Goffman and the Infantilization of Elderly Persons: a Theory in Development

Goffman and the Infantilization of Elderly Persons: A Theory in Development Stephen M. Marson, Ph.D. Gerontology Program University of North Carolina at Pembroke

Rasby M. Powell, Ph.D. Department of Sociology and Criminal Justice University of North Carolina at Pembroke

ABSTRACT Infantilization a behavioral pattern, in which a person of authority interacts, responds or treats an elderly person in a child-like manner. This paper utilizes Erving Goffman's dramaturgical model as a framework from which to analyze the social forces involved in the development and maintenance of infantilization among the elderly in America. A brief summary of Goffman's work is offered and major theoretical assumptions are delineated. Key terms are defined and applied with his notion of the "total institution" (in this case, a care facility for the elderly). The use of Goffman's research methodology is addressed within the context of answering the theoretical questions raised within the body of the paper. Finally, ex post facto observations are offered as a support of Goffman's perspective. Can the social forces that induce dementia be reversed after the individual has been diagnosed? If Goffman is correct, the answer is probably yes. Five researchable propositions are offered to test Goffman's framework.

INTRODUCTION Salan (2005) introduces the concept of infantilization as a form of psychological elder abuse although she does not define the term infantilization. For our purposes, infantilization is a behavioral pattern in which a person of authority (social workers, medical personnel, etc.) interacts, responds or treats an elderly person as if to a child. Her qualitative study of five adult care agencies finds elders regularly treated as children. She asserts that prolonged infantile interaction with an elderly person “undermines self-identity and personhood” (page 85). Although she uses Goffman (1961) to illustrate the how infantilization of elders is a form of elder abuse, her findings are not articulated within the context of any theoretical framework. While her work identifies infantilization as a form of elder abuse, there are no practical solutions offered for dealing with the problem. We plan to extend her work by employing Goffman’s theoretical perspective in a manner that practitioners can readily exam their own behavior and social interaction. The major problem in social gerontology today is the lack of a theoretical foundation. One can skim the major college textbooks in gerontology and discover no theory themes. In a text of readings, Kart and Manard (1981) attempted to show how other authors have utilized traditional psyche-social theory, but these are old publications which have not been explicitly integrated within the confines of quantitative inspired publications. In fact, if one were to review recent journals of social gerontology, one would notice that articles emphasize statistical techniques and rarely relate to a conceptual framework within which the statistics have been (or should have been) employed. One has an intuitive "feeling" that contemporary authors collect data, toss it into a computer, and then report statistically significant data. The randomness of this approach has some obvious problems. In fact, Bengtson et al (2009) notes that editors of contemporary gerontological journals project the image that the enterprise of theoretical explanation is "little more than intellectual nonsense." One approach that has been attempted to secure a theoretical position for social gerontology is the construction of new theories. The best known are: Activities, Disengagement and Subculture. Although, they are still discussed in gerontology textbooks, it is important to note that they have been discredited. Furthermore, these theories offer little assistance in doing empirical/statistical research. This failure could help explain the random quality of findings in contemporary scholarly journals in the field of gerontology. Besides failure in the scholarly arena, the contemporary theories also have failed in the practical world of social services for the elderly. Practitioners perform no better with these new theories than they do with no theory at all. That is a terrible commentary. Another way to approach gerontological research is to begin with an acceptable framework [i.e. Marxism; see Marson & Della Fave (1994), Functionalism: see Marson & Powell (2012)] and attempt to relate it to issues peculiar to the aged. Not only will it test the applicability of the theory, it will also illuminate some aspects of interaction and society that have not been addressed. One aspect of aging that clearly requires some illumination is dementia. The social origin of dementia is an intriguing aspect of gerontology that has been empirically identified (Butler & Lewis, 1972; Levin & Levin, 1980; Shelton, 1965) but never theoretically substantiated. This is the inherent problem of social gerontology discussed earlier -- quantitative analysis with no theoretical substance. Perhaps the work of Goffman (1974; 1961; 1990; 1986; 1967; 1963) could provide some illumination on this issue that other perspectives cannot. Thus comes the question for this paper: Can the dramaturgical model be used as an effective analytic tool in the social study of dementia? The first section of this paper will offer an empirical event in which the scripts of two actors (social workers in a nursing home) and their actions are described. The scenario is an accurate portrayal of the actions of the two social worker and their mutually exclusive impact on residents diagnosed with dementia. Since the actions of these social workers appear to have profound consequences, we find a need to house these actions within a theoretical framework. Such a framework, if successful and coherent, will lay the foundation for improved quality of care within institutional environments. We believe that Goffman’s dramaturgical approach is a good fit and it basic concepts will be presented. However, we recognize the neurological dimension of the medical diagnosis and provide a framework to identify the limitations of the social theory. This task will be a very modest attempt of a formidable undertaking. The real test of fruitfulness of the dramaturgical approach is its ability to illuminate uncharted aspects of aging. THE EMPIRICAL EVENT Two social workers are presented: Susan and Debbie. After their interaction with the residents is described, proposed consequences are presented. Susan Although not professionally educated as a social worker, Susan has a college degree in criminal justice and an extraordinary pleasant personality. The nursing home CEO hired her primarily because she was such a pleasant person who was consistently optimistic. She has had a considerable amount of in-service training in the delivery of social work services. However, her training was not generic but was specifically in the arena of gerontological social work services. Because she was hard-working, she became well-liked and respected by the staff. The residents of the nursing home liked her too. She was consistently prompt in addressing all their needs and thought nothing of working off the clock to deal with critical issues. Clearly, she afforded the residents the highest priority in all of her daily professional obligations. As a result, her annual evaluations from the CEO and her