Sociology Mind
2012. Vol.2, No.4, 465-476
Published Online October 2012 in SciRes (
Copyright © 2012 SciRes. 465
Defending the Self in a Total Institution: Staff Prompting
and Patient Burlesque*
Karen Bettez Halnon
Sociology, Pennsylvania State U ni v ersity, Abington, USA
Received August 18th, 2012; re vis ed September 19th, 2012; accepted September 28th, 2012
This paper offers an analysis of forms of social interaction between direct care staff and patient members
of a state institution for the “Mentally Retarded” (MR) and dually-diagnosed (MR with a mental disorder
diagnosis) located in the northeastern United States. This work’s significance is that it updates and ex-
tends Erving Goffman’s (1961) classic study of the underlife of total institutions. It does so by delineating
a sub-type of secondary adjustment to total institutions, termed ancillary adjustment. Ancillary adjust-
ment is defined as performances of patient role that undercut the institutions official prescription for pa-
tient identity toward normalizing direct staff member identity. It is shown how ancillary adjustment arose
as an unintended consequence of the institutional reforms of the 1970s, or how, under a professionally
reformed and bureaucratized “New School”, direct care staff members experienced themselves as disem-
powered and discredited as “normal” professionals and defensively and repeatedly cued hyper-stigma-
tized comedic spectacles through types of staff-patient interaction termed staff prompting and patient
burlesque. This paper is based on a three-year fieldwork study entitled Defending the Self in an Institution
for the Mentally Retarded that utilized Glaser and Strauss’ (1967) and Strauss and Corbin’s (1990)
grounded theory methods for qualitative research.
Keywords: Stigma; Normalization; Underlife; Total Institution; GOFFMAN; Mental Patient; Mental
A staff member pointed to the scars remaining from a lo-
botomy performed on (Jason) and inquired, What happened?’
(Jason) responded, They took my brains out.’ The staff mem-
ber probed, Who?’ (Jason) concluded the dialogue, The doc-
tors!’ Laughter gushed down the hall from the dayroom
(Fieldnotes, 1992: p. 6).
“(Harry), a graying Mentally Retarded man in his fifties, was
prompted again to perform a kind of sideshow when staff dis-
cussed his dramaturgical talent in his presence. One staff
member asked, Have you ever seen (Harry) when he wraps his
legs around his head? It is hilarious!’ (Harry) followed the
indirect cue by displaying his talent, as he sat silently on the
couch, staring off toward the television (Fieldnotes, 1992: p.
Today again (Lenny) was prompted when (two male staff
members) cued him to approach a float (a staff member from
another building covering the shift) with his usual humorous
approach, Do you like me? Do you like me? Do you like me?’
As he did so, drool spilled from his mouth and the targeted staff
quickly moved back in repulsion. Everyone in the room burst
into laughter (Fieldnotes, 1992: p. 26).
This paper is about forms of interaction observed at a state
institution located in the northeastern United States: staff
prompting and patient burlesque, or direct care staff cueing
patients to perform as hyper-stigmatized comedic spectacles.1
In these carefully guarded theatrical displays adult male pa-
tients were repeatedly prompted by male, working class, direct
care staff members to perform beyond their al ready stigma tized
status as institutionalized, Mentally Retarded, and/or mentally
ill persons.
Patient burlesque played upon a number of symbolic displays
of debasement: patient ignorance, begging, self-denigration,
sexual exposure, gibberish speech, and alterations of the nor-
mative mode of communication. It also involved “comedic”
scenes of patients asserting their discredited selves, violating
the social space of others, and performing various animated
spectacles and sideshows. It is argued that staff prompters en-
gaged in these interactions as a method of defending their
stigmatized selves through the dramatization of high contrast
deviant others in a reformed and professionalized total institu-
tion dedicated to normalizing patients.
*I wish to expre s s my heartfelt th anks to Pau l Gray and David Karp for their
invaluable instruction on qualitative research methods; to Kathy Charmaz
and Paul Gray again for encouraging me to finally publish this work; to
Vivian Qin , the edi torial s taff and t he reviewer s at Sociology Mind for their
constructive comments; and especially to all those persons and/or individu-
als at Glendale who opened and entrusted their institutional world to me.
1The term “patient” is used in all subsequent writing (both text and quoted
fieldnotes) to maximize clarity and consistency. However, several terms
were used to refer to patients during the study, each successive change in
nomenclature attempting to relinquish the negative connotations that caught
up with the last term employed. Currently, patients/clients/residents/citizens
of the institution are called “persons.”
Several factors explain staff prompter stigma: lack of
self-identification as normal professional employees; daily
intimate contact with patients; patient elites assuming staff
member roles and unofficial evaluators of employee worth;
open patient knowledge disputes with higher ranked employees;
a policy of normalization that bitterly coexisted alongside mul-
tiple impediments to achieving normal employee status; and on
the face of it, engaging in what professional staff members
would surely define as patient abuse. However, a sociological
analysis of the multi-layered meanings of staff prompting and
patient burlesque will reveal a complexity of complicity whereas
the institutional arrangements share at least equal responsibility
for the interactions discussed.
Literature Review and Study Significance
What is close conceptually to patient burlesque are images of
Otherness produced through practices such as freak shows,
blackface, pornography, and through a more particular histori-
cal case, French neurologist Jean-Martin Charcot’s hysteria
shows. In each of these examples, like patient burlesque, stig-
matized individuals perform as super-stigmatized before an
audience and, in entertaining others, magnify their already
stigmatized statuses. As Bogdan (1988) puts it, in the freak
show of Barnum and Bailey the extremely tall man is trans-
formed into a “giant”. Similarly, in blackface, the African
American in white racist society becomes the “strutting dandy”
or “shuffling darky” (Gubar, 1997: p. 113). In pornography, the
woman in sexist society is exaggerated in her stigmatized status
as she is reduced to a naked sexual object (Dworkin, 1989). In
Charcot’s theater of hysteria, the medically elusive madwoman
becomes the objectified spectacle of enormously detailed tax-
onomological classification (Micale, 1995). In these images—
like patient burlesque—Others are portrayed as willingly objec-
tified. While mimesis-mimicry or “burlesquing the mockers
through self-mockery” (Gubar, 1997) are undoubtedly dimen-
sions of these practices (and will be noted briefly), this paper’s
focus is on the value of staff prompting and patient burlesque as
a form direct staff member self-defense in a total institution.
The literature on domestic violence points toward a partial
explanation. Dutton’s (1995, p. 83) psychological profile of the
batterer provides evidence of a relationship between abuse and
self-defense. Because of a typical history of parental shaming,
batterers suffer from “an attack on the global sense of self”. As
a defensive measure, shame-prone batterers in turn shame their
partners. Dutton explains further, “These men have a need to
shame and humiliate another human being, to finally obliterate
their own shame and humiliation” (Ibid, 35). Martin (1976: p.
68) echoes Dutton’s and also Lederer’s (1968) reported links
between the batterer’s insecurity and domestic violence when
she claims that wife beaters only experience themselves as
potent with a woman defective or somehow inferior”.
If their wives do not assume that they are inferior or con-
sider themselves equal to their husbands, apparently these men
feel they have to beat them down to size. If his wife is attractive,
the batterer, in order to maintain his potency (that is, his male
supremacy), has to disfigure her.”
Analogous to the domestic violence situation is the social
situation of patients and staff prompters. A definition of the
patient as normalizing (or institutionally defined with the ex-
pectation of becoming a “culturally normative” person through
re-socialization) grates against the contrasting failure of staff
prompters to achieve institutional status as “normal” profes-
Defending against a kind of “relative deprivation” of nor-
malcy potential in the total institution, staff prompters focused
their various ridiculing activities on what most directly sym-
bolized their own exclusion from institutional normalcy. Lack-
ing the college education to qualify as professionals, direct staff
prompted patients to display gross ignorance and infantilism,
and through doing so, effectively “beat them down to size”. The
transition from presumed normal in society (or white male
pre-employee) to a structural situation in a total institution that
called such normalcy into question (employee status without
the educational credentials subjectively necessary to perceive
oneself as a professional) became an occasion for defending the
Kaplan’s (1980) work on “deviant behavior in defense of
self” demonstrates more generally that the “self-esteem motive”
lies behind a range of deviant behaviors, such as suicide, de-
linquency, drug abuse, and violence. Kaplan (Ibid., 9) argues
that deviant behavior is likely to ensue when three conditions
are met:
“1) Self-perceptions of failure to possess personally valued
attributes or to perform personally valued behaviors (and self-
perception of possessing attributes or the performance of dis-
valued behaviors).
