settlement" aimed "at achieving an agreement that determines what each party gives and receives in a transaction between them". The negotiation model is, therefore, crucial in the two party practitioner-client relationship which has two possibly opposing health and explanatory models. This is especially true of the chiropractor - new client relationship in which the chiropractor may be viewed as practicing deviant medicine and the new client comes as an adherent of "official" scientific medicine. Given the social, political and economic constraints discussed in Chapter 1 which mediate chiropractic clinical effort in British Columbia, there is probably no clinical healing encounter which is more ripe for negotiation than the chiropractor-new client encounter. - 125 -The role of negotiation in medical work has been recognized by several social scientists (Strauss et a l . , 1963; Glazer and Strauss, 1964; Scheff, 1968; Kleinman, 1975; Kleinman et a l . , 1978; Katon and Kleinman, 1981; and Kleinman, 1980). Strauss and his colleagues (1963) have noted that in order to obtain certain desired outcomes, hospital personnel develop various strategies in response to problematic situations. These negotiation strategies are, to some extent, patterned by the general mandate of the hospital to help the sick, and the collective orientation of this mandate provides a measure of organizational cohesion. Glazer and Strauss (1964) and Scheff (1968) have called attention to the importance of the degree of shared awareness and the structure of interaction as important factors which direct the nature of negotiation. Kleinman (1975, 1976, 1980) and Kleinman et al . (1978) view the clinical process as essentially a negotiation process. Because health care involves exchanges between the holders and users of different explanatory models, the practitioner and client negotiate as "therapeutic allies" for treatment. In this study, clinical negotiation between chiropractor and new client is viewed as the key arena for client socialization. Negotiation is important because it may engage the client's trust, prevent major discrepancies in the evaluation of treatment outcomes, promote compliance, and reduce client dissatisfaction. There are, however, some barriers to negotiation in medical care. To begin with, and as I have discussed in Chapter 2, the roots of contemporary allopathic doctor-patient relationships are in the authoritarian power structure of traditional practitioner and patient interactions. Professional biomedical relationships have always been hierarchical. Therefore, the social class and - 126 -prestige of the client can influence how much "power" or influence he is accorded in the clinical encounter. The situation is somewhat different for chiropractic. Not being the "official" medical system, clients are not mandated to visit chiropractors in order to legitimate ill-health. Rather, clients visit chiropractors because a friend, family member or colleague has asked them to do so or because the client has decided on his own. Sometimes they visit because they have read about it in newspapers. Even when they have decided to visit a chiropractor, they often experience difficulties either because they lack knowledge of chiropractic or because they are unable to easily locate one. Given the deviant perceptions of chiropractic that have been fostered over time, it would seem that greater authority in the relationship would be enjoyed by the client. If this is indeed true, it becomes all the more necessary for the chiropractor to "please" the client and work hard at negotiating compliance to chiropractic treatment. For successful clinical negotiation to occur, both the practitioner and the client must develop a therapeutic or working alliance. Greenson (1967:191) has defined therapeutic alliance as "the relatively non-neurotic rational rapport that the patient has with his analyst". In the traditional allopathic doctor-centred approach, this alliance is helped by "the patient's motivation to overcome his illness, his sense of helplessness, his conscious and rational willingness to cooperate and his ability to follow directions". However, Meissner and Nicholi (1978) stress that the working alliance is based on both - 127 -the patient and physician's explicit agreement to work together toward a mutually desired objective, the improvement of the patient. In order to carry out a negotiation, certain fundamental characteristics of an effective practitioner-client relationship are essential. These include setting up and establishing a milieu that is warm and accepting, in which the client can express troublesome feelings, values and beliefs. The central feature in this milieu may be the practitioner's empathy. Empathic feelings on the part of the practitioner could help el ic i t the client's explanatory model, and, therefore, increase the affective bonds between the practitioner and client. Sometimes, the formation of a working alliance may be hindered by negative feelings arising either in the client or the practitioner. These feelings can be based on such things as the client's or practitioner's appearance, persona-l i ty and behaviour, or on conflicts in perspectives and expectations that emerge but are not resolved. Also, negative feelings can be based on unconscious processes whereby the client or practitioner transfers experiences and emotions they have had towards people in past situations. For example, a client may react negatively to a practitioner because he is reminded of unpleasant past experiences with another practitioner or other individuals. In general, negative feelings can arise from "distrust" on the part of either partner in the relationship. Katon and Kleinman (1981) observe that some conceptual differences can exist between client and practitioner. These include situations in which the client and practitioner use the same term but actually mean different things; - 128 -use the same term, apply it to the same phenomenon, but have different aetiologic concepts; use