2) Self-perception of failure to be the object of positive atti-
tudes by personally valued others (and self-perceptions of be-
ing the object of negative attitudes by personally valued oth-
3) The failure to possess and employ normatively defined
self-protective response patterns that might preclude the oc-
currence or mitigate the self-devaluing effects of such experi-
Kaplan notes, moreover, that “The probability of outcomes,
in turn, is influenced by such variables as placement in the
social structure (which influences such outcomes as disjunc-
tions between socially defined goals and access to the goals
and/or the probability of other stigmatizing experiences).”
In this paper I will explain that although staff prompters
outwardly rejected the value of professional status and associ-
ated professional behaviors, they clearly experienced their
status as high school graduates and their daily practical man-
agement of patients as devalued by college-educated staff who
had the institutional authority to enforce their professional per-
spective. And unlike professional staff who were able to guard
themselves from “courtesy stigma” (Goffman, 1963) through
infrequent contact with patients, the job requirements of direct
care staff placed their distance from patients at a minimum.
Their status as normals in an institution dedicated to normaliz-
ing patients was further impeded by professional staff who
permitted patients to judge staff members, by patients who
assumed (at the ironic bequest of staff prompters) staff member
roles, and by patient elites who actively distanced themselves
from staff prompters. I will argue that the “deviant self-protec-
tive response pattern” of staff prompters was to hyper-stigma-
tize patients through theatrical displays and while doing so, as a
kind of “jocular aggression” (Pogrebin & Poole, 1988), mock
the patient’s normalization program.
The ethnographic work that comes closest to this study is
Wiley’s (1988) on a holistic therapeutic community for schizo-
phrenics in which the hierarchical distinctions between staff
and patients were nearly nonexistent, and where “each status
converged to the extent that it was often difficult for anyone at
a given time to know who was who” (Ibid., 5). At Quaesta, that
sponsored a “democracy of interaction,” “the attempt to exert
authority by virtue of professional status (was) both formally
and informally, frowned upon and negatively sanctioned” (Ibid.,
9). While Wiley (Ibid., 18, 22) notes the positive consequences
of “role blurring” (“an unusual sense of camaraderie among
Copyright © 2012 SciRes.
staff and resident”), her analysis focuses on how staff aimed to
reassert their authority over patients through “subtle interac-
tional devices.” For example, when a “resident became too
insistent on the democratic principle of order” in a heated de-
bate “the staff often called attention to the individuals thera-
peuticissues’” (Ibid., 23). “Psychic trashing,” a similar control
technique, was used by therapists who were in “the most pow-
erful position to define the reality of the situation over the
competing definition of the resident” (Ibid., 24). Wiley con-
cludes by outlining the “essential conditions (circumstances or
characteristics) under whichrole blurring is most likely to
occur.” In order of salience, she specifies “an equalitarian
ideology that demystifies the role of traditional authority” and
a general deprofessionalization of the occupational or organ-
izational context” (Ibid., 33). In this paper I will show, however,
that in the case of a total institution with a clear hierarchy of
staff authority, professionalization coupled with normalization
(the two measures of staff and patient normality in reformed
total institutions respectively) may give rise to substantial role
blurring between direct care staff and patients. I will show fur-
ther how, in consequence, such blurring may lead to “blatant
interactional devices” for reasserting social control.
This paper contributes more generally to the literature on
normalization principles (Wolfensberger, 1972, 1980; Whitman,
1995; et al.) by explaining the difficulties of implementation in
a reformed total institution. The contribution lies in the lack of
literature devoted to explaining such difficulties within total
institutions during their last phases of operation, since (institu-
tional pseudonym) Glendale’s explicit mission, as the general
undertaking of all similar institutions guided by normalization
principles, is community integration of patients and eventual
institutional closure. Given this charge, the relevant sociologi-
cal literature focuses almost entirely on de-institutionalization,
critically assessing its failures (Dear & Wolch, 1987; Grob,
1995; Isaac, 1990; Johnson, 1990; Kip, 2000; Mechanic, 1990;
Scull, 1989; et al.) and seldom highlighting its successes. The
works of Bilken (1989) and Taylor, Bogdan, Biklen, and Fer-
guson (1989) that examine the “bright side” of community
integration (Taylor et al., 1989) stand as clear exceptions. Posi-
tive assessments are typically found in professional (e.g., Malik
& Shaver, 1979) rather than strictly academic or sociological
reports. While the literature reviewed focuses on assessing how
well community care has been realized under the auspices of
normalization principles and it counterpart, de-institutionaliza-
tion policy, this paper focuses on the implications of coupling
professionalization and normalization in the continued opera-
tions of a reformed total institution. More specifically, I will
show how this coupling had the unintended consequence of
providing an organizational structure ripe for exploitative in-
teractional forms that would magnify rather than reduce patient
deviance; and thus, undermine the central purpose of the re-
formed institution, to culturally prepare patients for discharge
and community integration. Thus, while I do not entirely depart
from typical negative sociological assessments, I will provide a
closer lens on institutional analysis that appears to have been
largely abandoned after the 1970s implementation of de-insti-
tutionalization policy.
The analysis to follow focuses around Erving Goffman’s
concept of “adjustment,” as explained in the series of essays
that constitute Asylums: Essays on the Social Situation of Men-
tal Patient and Other Inmates (Goffman, 1961). In “The Un-
derlife of a Public Institution: A Study of Ways of Making Out
in a Mental Hospital” Goffman defines two types of adjustment,
primary and secondary. Primary adjustment is the inmate’s
outward and apparent acceptance of his role and his self as
patient as defined by the total institution. Of the primarily ad-
justed patient he says, “he is transformed into a co-operator; he
becomes thenormal’, ‘programmed’, or built-in member
(Ibid., 189). In “The Moral Career of the Mental Patient” and in
“The Characteristics of Total Institutions” Goffman describes a
panoply of mortifying practices necessary for these self and
role adjustments including, for example, will-breaking ceremo-
nies, deprivation of personal property, personal disclosure
through case record and staff gossip, surveillance, echelon staff
authority, and regimentation of daily life. Primary adjustment is
made possible by stripping the patient of his previous role and
self and replacing them with the behavioral and identity expec-
tations of the institution. Goffman says, moreover, that primary
adjustment is no less than the radical transformation of subjec-
tivity and the alternation of social worlds.
Through this orientation and engagement of attention and
effort, he visibly establishes his attitude to the establishment
and to its implied conceptions of himself. To engage in a par-
ticular activity in the prescribed spirit is to accept being a par-
ticular kind of person who dwells in a particular kind of world
(Ibid., 186).
Emphasizing the resilience and expedience of human beings
to defend their selves in the most constraining circumstances,
Goffman shows how the patient’s primary adjustment may be
more apparent than absolute. Patients, he says, employ an array
of strategies to defend their selves in total institutions; for ex-
ample, through make-do’s; working the system; avoiding hos-
pital surveillance; designating free spaces, group territories, and
personal spaces; creating fixed and portable stashes; utilizing
undercover systems of communication; and engaging in private
coercion, economic exchange, and social exchange. These sec-
ondary adjustments, or what Goffman collectively terms the
patient underlife of the institution, “represent the ways in which
the individual stands apart from the role and the self that were
taken for granted for him by the institution” (Ibid., 187). Goff-
man succinctly distinguishes the two forms of adjustment: “To
prescribe activity is to prescribe a world; to dodge a prescrip-
tion can be to dodge an identity” (Ibid., 189).
Writing in 1961, Goffman (Ibid., 205) said that “secondary
adjustments on the part of Central Hospital employees should
be considered minor. I will therefore not consider many of the
standard secondary adjustments practiced by subordinates in
work organizations, such as restriction of output, ‘make work’,
government work’, collusive control of productivity report-
ing...” That Goffman’s work focuses on the underlife of pa-
tients rather than staff is justified by the extensive literature he
cites that accounts for the latter at the time. However, what
Goffman’s qualifying and typically exhaustive comments point
to is the absence at the time within Central Hospital, or else-
where reported to his knowledge, of a form of staff secondary
adjustment as a double defense reaction; first, against the pa-
tient’s primary adjustment as normalizing; and second, against
multiple impediments to achieving primary adjustment as nor-
mal professional employee. That I am able to elaborate on this
process, as “ancillary adjustment,” is surely due to a shift in
perspective, from Goffman’s on inmates prior to reform policy,
to a focus on the social situation of staff and patients after the
implementation of patient normalization principles. Because
this work is based upon a single institution and a subversive
Copyright © 2012 SciRes. 467
practice within it, its generalizability depends upon subsequent
findings. Nevertheless, that weakness of this ethnographic work
may be compensated for by the details I provide of the under-
life of an institution ordinarily closed off from the public and
sociological eyes.
Research Methods and Study Background
For a period of three years (1990 to 1993) I conducted a
fieldwork study at a state institution located in the northeastern
United States, identified throughout by the pseudonym Glen-
dale. “Grounded theory” methods (Glaser & Strauss, 1967;
Strauss & Corbin, 1990), and Lofland and Lofland’s (1984)
qualitative methods for analyzing social settings guided this
research. The research focused on the general question: how do
members of a total institution defend their selves? Erving
Goffman’s works on the presentation of the self (1959), stigma
(1963) and the underlife of total institutions (1961) were used
as general conceptual guides in analyzing the data. My general
aim was to extend Goffman’s insights on the underlife of total
institutions and the experience of stigmatized persons. In ac-
cordance with inductive research methods, fieldnotes were read,
coded, re-read, and re-coded until concepts and categories be-
came evident. Once concepts and categories emerged from the
data collected (and were manually placed as cut and pasted
from computer documents into manila files), a more purposeful
search for supporting examples and negative or disconfirming
cases was pursued in the field. The broader thematic signifi-
cance of the present work was given shape in the writing proc-
ess. This paper represents a small slice of three years of data
collected at a state-of-the-art total institution.
During two consecutive summers (1989 and 1990) I held a
job as House Director, a live-in position where I coordinated
weekly vacations for patient groups of ten at one of Glendale’s
off-grounds vacation residences. Regular Glendale staff ac-
companied each group of ten. Living in the same house and
being actively engaged with staff and patients from approxi-
mately 5 am to 11 pm each week provided an immersion into
the lives of approximately 50 direct care staff and 120 patients
each summer. Informal discussions with direct care staff during
these summer months yielded a rich understanding of their
perspective of working at a reformed and professionalized in-
My job required weekly reporting of the program to the up-
per administration at Glendale. Over summer 1989 I cultivated
a friendly rapport with them, which was enhanced by the fact
that a close relative of mine was closely linked to the institu-
tional administration. At the conclusion of the first summer
program, I proposed the fieldwork study to the Glendale ad-
ministration. While administrators were receptive to the idea,
and told me that I would be permitted access because “we can
trust you,” official access to the institution involved a year-long
process of seeking and obtaining formal approvals from the
state department(s) overseeing the Glendale administration. By
the next summer I was granted official access to facility
grounds, patient records, and institutional archives. I agreed
that patient and institutional identities would remain anony-
mous in any written documents resulting from the study. Pseu-
donyms for both are used throughout. Another agreement was
reached concerning not describing certain unique features of the
institution that would make its identity obvious to readers of
published documents. I have taken all possible precautions
while preserving the integrity of the data.
Weekly observation hours were spent largely talking infor-
mally with patients and staff on units, in the canteen, and else-
where on institutional grounds. Additional formal, tape-re-
corded, semi-structured interviews with patients and staff
members were conducted over a period of one year, but were
the least informational. I found that the richest data was ob-
tained when I held the least formal researcher role. Field notes
written following each observation session, which are the basis
of this paper, were the most useful source of data. Material
taken directly from them is indicated throughout by use of quo-
tations. In general, I have relied upon short quotations and
summary to maximize materials incorporated in this paper.
Explanatory comments are placed in parentheses within or after
Observations of patient burlesque and staff prompting be-
tween direct care staff and patients came late in the study, once
staff members knew I was no longer an employee of Glendale
with a reporting duty, and after many assurances that I was “not
working for the administration, but just conducting an aca-
demic study.” I found many staff members, who were later
identified as staff prompters, highly responsive to the fact that
they would have, through participation in the study, input into
explaining the pejorative “book knowledge” of professionals,
which they, as a whole, deemed inadequate. As one staff
prompter put it, “Maybe you can tell them the way it really is.
Book-knowledge, therapy, baby talking (patients) dont have
anything to do with reality.” Another remarked, “The psychs
(psychologists) and professionals sit in the office all day. The
college-educated paper pushers have no clue about what we
really need.” In cultivating a rapport with these men I at-
tempted to present myself as a neutral conveyer rather than an
adherent of book knowledge.
The data presented in what follows are based upon observa-
tions involving a total of 15 staff prompters and 20 patients.
Patients targeted for burlesque were typically involved in more
than one performance, and in a few cases, several performances.
All direct care staff and patients involved in the dialogues were
male. To the extent that female staff members and female pa-
tients were involved in the interactions their roles were consis-
tently limited to audience members. As a woman researcher the
gender positioning in the interactional form made it relatively
easy for me to adopt an observer role.
Patient performers were primarily those who gave off clear
and significant signs of mental illness, and secondarily those
who gave off serious signs of moderate to severe Mental Re-
tardation. In no case was a “high level” patient (that is, the
Glendale lingo for a patient with a very low level of Mental
Retardation) a participant in the dialogues. To clarify, Glendale
housed a large number of residents who, while their primary
diagnosis had to be Mental Retardation in order to live there,
their expressions given off to me, to staff, and to patients were
often much more descriptively those of mental illness than of
Mental Retardation. Population mixing was the subject of much
heated discussion at Glendale. The general consensus expressed
by staff prompters, high level patients, and many professional
staff members was that mentally ill residents were inappropriate
members of the Glendale community, or physical and social
threats to the Mentally Retarded. As one high level patient em-
phatically and loudly defended from the front of canteen one
day (a place ordinarily visited only in passing by high level
patients), “They think Im mental, but Im not! I might be re-
Copyright © 2012 SciRes.
tarded, but Im not mentally ill!” As a rule, high level patients,
some of whom were members of patient rights committees,
who observed staff prompting and patient burlesque, ignored
the behavior and to my knowledge never filed any reports.
While the aim of this paper is to demonstrate how some direct
care staff benefited from the construction of mentally ill and
low level patients as hyper-stigmatized, it may be noted that the
reticence of high level patients who observed staff prompting
and patient burlesque is suggestive of their own profit from
displays of radical Otherness.
As a young researcher I struggled with the ethical issues
arising from the interactions I witnessed as audience member in
the course of my fieldwork and reported in this paper. Con-
flicting allegiances to patients, Glendale administrators, and
staff prompters also; as well as feeling guilty about my role as
passive yet present audience member, explains in large part
why this research did not find its final form as my dissertation.
I present a portion of this research now as a somewhat delayed
but hopefully constructive informational piece. That this paper
focuses on the perspective of staff members rather than patients
is not an apology for that perspective, but to provide what I
believe is necessary knowledge in the formulation of effica-
cious solutions.