different nosologies for the same referents; have different emotive meanings attached to same illness condition; or simply do not use the same terms. They suggest a model of clinical negotiation in which the practitioner first elicits the client's explanatory model as the basis for further progress. Through negotiation, each participant may shift his own explanatory model until there is agreement on treatment, or at least some form of compromise has been realized. Katon and Kleinman caution that some areas of conflict may persist, but in all instances, negotiation must involve ongoing monitoring of the agreement. The elicitation and presentation of the client's and the chiropractor's EMs, as suggested by Kleinman, occur in the context of how people "usually" relate to each other or how they present themselves during the process of "normal" interactions. Regarding everyday contacts between two individuals and the associated behaviours, reactions and expectations, Goffman (1959:249) comments as follows: "When one individual enters the presence of others, he will want to discover the facts of the situation. Were he to possess this information, he could know, and make allowances for what will come to happen and he could give the others present as much of their due as is consistent with his enlightened interest. To uncover fully the factual nature of the situation, it would be necessary for the individual to know all the relevant social data about the others full information of this order is rarely available; in its absence the individual tends to employ substitutes - cues, tests, hints, expressive gestures, status symbols, etc. -as predictive devices." - 129 -Goffman further comments "that since the reality that the individual is concerned with is unperceivable at the moment, appearances must be relied upon in its stead. The more the individual is concerned with the reality that is not available to perception, the more must he concentrate his attention on appearances" (p.249). The implication of Goffman's comment is that the negotiation of EMs by chiropractors and new clients is undertaken in the context of what people usually do when they interact. They define the "reality" of the situation and the communication that is being presented. They also use "appearances" to define the environment. These cognitive behaviours are the starting points in the socialization process prior to the negotiation of EMs. How the parties in the interaction appear to each other as well as the appearance of the chiropractic clinic are important aspects of forming the impressions that influence the "reality" of the negotiation. Both the expressions that are given off and the symbolic gestures that are used in the interaction such as cues, hints, expressive gestures and symbols are used as sources of information and as predictive devices for evaluating the reality of the interaction. How "genuine" is the negotiation of EMs between the chiropractor and the new client? Kleinman (1980) and Katon and Kleinman (1980) have indicated that crucial to the "shift" in EMs and in the structure of clinical relationships is a recognition that clinical care should involve a genuine negotiation between the practitioner and the patient. However, Goffman (1959) has noted that in the Anglo-American culture, there are two common-sense models according to which people formulate their conceptions of behaviour, namely, "the real, sincere or - 130 -honest performance; and the false one that thorough fabricators assemble -whether meant to be taken unseriously as in the work of stage actors, or seriously as in the work of confidence men" (p.70). Goffman writes about "contrived performance" or something which has been "painstakingly pasted together". Thus, in the "real world" of face-to-face interactions, performances such as negotiations for some particular purposes may be, in part, "contrived performances" by one or both participants in the interaction. Goffman (1959:46-47) writes: " performers often foster the impression that they had ideal motives (they) may even attempt to give the impression that their present poise and proficiency are something they have always had and that they have never had to fumble their way through " Viewed in this way, it is possible that some aspects of the process of EM negotiation may be "contrived performances" and other aspects, real or genuine negotiations. In clinical interactions, individuals present products (beliefs, norms, habits) to others, and sometimes they will tend to show others only the end product with which they wish to be evaluated, such as "something that has been finished, polished and packaged" (Goffman, 1959:44). Thus, "there is a tendency for performers to offer their observers an impression that is idealized" (p.35). On the decision to take a course of action, Goffman (1969:15) writes: "If the subject has not decided on a course of action yet, he can feign that he has, or he can feign that he hasn't when he has feigning refers to beliefs, attitudes and preferences misrepresented strategically." - 131 -In chiropractic-client interaction, a client may "feign" agreement with the outcome of the negotiation without "actually" being in agreement with the decision. In such an instance, the client may withdraw from treatment soon after the initial visit to the chiropractor. Similarly, a chiropractor may "feign" interest in the patient's explanation of "cause" in order to develop an argument against i t . 