Staff Prompters and Stigma
The typical staff prompter at Glendale was a young (early
20s to early 30s), white, unmarried, working class man whose
education consisted of four years of high school. In a few cases
(2 of 15), he had taken a course or two at a local community
college. Staff prompters seldom traveled far beyond their
community, except in the case of military training. Prompters
self-reported spending their free time engaged in a variety of
local town activities characteristically including playing or
watching sports; drinking alcohol at parties or bars; talking
about or spending time with “girls”; driving or working on their
cars; or just “hanging out” with friends.
The socioeconomic position of staff prompters was a pre-
carious one. Staff prompter high school graduates came to
Glendale with the opportunity to earn a relatively good wage by
community standards. In addition, they would receive liberal
state benefits, and be hired as direct care “professionals”. How-
ever, in their employment at Glendale these men found that
they did not gain the anticipated rewards of occupational pres-
tige, but rather, were socially located at the margins of the in-
stitution. They found their roles as professionals at Glendale
discredited in a n u m b e r of significant ways.
It is important to clarify Erving Goffman’s meaning of
stigma. Stigma is a relational phenomenon. Stigma, or spoiled
or discredited identity, does not simply inhere in an attribute of
a person. It is rather a case of a discrepancy between expecta-
tions and a realization, or to be “incongruous with our stereo-
type of what a given type of individual should be” (Goffman,
1963: p. 3). More precisely, Goffman says that it is a discrep-
ancy between virtual identity and actual identity. Stigma is
falling short of virtual identity, or “an undesired differentness
from what we had anticipated” (Ibid., 5). To be normal, on the
other hand, is to be congruent with such demands and expecta-
tions, or to be one who displays a match between virtual and
actual identity. Upon hiring, the virtual identity of staff
prompters at Glendale was that they were professionals. Dis-
crepant with that expectation, the actual identity of staff
prompters was that they did not perceive themselves, nor did
others perceive them as professionals. For a large variety of
reasons explained below, they were excluded from the category
of normal employees at Glendale.
Lack of Self-Identification as Professional Employees. The
single, expected and demanded role of staff members at Glen-
dale was to act as a professional. Regardless of educational
background, all new employees were inducted as professionals
through a full time, one-week orientation program in which
empathy for patients and respect for patient rights were central
themes. A major impediment to achieving normal institutional
status was therefore not lacking knowledge of the requirements
of professional comportment, but a discrepant definition of the
role. Professional was a term used pejoratively among staff
prompters to refer to higher-ranked, college-educated employ-
ees at Glendale who did not engage directly and continuously in
the day-to-day care of patients. Professional, for staff prompters,
was a negative term that referred to upper administration, psy-
chologists, social workers, nurses, and some aloof or educated
building managers. College-educated professionals, according
to staff prompters, were “paper pushers,” “educated people
who dont know shit about (patients),” employees who “spend
all day in the office and come up with behavior plans that have
absolutely nothing to do with what (patients) really need. But
we have to implement them!” Thus, the role of professional was
foreign in terms of self-identification. In absence of that self-
identification, the achievement of normal status at Glendale
was, to begin with, a highly dicey prospect.
Engaging in Patient Abuse”. Glendale’s official under-
standing of the institutionalized patient in need of services was
as a social deviant. But patient deviance was understood to be
largely correctable through the use of normalization devices
such as behavior plans, individual psychotherapy, employment
programs, hobby groups, 12-step programs, and circle groups
for the development of interpersonal skills. What aspects of
deviance were not rectifiable through such measures were to be
compassionately accepted. Thus, Glendale’s mission was to
reduce patient deviance, not to expand it.
To entice patients to perform beyond the official self and role
prescribed by the total institution, or beyond the patient’s pri-
mary adjustment, was a serious transgression. Such interactions
would be considered, if detected, egregious and reprehensible
not only because they violated patients’ legally enforceable
rights, but also because they constituted a subversion of the
institutional goal of normalizing patients. Therefore, to prompt
patients to act like hyper-stigmatized spectacles was to abandon
the expected role of any employee of the institution, and to be
subject, if caught, to termination and legal prosecution. Patient
abuse, in the form of actively ab-normalizing patients, was thus
grossly discrepant with the expected role of Glendale, and thus
fully discredited staff prompters from the status of employee
normals. However, that staff prompters guaranteed their selves
as discredited through a set of interactions with patients that
would be condemned by professionals was more an instance of
secondary deviation than of primary deviation (Lemert, 1951).
Below I will explain how patient burlesque and staff prompting
did not constitute but rather compounded a complex institu-
tional situation that impeded staff prompters’ expected normal
status or primary adjustment as professional employees.
Daily Intimate Contact with Patients. The normal status of
staff prompters as professionals was further hampered by their
daily situational closeness to mentally ill and Mentally Re-
Copyright © 2012 SciRes. 469
tarded patients, which threatened with “pollution” and “con-
tamination” of stigma (Goffman, 1963; Goffman, 1961). More-
over, the threat of “courtesy stigma” (Goffman 1963), or
“catching” stigma through association, was not possibly re-
solved through the general strategy of “mystification” or social
distance (Goffman, 1959). This is because of the specific nature
of staff prompters’ daily work, which required ongoing verbal
interchange with patients and intimacies such as seeing, wash-
ing, and touching patient body parts and excretions. A high
level of intimacy placed staff prompters’ social distance at a
minimum. It was th is comparative difference t hat made it com-
paratively difficult for direct care staff to maintain the reality of
themselves as professional normals. Stability of self as a nor-
mal employee was a more realistic possibility for psychologists,
social workers, and administrators, and the like, who were
shielded from courtesy stigma through much less frequent and
intense interaction with patients. The “paper pushers”, largely
because of the bureaucratic necessities of extensive behavioral
and therapeutic planning and documentation, did indeed spend
the majority of their time in their offices or removed from the
regular round of life on the wards. This may explain why when
they did appear they often made dramatic displays of their (os-
tensible) knowledge of patients.
Open Knowledge of Patient Disputes with Higher Ranked
Professionals. Staff prompter stigma through close association
with patients was compounded by de facto professional exclu-
sion through open disputes with higher ranked professionals
concerning patient care. Arguments were typically over what
“really” constituted normalization. Disputes centered on issues
such as how patients should dress. Should Jerry be allowed to
wear a Mickey Mouse shirt and should Shawn be allowed to
dress up like a firefighter? The most contentious issue con-
cerned paperwork taking precedence over time that might be
spent engaged in more normalizing activities with patients. A
male patient who was seeking a sex change was also a heatedly
discussed topic among staff prompters who interpreted the pa-
tient as homosexual, who agreed that that “being a fag is not
normal,” and who expressed incredulity over the rumor that the
operation might be funded by the State.
Professional explanations of patient rights to dress as patients
choose, guarantees of compliance with state and federal guide-
lines for care and service through documentation, and staff
prompters perception of professional assistance in a patient’s
sex change (that was in fact quietly and unofficially discour-
aged by professional staff),were viewed antagonistically by
many direct staff and staff prompters in particular2. While most
of the hostility toward the requirements of implementing nor-
malization principles was expressed beyond the earshot of
higher ranked staff, sometimes direct care staff would directly
dispute issues. In these cases, their extensive practical knowl-
edge of patients was often discounted when higher ranked pro-
fessionals corrected and condescended to them in the presence
of staff and patients. These open disputes informed all who
witnessed them of who the “real” professionals were, and in
consequence, undermined direct care staff members’ expected
occupational status as professionals. Thus, in this case, status
ambiguity as normal was not due to lack of social distance as in
the case of intimate daily contact with patients. In this instance,
knowledge contests between direct care staff and higher-ranked
professionals created a large space of role distance between
employees at Glendale.
The association between knowledge-of-patient disputes and
inappropriate patient care may be exemplified by explaining a
common New School (Glendale lingo for after-reform) activity
of professional staff, which staff prompters sardonically termed
“baby talking the (patients).” During a full day of observation
one patient continually harassed a staff prompter by following
him from room to room, physically blocking him, talking di-
rectly into his face, and repeatedly demanding “Take me out for
spaghetti and meatballs!” From fieldnotes, the event is recorded
at greater length.
“(Zachary) must have made this demand a hundred times
during the day! Finally, at his breaking point, (the staff
prompter) reprimanded him in a loud voice, Shut up, already!
Ive had enough of you!’ As he did, a psych emerged from the
office into the hallway, having overheard the interaction. In the
presence of (the patient), (she) condescended to the staff mem-
ber, told him that his response to (the patient) was not appro-
priate,’ and proceeded to model a gentler, ostensibly more
therapeutic interaction, that is, to baby talk the (patient). The
disgruntled staff member listened quietly and nodded his head.
After the psych departed, (the staff member) declared to a
sympathetic co-worker that his response was hardly excessive
by normal standards. A punch in the face would be his nor-
malization in the real world!’ (the staff prompter) declared. A
short time later I could hear a physical altercation inside
(Zacharys) room. It sounded as if (the staff member) threw him
up against the wall while he was yelling at him. (The staff
prompter) emerged from his unofficial office, (Zacharys) room,
and announced victoriously, Now, Im in charge!’” (Fieldnotes,
1992: p. 34).
2The insistence of more realistic normalization principles was inconsistent
among staff prompters. Beyond the patient burlesque and staff prompting
interactions delineated in this paper, “kitchen switching” stood as a major
contradiction. Staff prompters expressed much hostility over the fact that
“patient snobs” (elite patients to be discussed below) were regularly allowed
in the kitchen by “professional” staff. According to staff prompters, the
“kitchen area is for staff, not (patients).” It was of considerable consterna-
tion that patient snobs were ordinarily allowed to occupy the kitchen with
many “professional staff,” sharing a cup of coffee, cigarette, or extended
conversation. During my first summer at the Glendale vacation residence I
was accused when doing the same, or of not treating them like(patients).”
When mixed i nt erac ti ons bet ween p rof essi onal s and elit e p ati ent s t ook pl ace
in the kitchen, staff prompters avoided the area, coming in briefly only to do
what was necessary. However, when professionals were absent, staf
prompters rigorously enforced “low level” patient exclusion from the
kitchen, but at the same time tolerated patient snobs who often (like
prompters, in the first case above) expeditiously passed through. I inter-
preted this behavior on the part of patient snobs as a statement of their ex-
ceptional status as patients, and I interpreted the silent disapproval of this
behavior on the part o f s taff prom pt ers as their uneasy recognition of it.
Without exception, in informal interviews staff prompters
self-described themselves as disrespected and unappreciated by
professionals and expressed antagonism toward them. More-
over, while staff prompters expressed disbelief in the more
credible knowledge of patients and their treatment by profes-
sionals, they expressed a discontented yet outwa rdly defere ntial
understanding that such knowledge was the more institutionally
legitimated knowledge. The observed disposition of staff
prompters was quintessentially authoritarian (Adorno et al.,
Patients Assuming the Roles of Staff Members and Evalua-
tors of Staff Prompters Professional Worth. The assault on
staff prompter normal self was reinforced by the roles assumed
by a small group of high status mildly Mentally Retarded pa-
tients. “(Patient) snobs,” as they were labeled by staff at Glen-
dale because of their selectivity in interactions with both staff
Copyright © 2012 SciRes.
and patients, overtly distanced themselves from staff prompters.
Eye contact was avoided. Entrance to rooms occupied by staff
prompters was delayed. Conversation was avoided or sharply
curtailed. Casual conversation between the parties was never
witnessed. Tension marked all minimal interactions. Patient
snobs’ expressed attitude toward prompters was one of civil but
evident disdain. When prompters verbally addressed patient
snobs, they listened politely and complied to the extent the
request was deemed reasonable; if not, the typical response was
to inform the prompter of the “correct” institutional policy and
to walk away, much like professionals condescended to staff
It is important to emphasize that as a rule patient snobs lim-
ited their interactions to those with professional staff, a small
exclusive group of especially high level patients, and a few
elderly patients for whom they assumed caretaker roles; for
example, for a deaf-mute patient they always addressed with
“hey, dummy.” The exclusiveness of patient snob interactions
with others magnified the stigma of staff prompters at Glendale
because what was common, indeed, about patient snob selectiv-
ity was their equally emphatic exclusion of “crazies” (patient
snobs’ label for seriously mentally ill patients) and staff
prompters. This judgment effectively placed the two groups in
the same general category of seriously stigmatized others3.
To intensify the already tense relationship between snobs and
prompters, a commonly utilized informal measure of a “good”
staff member by many professional staff at Glendale was the
patient snobs’ opinion of the staff member. This opinion fa-
vored considerably in me gaining access to the institution. Two
professional staff who were closely affiliated with patient snobs
informed me that Hal, the leader of the patient snobs, “took it
upon himself to put in a good word for me” with the admini-
stration. At Glendale, such reports were given serious consid-
eration in accordance with patient rights protections, especially
in the case of patients with a minimal level of Retardation who
could express their opinions with greatest coherence. Thus,
patient snobs were equipped with the power to define the gen-
eral worth of staff, which is to say inevitably and understanda-
bly to define staff prompters as unprofessional. Such authorita-
tive knowledge of staff by patients bitterly coexisted alongside
the frequent dismissal of staff prompters’ knowledge of patients
by professionals. Therefore, a further source of stigma for staff
prompters was that patient snobs reversed the usual social dis-
tance protocol. Patient snobs deliberately and explicitly dis-
tanced themselves from staff prompters and were endowed with
the authoritative knowledge to judge them. In other words, the
stigmatized patient assumed the role of the avoiding, judging
normal. Why patient snobs did not manage to have staff
prompters fired was assuredly due to the social benefit they
gained through patient burlesque. Much like what prompters
gained through the displays of hyper-stigmatized mentally ill
patients, high level patients gained perhaps several-fold consid-
ering their even closer social proximity to them as institutional-
ized “patients”.
A more explicit yet equally anomalous alliance between staff
prompters and patient snobs explains an additional source of
stigma for staff prompters. Elucidating it requires a brief history
of institutional arrangements between patients and staff mem-
bers. In the Old School (the institutional lingo for Glendale
before institutional reforms and professional restructuring)
patient care was charged to a small group of laterally organized
staff, under the supervision of a superintendent and very small
support staff. Maintaining order in the Old School was fairly
simple, as one staff member recalled, “if the kids (that is, adult
patients) acte d up, you took them out behind the building. That
usually solved the problem.” A common subsidiary strategy of
governing mass patients for Old School staff was the designa-
tion of “patient heavies” (my descriptive term, not Glendale
lingo) who served as staff assistants in gaining the compliance
of uncooperative patients through verbal intimidation and cor-
poral punishment. A small number of “hard working, more
intelligent kids (adult patients)” were selected to “keep the
others in line,” reported one Old School employee. It was also
often the case that a staff member who struggled with the as-
signment of managing two buildings at a time would delegate
supervisory authority of one of the buildings to a patient heavy.
Three patient heavies, at the time of this study in their late
sixties and early seventies, still retained authority that was
delegated years before. Significantly, these men were also the
most prominent patient snobs. Staff prompters, aware of the
legendary roles of patient heavies, occasionally settled “behav-
ior problems” by threatening to get Hal, Joe, or Jim. “Acting
out” patients responded to the simple threat to make a telephone
call to a patient heavy. It should be noted that while patient
heavies/patient snobs, as a rule, did not interact with staff
prompters as an expression of their disrespect for them, they
did as a rule accommodate requests to assume their Old School
role. This role ordinarily involved simply walking into a room
and asking in a commanding voice, “What’s going on here?” or
“What’s the problem?” A patient heavy’s authority no longer
rested on his physical ability to impose physical harm, as the
age, health, and general physical condition would have made
the successful application of corporal punishment on younger
patients highly improbable. Rather, patient heavies’ authority
rested on their legendary reputation.