3.3 Language, Normal Conversation and Negotiations in Clinical Settings In this section, I am specifying how one can examine clinical negotiations by considering the structuring of language in conversation which is more detailed than Kleinman's method for understanding the negotiation process. When listening to conversation, one is impressed with the variety of ways that information is exchanged. When analyzing discourse, one is equally impressed with its organized character. Theory and research suggest that language is a social production in which different linguistic arrangements are visible in different situations and in which there is a relationship between the spoken word, the actions performed, and the structure of talk (Fisher and Todd, 1983; West, 1983; Fisher, 1986). More recently, language has been analyzed as discourse - a naturally occurring, locally organized, social production - both in ordinary conversation (Fisher, 1986) and in medicine (Mishler, 1984). The function of language in medical interviews is to assist in the negotia-tion of illness labels and in arriving at treatment decisions. Language, therefore, provides information, moulds the decision-making process, and influences medical outcomes, while at the same time, reflecting and sustaining institutional authority. - 132 -It has been shown that in normal conversation, there is balanced partici-pation among all conversational partners (Shuy, 1983). Each of the partners in the conversation ask questions, initiate topics, and they interrupt each other about equally. In other words, ordinary conversation is characterized by a symmetrical discourse structure. If, in ordinary conversation, a greeting is initiated by one conversational partner and is not followed by a greeting response by the other partner, the absence is noticeable. The first greeting calls for the second greeting and the second greeting reinforces the appropriateness of the other (Schegloff and Sacks, 1973). In ordinary conversation, this assymmetry is disrupted when one partner has more status and power than the other. For example, Zimmerman and West (1975) have demonstrated that when men are talking with men or women with women, the interruptions are about equally distributed across the conversational pair. But when men and women talk with each other, men do the most interrupting. Zimmerman and West conclude that this finding reflects the higher status of men in soci-ety. By implication, in situations in which conversational partners have unequal status, such as in physician-patient relationships, the most interrupt-ing will be carried out by the higher status interactant, in this case, the physician. Practitioners and clients each have information that the other needs in order to reach a "diagnosis" and/or decide upon a treatment. They exchange their information through the negotiation process of initiation and response. Clients describe symptoms and ask for clarification about their health problems while the health practitioner makes a diagnosis and recommends treatment. Clients react. They can either agree, disagree, or negotiate. According to - 133 -Fisher (1986), the entire conversation contains four separate discourse forms which serve different functions, namely: "corrections, comments on the inter-action, back channel utterances, and overlaps" (p.68). (a) Corrections These are similar to evaluations and are performed by the person in authority and they basically serve a teaching function. They are "attempts to get the facts straight by f i l l ing in the appropriate medical term or correcting a mistaken impression" (Fisher, 1986:68). Fisher (1986) argues that in the physician-patient conversation, the dominant partner - the physician - is more likely to interrupt the less dominant partner - the patient, whereas in casual conversations, interruptions are shared relatively equally by partners in the conversation (West, 1983). However, Shuy (1983) disagrees and suggests that in medical interactions, patients more often interrupt doctors. He goes on to argue that dominance is usually displayed, not in the interruption, but in who keeps the floor after-wards. In the same context, Fisher (1986) argues that when the doctor wants the floor, he claims it and gets i t ; thus, demonstrating dominance. (b) Comments Although comments on the interaction are made by both physicians and patients, Fisher (1986) finds that "they display that the hearer is following the interaction, has additional information to add or is competing for control" (p.69). Fisher finds that in her study, the patient wrestles with the doctor - 134 -for control. After each comment act, the doctor maintains or reclaims the floor to continue the topic under discussion or to initiate a new one. (c) Back Channel Duncan (1972:45) has observed that back channel comments are similar to comments on interaction, except that they take the form of "clucking" noises such as "uh", "urn", "hum", and they do not usually mark the end of sequences. In everyday conversations, back channel comments are used to indicate that the hearer is listening and understands the preceding "chunk" of information. During a medical interview, "yes" or "no" would be strong responses. "Yeah", "uh-hum" or "huh-uh" are weaker responses and they may indicate uncertainty. Fisher (1986:73) notes that "the doctor either recycles the utterance immediately preceding the back channel comment, or he continues as i f he has not heard it". (d) Overlaps or Simultaneous Speech These are similar to back channel comments except that they occur in the foreground or main channel, thus, they represent a struggle for the floor. For example, a patient may request information from a doctor, and while the doctor is trying to provide i t , the patient interrupts him, challenging the information he has just given or vice versa. The institution of medicine lends authroity to its dominant actors - the allopaths. This authority shapes the structure and form of medical discourse and it has consequences for the delivery of care. Several studies (West, 1983; - 135 -Fisher, 1983,1986; Shuy, 1974) have shown that although the style of doctors can vary, patients can have input into the decision making process but the asymmetry of the medical relationship remains constant. The institutional authority of the medical role and the control it provides for allopathic physicians does not change. What, therefore, is the nature of the relationship between chiroprac-tors and their clients? Is it so different from that of allopathic physicians that clients do indeed "prefer" the relationship and opt to