It appears that even while generally estranged from each
other, staff prompters and patient heavies each benefited from
this particular temporary alliance. By assuming a position of
authority directly over patient “crazies,” patient heavies re-
claimed and re-lived their near-staff status of the Old School; a
method of nearly escaping their demoted and less differentiated
status as patients in the New School. And of at least equal sig-
nificance, they also displayed a managerial efficiency exceed-
ing that of staff prompters, the official staff members of the
New School. While prompters may have benefited from the
immediate resolution of patient behavior problems, and may
have even given others the temporary impression that they
could direct the actions of the least socially accessible patients,
they did so by appealing to their more effective behavior man-
agement skills. Despite the rewards, the result was a further
blurring of the lines between themselves and patients.
The Policy of Normalization. The 1970s was an era of reform
for institutions for the Mentally Retarded in the United States.
A hierarchy of college-educated administrators, psychologists,
social workers, nurses, and building managers trained in the
vocabulary of normalization assumed positions of authority and
prestige in the institutions. One of the leading experts on the
3A notable exception to patient snobs’ explicit avoidance of patient “cra-
zies” was the event of a funeral. For example, when a patient in the latter
group di ed, each of the patien t snobs attended the funer al, shook the han ds
of the deceased friends standing in the reception line, and expressed a few
apparently sincere words of condolence. This exceptional behavior on the
part of patient snobs was a central staple of the next week’s staff conversa-
Copyright © 2012 SciRes. 471
subject, Wolf Wolfensberger (1980), defined the concept of
normalization as “the utilization of means which are culturally
normative as possible, in order to establish and/or maintain
personal behaviors and characteristics which are as culturally
normative as possible.” Glendale’s organizational guidelines
for the care of the Mentally Retarded defined normalization in
nearly identica l words.
The policy of normalization presented a problem for staff
prompters. The subjective perspective of staff prompters was
that they experienced themselves as abnormalized within an
all-encompassing total institution dedicated, at the same time,
to normalizing patients. As one staff prompter expressed the
typical jealous sentiment, “All we ever hear about is (patient)
rights this, and (patient) rights that! What about our rights? We
dont have any rights.” The perspective of prompters was that
while they were constantly disrespected and devalued as and by
professionals, patients were explicitly invited to normal status
through a program entrenched with a philosophy of patient
rights. Seen in this light, the professionally-directed normaliza-
tion of patients was not merely perceived as a poorly informed
behavior management strategy, as staff prompters often com-
plained; but more “dangerously” and less discursively, a policy
that reversed the “proper” staff and patient roles as normal and
stigmatized respectively, or what translated equivalently as a
“faulty” over-emphasis on patient rights. To invert this reversal
staff prompters found a dramaturgical solution.
Staff Prompting and Patient Burlesque
The staff prompter cued a patient with a short, familiar
phrase. The patient responded in a rehearsed manner. The au-
dience laughed at the vivid display of hyper-stigma. The bur-
lesque was repeated on numerous subsequent occasions on cue,
before a carefully segregated audience. Most patient burlesques
originated from incidental and potentially transitory odd dis-
plays by a patient in the presence of a staff prompter. In many
cases, however, original performances were authored entirely
or heavily edited by them.
Patient burlesque was prompted through a variety of methods:
by specific verbal or gestural initiating cues; by staff prompters
talking enthusiastically about a performance in the presence of
the patient performer; by staff prompter impersonations of the
performance the company of a patient performer; by staff
prompters providing the necessary lines of dialogue on cue (in
the cases that the staff prompter’s lines were intermediary links
in a patient-initiated performance); and by staff prompters
bluntly asking the patient to perform. In no case did I witness a
staff prompter negatively sanction a patient for refusing to per-
form. In a few cases, repeated prompts were given to elicit
compliance. The usual scenario was that the patient willingly
participated, presumably for the attention he received. However,
this may have been the paradoxical result of stigmatized pa-
tients resolving issues of “attention deprivation” (Derber &
Magrass, 1988), which is therefore to trade in one assault on the
self (“social invisibility”) for another (“objectified spectacle”).
It is important to stress that staff prompters prompted patient
burlesque over and over and over again. The effect of the re-
peated performances was that potentially transitory deviant
behaviors of patients became fixed deviance characteristics of
them. In more precise sociological nomenclature, staff prompt-
ing and patient burlesque had the effect of transforming “resid-
ual rule-breaking” into “careers of deviance” (Scheff, 1984;
Becker, 1963). The analysis to follow then addresses Thomas
Scheff’s (1984: p. 48) question,
If residual rule-breaking is highly prevalent and is usually
transitory, ... what accounts for the small percentage of resid-
ual rule-breakers who go on to deviant careers? To put the
question another way, under what conditions is residual rule-
breaking stabilized?”
In the pages to follow I will illustrate how the labeling proc-
ess Scheff writes about at length can be facilitated through a
type of highly theatrical acceptance of the deviant role.
While patient burlesque took place in the covert “backstage”
(Goffman, 1959) activities of staff prompters, patients some
times initiated performances in the presence of staff who were
not directly involved in the backstage activity. These “front-
stage” (Ibid.) performances took place when a prompt was ini-
tiated by the lines of a patient and required minimal or no lines
of staff members. In these cases, n on- con fe derate staff appeared
to consider the burlesque activity merely idiosyncratic of the
patients involved. And when patients performed for these
“mixed audiences” (Ibid.), staff prompters often took on a dis-
quieting silence. They were assuredly crossing their fingers that
the dangerously close back and front stages would stay intact.
While patient burlesque was ordinarily performed for an ex-
clusive clique of seasoned staff prompters, others who were
judged allegiant to unofficial employee practices, or at least
indifferent to the enforcement of official rules and regulations
governing patient care, were occasionally permitted into the
backstage. However, backstage activity was carefully guarded
from the out-group composed of administrators, psychologists,
and other staff members who were perceived to advocate and
enforce the official policies of the institution which placed sig-
nificant emphasis on patient rights; that is, the professional staff.
I often wondered, with substantial discomfort, why I was let in.
I finally concluded that it was a combination of trust that was
cultivated, my own working class background which I pur-
posefully made known to staff prompters, and the view of staff
prompters that there was nothing really wrong with the activity,
even if professionals would assuredl y v iew it th at way.
Below I provide a thematic analysis of the content of staff
prompting and patient burlesque. The central theme is the hu-
mor of the patient’s hyper-stigma. The point of the perform-
ances was to vividly display the patient’s debased and disen-
franchised condition. A prominent secondary theme woven
within the central theme is the value and power of phallocentric
heterosexua lity. The content of the latter type of prompted bur-
lesque is sexist, homophobic, and some times violent.
The Humor of Hyper-Stigma
Hyper-stigma is displayed in nine humor themes in the con-
tent of staff prompting and patient burlesque. The overall effect
of these interactions was the extreme debasement or mortifica-
tion of the patient. This was achieved through magnifying the
patient’s limited intellectual ability; directing the patient to
self-denigrate himself before an audience; transforming sexual
violence against the patient into a form of entertainment; in-
vading the patient’s sexual privacy; eliciting humor from the
self-assertion of a discredited person-patient; laughing at the
patient as he spoke gibberish or dramatically sang his activities
and complaints; and through deriving humor from patient beg-
ging, patient violations of social distance, and patient perform-
ances of degrading sideshows.
Copyright © 2012 SciRes.
The most general humor theme in the data analyzed was the
patient’s limited intellectual ability. Prompted burlesques on
this theme provided blatant displays of patients’ disqualifica-
tion as intellectually competent adults. Many examples are
illustrative and can be divided into patient-initiated and
staff-initiated dialogues. Exemplifying the former type, Robert
started a dialogue by asking, “Can I ask you a question?” The
staff prompter joined in by answering, “Yes, Robert.” Robert
demanded, “I want a Fresca and I want it now!” (or “Give me a
new suit today!” or “Give me a cigarette!”) The audience
laughed with delight. The humor of this prompt was drawn
from Robert characteristically making a demand following the
request to ask a question; or more precisely, the humor was
Robert’s apparent ignorance of the difference between a ques-
tion and a demand. A second example of patient-initiated bur-
lesque involved Carl looking down, patting his bulging stomach,
and saying in a slow, long, throaty voice, “Hi, Buba!” The hu-
mor of this prompt was the reduction of a macho (suggestively,
beer-drinking) man, to the resemblance of child amusingly
attributing impossible autonomous animation to bodily organs,
much like a two year old child imaginatively applies animation
to all sorts of inanimate things. A final example of a pa-
tient-initiated burlesque involved Mark approaching staff
members and asking, “Is it snowing out?” The humor of this
burlesque was drawn from the fact that Mark was apparently
unaware of seasonal changes, as he asked this question during
the entire year.
The humor theme of the patient’s limited intellectual ability
was also contained in a number of staff-initiated prompts. A
flagrant example that drew humor from the limited intellectual
ability of patients occurred whenever a staff prompter pointed
to the scars remaining from a lobotomy performed on Jason and
inquired, “What happened?” Jason responded on cue, “They
took my brains out.” The staff prompter probed, “Who?” Jason
concluded the dialogue, “The doctors.” Laughter gushed down
the hall from the dayroom the day I was first introduced,
through this example, to the practice of staff prompting and
patient burlesque. Thereafter witnessed dozens of times, the
dialogue was always the same. When in-group staff members
wanted to present this highly “entertaining” exhibition to osten-
sibly safe uninitiated others they instructed them to present
Jason with the appropriate cues. The apparent humor was that
Jason was ignorant enough to partake in this extremely
self-mortifying dialogue, providing his audience with a hu-
morous testament of his “lack of brains” for doing so.
A milder example of staff-initiated burlesque was when
Eddie was presented with any question that required a numeri-
cal answer and he routinely answered “ten.” The obvious cue
was any question requiring a numerical answer. A similar bur-
lesque took place when a staff prompter pointed to any animal
except a duck and would ask Richard, “What’s that?” Richard
exclaimed in a child-like voice and manner, “A duck!” The
humor was that again, like a very small child, Richard was
seemingly incapable of making distinctions between types of
A second humor theme in patient burlesque was the patient’s
self-denigration. This theme can be exemplified through a
fill-in-the blank prompt. A swear was rhymed with the patient’s
last name, whereby the patient was instructed, in effect, to de-
grade himself by the action of the prompting activity as well as
by the content of the interchange. The staff prompter would say
slowly with a long anticipatory breath, “(John Schick)...” And
John would answer as accustomed, “... is a (prick).” Staff
prompters would snort with delight as John looked toward them,
smiling softly, as he compliantly and effectively closed the gap
between self-reference and identity (Strauss, 1972: p. 380).
A third humor theme was sexual violation. For example, one
staff prompt demonstrated a clear and disturbing disregard for
the suspected sexual violations committed against a patient. As
the background story was told, the patient prompted in this
burlesque was suspected to be raped by his father when away
on home visits. In the prompt referencing the information the
staff prompter inquired, “(Jake), what happens when you go
home?” Jake replied as expected, “My father fucks me up the
ass.” Loud throaty laughter would follow. Sexual violation in
another context involved the invasion of the patient’s sexual
privacy. For instance, a patient known to masturbate was re-
currently prompted when staff prompters entered his room and
asked, “What are you doing?” Joe would respond as rehearsed,
“I’m fucking the bed.”
Being diagnosed Mentally Retarded, and often mentally ill as
well, and being a resident of a public institution with all that
implies produces such a degree of stigma that the patient, it is
frequently presumed, is less than an ordinary person (Goffman,
1961). From this perspective it could be constructed as humor-
ous when such fundamentally discredited persons strongly as-
sert themselves. An example of the humor of the self-assertion
of a discredited person, a fourth humor theme in patient bur-
lesque, is exemplified by the way Lenny disputed an action or
instruction of a staff member. When doing so he would stare
them in the eye, wave his pointer finger in their face, and
threaten angrily, “I’m gonna tell my mother!” or “You’re going
to court!” The audience would burst into laughter. Another case
in point was when Larry would make a request of a staff mem-
ber. Directly following the appeal he would command loudly,
“Please. And don’t ever forget to say thank you!” or “Don’t
think about it. Just do it!” Again the staff prompters would
chuckle, seemingly ignorant of the possibility that Larry may
have been surreptitiously mocking their authority.
A fifth humor theme of patient burlesque is the patient
speaking nonsense. For example, Vincent initiated a dialogue
when asking and approaching a staff member, “What do you
think? Am I right or am I wrong?” The staff prompter joined in
by questioning, “About what?” Vincent completed the dialogue,
“Nevermind! Just tell me. Am I right or am I wrong?” Vin-
cent’s burlesque was prompted habitually through impersona-
tion, direct request to perform, and discussions of the humor of
the dialogue in Vincent’s presence. Other examples of patients
speaking nonsense include Paul declaring schizophrenically to
anyone present, “I am Gloria Sticks. I am everyone. Everyone
is me;” when Sean announced excitedly, “Come on down.
You’re the next contestant on the Price is Right;” and when
Lenny reverberated enigmatically, “Purple sperm. Purple sperm.
Purple sperm.” Language being the fundamental building block
of culture, to speak a form foreign or indecipherable to others is,
in effect, to reside fundamentally outside that culture. Therefore,
the humor of patients speaking nonsense for staff prompters
was the humor of the patient’s radical cultural departure.
A sixth humor theme of patient burlesque, with similar im-
plications discussed above, is the humor of patients altering the
normative mode of communication. Lenny exemplified this
theme when he replaced ordinary speech with singing. He per-
formed a marching song every morning after breakfast, stand-
ing up at the table and singing “Anchors Away” while he
Copyright © 2012 SciRes. 473
marched. He was also known to and encouraged to sing “Jum-
blelye” and “The Good Ship Lollipop.” When Lenny was angry
he sang “Eight Days a Week” while taking his morning shower.
This patient’s vivacious performances were the most favored
among staff prompters.
Lenny’s performance borders on a seventh humor theme, the
patient’s spectacle and sideshow. This theme was illustrated
when Carl said “Buckwheat!” as he took off his hat and
snapped the nail of his pointer finger off his thumb, hitting his
forehead. The snapping was done repeatedly and in quick mo-
tion. The humor was drawn from the reduction of a heavy-built,
potentially physically dangerous, towering man to a silly slap-
stick ninny. Harry, a graying Mentally Retarded man in his
fifties, was prompted to perform a sideshow when staff dis-
cussed his theatrical “talent” in his presence. A staff prompter
would say, “Have you ever seen (Harry) when he wraps his legs
around his head? It is hilarious!” Harry followed the indirect
cue by displaying his talent, as he sat silently on the couch,
staring off toward the television in front of him. Staff membe rs
chortled and cooed. A soft smile revealed Harry’s satisfaction
with the performance and belied his general “expression given”
(Goffman, 1959) of his obliviousness to the staff conversation
and his simply coincident display. Bernie joined the sideshow
from time to time with his talent of making all sorts of realistic
animal sounds: cows, ducks, cats, horses, etc. The effect of
spectacle and sideshow was to provide a theatrical display, a
magnification, of the perceived oddity of the patients involved.
One of the folkways of total institutions is begging. This is
the consequence of many patients lacking or losing, through
extortion, distraction, or theft, money necessary to acquire de-
sired goods. Begging functioned as a corrective measure for
patients reduced to a condition that precluded the immediate
possession of monetarily obtained resources. As further the-
matic humor content, staff prompters exploited this disenfran-
chised condition. For example, Felix, a tall, quiet man towing a
garbage bag in hand, would shuffle around Glendale grounds
approaching anyone he encountered, saying softly at first and
gradually speaking more quickly, loudly, and aggressively if
the person approached did not comply, “Can I have a penny?