remain as chiroprac-tic patients? One of the ways to understand differences in allopathic and chiropractic relationships with patients and clients is by examining the asymmetry of the relationships. All four forms of the comment act - correction, comments on the interaction, back channel, and overlap - reflect the asymmetry of the practitioner-client relationship and they show how the asymmetry is enacted in ongoing interactions between them. Corrections are much like evaluations. The doctor or the person with the most authority corrects patients' pronunciation of medical terms, correct their understandings of their medical problems, and have the last word on the definition of the problem. All of the other comment acts share one feature with corrections (or evaluations). They display the authority of the doctor. They can signal the completion of a sequence, they can be used to hold the floor, and they can be used to add or reinforce information. The negotiation between the concerns of doctors and patients, structures the exchange of information necessary to make a diagnosis and reach a treatment decision. They may also discuss topics that are not directly oriented to - 136 -treatment decisions, but which also contribute general information to the decision-making process. Thus, medical interviews are assembled through the production of topics, and both the medical interview and the production of topics are influenced by the practical concerns of the participants, negotiated as they communicate, and structured by the asymmetry of their relationship, unlike ordinary conversation (Shuy, 1983) in which one conversational partner does not ask a l l , or even most, of the questions or initiate all or most of the topics. Fisher (1986) has noted that although doctors and patients negotiate medical decisions, the negotiations are heavily weighted in the doctor's favour. How do chiropractors and new clients negotiate treatment decisions? What aspects of the chiropractic-client relationship encourage new clients to remain in chiropractic treatment? How are chiropractic clientele made? I have argued that answers to these questions can be obtained by describing and analysing the chiropractic treatment environment, the relationship between chiropractors and new clients, the negotiation of explanations for illness problems and the nature of conversational discourse between clients and chiropractors, and by comparing the findings with what one knows about the processes of the "official" allopathic medical care. The thrust of the study is to look for those factors which lead new clients to become chiropractic patients by examining what chiropractors do to convince them, bearing in mind the nature of the constraints that are faced by chiropractic, as a healing profession in the province of British Columbia. I, therefore, argue that the success of chiropractic depends upon its ability to socialize new clients during the initial set of clinical encounters - 137 -and interactions such that the social stigma of chiropractic and the various political legal and economic constraints imposed upon chiropractic, are effectively dismissed in the chiropractic-client relationship. - 138 -CHAPTER 4 4.0 METHOD OF STUDY Very l i t t l e research has been done on chiropractors at work. The main exceptions are the studies of chiropractic by Wardwell (1951), which employed a Parsonian approach in analyzing the phenomena of strain reduction, and the more recent work by Cowie and Roebuck (1975) which described chiropractic clinic as a 'deviant' enterprise. Because l i t t l e knowledge yet exists on chiropractors in clinical settings, it is important to study multiple clinical interactive settings in order to add to existing knowledge regarding chiropractic medical care. Much of the existing sociological work on chiropractic (see Chapter 1, Section 1.4) has examined issues such as marginality, statuses, deviant roles, professionalism and student socialization, all of which are largely outside the context of clinical behaviour and interactions. The contributions of this study are not only to document chiropractic clinical interactions in a local setting, but also to explain how chiropractors successfully socialize their clientele, given the historical limitations and social stigma affecting their work. Because there is l i t t l e information on chiropractic clinical interaction with clients, and because most other studies have utilized one approach to examine the complex issue of "success" of chiropractic, it was decided to use multiple approaches in order to minimize the methodological limitations of one approach (Forcese and Richer, 1973). - 139 -Preliminary inquiry three years earlier indicated that a pilot study would not be possible. Chiropractors are generally suspicious of studies about themselves because of "past experiences". A number of previous studies, in their opinion, merely sought to confirm their 'deviant' professional status and to provide "official" allopathic medicine with "slanted" reasons for opposing chiropractic. One leader of chiropractic put it this way: "We know from experience that many of the so called experts have made up their minds against us before they come to us. Some of them do not bother to visit a chiropractic cl inic, or talk to us, yet they come up with expert conclusions about us. When we talk to them, they select just the information that suits them I think their jobs will be at stake if they do not find something against us. After a l l , allopathic physicians dictate and influence their thinking and money." The situation may not be as accurate as the above comment indicates, however, it reflects the general view that is held by chiropractors that there are few studies which have examined them in clinical settings or which have shown a positive light on their work. Given these views by chiropractors about research, a pilot study was not possible. Nevertheless, it was vitally important that I obtain the utmost cooperation from chiropractors in my own