Come on. Give me all your pennies!” A similar humorous beg-
ging display was cued when staff prompters shortly delayed
giving Fred his hourly cigarette, and awaited the standard co-
medic moment when he would compliantly slur in a long deep
voice, “Can I have a goooood cigarette today?” As the brawny,
six and a half foot man stood before them with a passive ex-
pression in his eyes, he held out his two large, hairy fingers up
in air in anticipation. The humor of patient begging—an eighth
humor theme of patient burlesque—was drawn from the beg-
ging action and the diminutive level of begging.
A final patient burlesque humor theme is the patient violating
social distance. Exemplifying this theme was when Lenny
would often shuffle up to a staff member, puts his face in theirs,
and drool about or on them while asking repeatedly, “Do you
like me? Do you like me? Do you like me?” The humorous
moment was when targeted staff members expressed repulsion
as Lenny approached them in the manner described. This
prompt was employed in a way similar to a “kiss up” prompt.
In both case, the patient was used to playfully tease other staff.
The kiss up prompt originated when Alex did not “behave” in
the building and then wanted to go to the evening activity,
Bingo. The staff prompter involved told him that if he wanted
to go he would have to “kiss up” to the other male staff me mbe r
present. The degree of detail of the staff prompt was not heard
as the staff prompter whispered in the patient’s ear while
laughing with a trickster’s grin and peering through the corner
of his eye toward the targeted staff member. The result was that
Alex walked up to the targeted staff member and attempted to
kiss and hug him. The staff prompter looked on with laughter,
asking the targeted staff member in a mischievous fashion if he
liked it. He re we clearly see the fun made of homosexuality and
the level of intellectual ability of the patient. It was constructed
as “funny” that the patient qua pawn literally interpreted the
instruction to kiss up and that the homophobic staff member
squirmed and pushed the (feminized) patient away as he re-
peatedly and gently tried to kiss and hug him.
I have argued that staff prompters experienced themselves as
stigmatized in a reformed total institution because they were
unable to adjust to their normal and expected roles as profes-
sionals. Sources of stigma were that staff prompters did not
self-identify as professionals; worked in intimate contact with
patients; were often openly corrected in their patient knowledge
by higher ranking professionals; were negatively evaluated by
unofficial staff-evaluator patients; and were dependent upon the
greater managerial skills of patient heavies. Experiencing
themselves as abnormalized in an institution that explicitly
invited patients to normal status, prompters defended their
selves through a subtype of secondary adjustment, or ancillary
adjustment, termed staff prompting and patient burlesque.
Theatrical displays of hyper-stigmatized patients served as
the unofficial staff prompter program of staff member normali-
zation. Burlesquing the patient’s grossly limited intellectual
ability sharply contrasted with staff prompters’ high school
graduate status when the patients confused questions and de-
mands, attributed autonomous animation to bodily organs,
misunderstood numerical relationships, misidentified animals,
and ignorantly announced their lack of brains. Patients were
further debased through an implicit comparison via patients’
linguistic incoherence as song replaced speech; when speaking
schizophrenic, charismatic, or enigmatic nonsense; when dem-
onstrating lack of self-efficacy and lack of integrity through
asserting discredited selves; through performing as slap-stick
ninnies; through begging for pennies and cigarettes; through
drooling while asking for approval; and more generally,
through participating in any staff prompting and patient bur-
lesque interaction.
An additional benefit of patient burlesque for staff prompters
was that it served as vehicle for expressing vehement phallo-
centric and heterosexist power. For example, it was displayed
repeatedly, crassly, and violently when Jake announced that he
was anally raped by his father; when John’s identity was re-
duced to a “prick;” when Joe declared his “fucking” activity;
and when Alex elicited repulsion from a presumably homosex-
ual advance.
Phallocentric heterosexism was also expressed in burlesques
that conveyed contempt for women professionals who consti-
tuted a vivid presence among the higher ranks of Glendale’s
hierarchy. For example, a frequently reenacted burlesque was
directed at a top female administrator of Glendale and required
the targeted patient to be highly animated in his theatrical dis-
play. The staff prompter asked Sam, “What does (Leslie John-
son) look like when she has an orgasm?” Sam exclaimed on cue,
Copyright © 2012 SciRes.
“Do the monkey!” while he wildly shook his face, with his
bottom lip puckered out, his cheeks wiggling from side to side,
and his eyes bulging and staring blankly ahead. Recasting
women’s authority in terms of animalistic sexuality was a
method of psychologically diffusing that authority in the minds
of staff prompters. Why this diffusion was especially important
for staff prompters was because prompters lacked authority, did
not think of themselves and were not thought of as profession-
als, and as a group were composed exclusively of men. In con-
sequence, prompters experienced women’s professional author-
ity as a triple threat to the integrity of their professional selves.
Moreover, patients burlesquing as hyper-stigmatized, con-
structed as humorous, may be considered a form of “jocular
aggression” that “avoids direct confrontation with a superior
that could lead to organizational sanctions” (Pogrebin and
Poole, 1989: p. 189). Much like what Pogrebin and Poole (Ibid.,
189-191) found in the case of police officers, this kind of hu-
mor “reinforces the solidarity of individuals within the group
because it is based on shared expectations. Like jokes, it causes
a collectivity of laughter that strengthens the group’s social
cohesion.” By laughing at—and often with—stigmatized pa-
tients—staff prompters mocked the patient’s program of nor-
malization and surreptitiously promoted their own program of
staff normalization. As an out-group to professionals, laughter
functioned, as it often does, to strengthen group solidarity
(Coser, 1959; Coser, 1960; Martineau, 1972). If not integrated
as normals at Glendale, then at least staff prompters could be
members of a tightly wedded group in manly camaraderie with
male patient performers. Moreover, as Durkheim (1997) ob-
served so long ago, the likelihood of counter-cultural groups
increases with the complexity of the division of labor. It ap-
pears then that the well-intended professional reforms of the
1970s had the unintended consequence of cultivating an organ-
izational environment ripe for abuse—or at least a rich organ-
izational counter culture—by those structurally situated at the
bottom. Stated from another important angle, patient residual
rule breaking was transformed into careers of deviance as staff
prompters defended their selves as normals in a total institution.
Finally, it must be noted that staff prompting and patient
burlesque took place amid a “shaky” reality, or in an organiza-
tion explicitly devoted to normalization. What made counter-
definitions of the institutionally adjusted patients stick was
precisely the repetitiousness of the dialogues. Berger and
Luckmann (1966: pp. 153-154) maintain, instructively, that
reality is “shaky” if one does not speak of it. They say that
gives firm contours to items previously apprehended in a
fleeting and unclear manner... Generally speaking, the conver-
sational apparatus maintains reality by talking through vari-
ous elements of experience and allocating them a definite place
in the world... language objectifies the world... language real-
izes a world, in the double sense of apprehending and produc-
ing it... In conversation the objectifications of language become
objects of individual consciousness... In the widest sense, all
who employ the same language are reality-maintaining others...
In order to maintain subjective reality effectively, the conversa-
tional apparatus must be continual and consistent.”
In further backstage activities with staff prompters, sharing
beer with them after work, I witnessed recurrent burlesquing of
the patient burlesques. Replayed with no less animation, and in
manly contests for best impersonations, these subjectively dis-
empowered and devalued working class men defended their
selves over and over and over again. Berger and Luckmann’s
words thus draw our attention to the power of the conversa-
tional apparatus. It was precisely the repetitive quality of staff
prompting and patient burlesque interactions within and outside
Glendale, or by staff cueing patient burlesque in Glendale and
reenacting performances as recreational activities after work—
that continually and consistently reinforced the “shaky” reality
of the patient’s contrasting hyper-stigma.
The findings reported here are as unsettling as the behaviors I
observed in the course of my research at Glendale. This, I sup-
pose, is the price of the “sociological imagination” (Mills,
1961). What I have attempted to do in this paper, and in the
analysis of data upon which it is based, is to temporarily sus-
pend my judgment of the ethical or moral meaning of staff
prompting and patient burlesque, at least to the extent that I was
able to see the motivation for it. Objectivity is never clean, but
only a conscientious approximation.
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