research, especially since my own training, many years ago, had been within biomedicine and allopathic health care. This cooperation was obtained by soliciting support for the study from the President of the provincial Chiropractic Association. The purpose of the study was explained and a letter from my faculty advisor helped to convince him that this was essentially a "university study" (Appendix 1). At the time, I had been responsible for administering the Department of Rehabilitation Services at - 140 -the local university hospital, so there was some understandable concern by the Association's President regarding the purposes of the study. I explained to each of the participating chiropractors that I was not evaluating chiropractic treatment per se. Instead, I was interested in chiropractic as a "medical system", in particular, how they "organize and carry out their work". The approach to the study combines different methods, each aimed at particular aspects of the research. The work routines of chiropractors are described through the techniques of interview, observation of chiropractic clinical settings and clinical interactions including "backstage" behaviours, and the examination of professional and clinical records. 4.1 Methodological Orientation Forcese and Richer (1973:79) have noted that the objective of descriptive enquiry is "the exploration and clarification of some phenomena where accurate information is lacking". They view descriptive studies as necessarily intended "to provide description, as thorough as possible, often with a view to providing material and guidance for subsequent research". Sociological studies on chiropractic have largely utilized methods such as survey techniques, usually conducted outside of the chiropractic clinical setting (Kelner et a l . , 1980; Parker and Tupling, 1976; Gardner, 1975). When observation of clinics have been undertaken, they have involved a single clinic in a particular locale (Cowie and Roebuck, 1975). In other instances, some social scientists have based the analysis of the success of chiropractic on prior conceptions of chiropractic which have been formulated without direct - 141 -observation of clinical interactions (Coulehan, 1975; Firman and Goldstein, 1975). Thus, there is lack of basic information of a descriptive nature on chiropractic clinical interaction with clients. In other words, additional information, from the point of view of chiropractors and their clients, is required to guide further development of knowledge about chiropractic. A descriptive as opposed to a quantitative methodology is chosen because, as Schwartz and Jacobs assert (1979:7), "the only 'real' social reality is the reality from within". Quantifications of reality are inventories of the social world, of lists of things to be found in societies, sub-cultures, institutions, hospitals, and universities. Things that are measured can be individual persons, groups, whole societies, speech "acts" and so on, all of which are extrapolations from reality. Qualitative methods, on the other hand, provide observations of actual behaviour in natural settings. The basic goal of sociology, is to develop ways of gaining access to the life-world of individuals. It is important to discover the daily activities, the motives and meanings, and the actions and reactions of the individual "actor" in the context of his daily l i fe . Thus qualitative methods, which rely upon natural language, are best for gaining access into the life-world of individuals. By life-world, I mean emotions, meanings and other subjective aspects of the lives of individuals and groups. This includes their daily actions and behaviour in ordinary settings and situations, the structure of those actions and the conditions that accompany and influence them. In the qualitative orientation, the lay person becomes the expert about his world. As Schwartz and Jacobs note (1979:7): - 142 -"Instead of trying to discover things about a social world that those within it do not know we want to know what the authors know, see what they see, understand what they understand. As a result, our data attempt to describe their vocabularies, their ways of looking, their sense of the important and unimportant and so on". The basic orientation of this study, therefore, is that in order to understand social phenomena, the researcher needs to discover the actors' definition of the situation, or his perception and interpretation of reality. Their interpretations of reality lead to ongoing interpretations of social interactions that they and others participate in, and which involve the use of language in symbolic ways. Therefore, in order to understand social interac-tions, language and meanings, the researcher needs to place himself within the social situation, either through participation or observation or both. From this orientation, social meanings which guide human behaviour do not only inhere in activities, institutions, or social ob.iects themselves. Rather, meanings are also conferred upon social events by interacting individuals who must first interpret what is going on from the social context in which these events occur. The emerging definition of the situation is seen to result from the interplay of biography, situation, non-verbal communication and linguistic exchange that characterizes all social interactions (Cicourel, 1974, Kleinman, 1980). It has been argued that researchers should spend less time cataloguing different kinds of social settings and more time describing the forms of interaction within these settings (Kleinman, 1975). Ultimately, it is the form and extent of interaction, not the setting per se, that are of greatest interest. Similar social settings often produce very different patterns of - 143 -interaction, while patterns produced by different settings may be quite similar (Jacobs, 1975). Ball (1967:295) has proposed that we go "directly to the unconventional actors and their subcultures; it is only within such procedures that the natural context of deviance (or any social inte