social work consultant were exceptional. She had one weakness that was never articulated in any of her evaluations because it was not measurable but was observable. She presented herself to staffers in a radically different manner than her presentation to residents. She had a tendency to speak to staff in a manner that was consistent with normal decorum and fit well within the expectation of professional communication. However, she shifted away from her normal decorum in a natural but abrupt manner as soon as she interacted with one of the residents. The shifting of her presentation did not seem to be a conscious effort to change but seem to a natural phenomenon. Her vocal intonation changed to higher pitched sweet tone. She spoke to elderly residents in a manner that can be best described as “child-like.” Her devotion to the residents was unambiguous. They liked and appreciated her and she was delighted to work with them. As a result, her presentation of speaking to the residents as if they were under 3-years old was never addressed. Her interaction was not identified as problematic. Debbie Unlike Susan, Debbie had completed college with a degree in social work (BSW). She did not have specific training in gerontological social work, but rather completed a generic social work curriculum. Upon the resignation of Susan, who left to be the CEO of her own nursing facility, Debbie was hired as the nursing home social worker upon recommendation of the facility’s social work consultant. Although Debbie had a pleasant personality, she did not possess the bubbly presentation that was Susan’s prime characteristic. Debbie could best be described as reserved. Initially, the nursing staff and the CEO thought Debbie’s reserved manner and lack of a bubbly personality would evolved into a problem of the residents trusting her. However, it took no time for Debbie to successfully integrate into the normal working routine within the nursing facility. The staff recognized her impressive work ethic and the residents accepted her without the level of suspiciousness as expected by the CEO. The staff and CEO were initially suspicious of Debbie’s social work intervention because she did not change her presentation when she shifted between the staff and residents. Her intonation and physical mannerisms did not change. Essentially, she was the same person without regard to whom she was speaking. The Observation; The Scenario A married couple from Jamaica was admitted to the facility and shared the same room. The supervising social work consultant visited the couple and noted that the wife could be best described as catatonic. She was breathing, but seemed to have little awareness of her environment. The husband was also bedridden and was in better shape than his wife. He can be best described as semi-catatonic. He was able to open his eyes and recognize when someone entered the room. He was not able to speak. Social workers are trained to interact with catatonic and semi-catatonic manner patients with an active voice. Staff operate under the assumption that the patient can hear and understand but not able to respond. The couple manifested no changes after three weeks of intervention with Susan. It was at this point where Susan resigned to open up her own facility. The social work consultant visited the facility for a supervisory conference with Debbie. Prior to doing so, he made his rounds and visited the residents. The first room he visited was the couple from Jamaica. He was shocked to see both of them aware of their environments and speaking coherently. Although they didn’t recognize him, he introduced himself and chatted with both them. When he left the room, he went to the Director of Nursing (DON) and described his visit with the Jamaican couple. He asked, “Do you think their change is due to the more mature approach that Debbie has with the residents?” Without time to reflect on the question, the DON replied immediately by stating an emphatic “yes.” She then noted that all of the residents had changed by stating, “They are more alert and responsive.” Eventually, the entire staff agreed that the new social worker’s approach had a positive impact on the social condition of all the residents. Debbie’s non-child-like approach was benefiting everyone. The major problem faced by gerontologists is identifying a theoretical framework that provides substance for the scenario. Rapping a theory around the incident is critical. Doing so provides others an opportunity for employing effective interventive strategies to improve the social living conditions for institutionalized elderly. Although unknown to many of those outside of sociology, Erving Goffman’s dramaturgical model can provide insight into the incident that can be easily employed by other practicing gerontologists. Following is a description of key point within Goffman’s work. FUNDAMENTALS OF GOFF MAN'S DRAMATURGICAL APPROACH In generally reviewing Goffman's work, one can immediately notice several obvious assumptions related to the above scenario. Goffman's perspective is based on a drama analogy. As one reads his work, one can reflect to Shakespeare's famous line from Act II Scene 7, of As You Like It: “All the world's a stage, and all the men and women merely players. They have their exits and entrances; and one man in his time plays many parts…” This "acting" analogy is a continuous theme in all of Goffman's writings. Thus, Goffman would suggest that Susan, Debbie and the nursing home residents were acting on role expectations based on a social script. He begins with some assumptions that are common to symbolic interactionisrn. Like Mead and Blumer, Goffman stresses the self as defined by others within the framework of social interaction. He also stresses the social forces that facilitate convincing others of a particular presentation. It is important for those unfamiliar with the dramaturgical model not to carry the acting analogy too far; for although Goffman has an appreciation of the normative constraints (the actor's script), his focus is on the actor, not the script. He addresses his attention on hiding behind socially acceptable masks. How would Goffman help us understand the mutually exclusive scripts that Susan had (cuties) versus Debbie’s script (stoic). He would likely suggest that Susan’s script was derived from her training as a criminal justice student, while Debbie formalized her role as a social work major. The second major theme of Goffman's work is also his major departure from symbolic interactionisrn -- the presentation of self is VERY problematic. According to Mead and Blumer, there is nothing inherently problematic in the symbolic interaction of individuals within the social structure. Fontana (1980) summarizes the differences between Blumer and Goffman by saying Blumer considers human beings as straightforward, honest, and cooperative participants in the construction or social order, while Goffman focuses on how people manage the impression they make on others. Blumer takes for granted that the self can be unproblematically defined by individuals in interaction. Therefore Blumer can be described as concentrating on interaction as a social process.... Goffman feels that society does not afford us the luxury of being self-assured (p. 63-4). Goffman's intent is to focus on the individuals who are interacting rather than on the interaction itself as Blumer stresses. The central advantage Goffman affords us that the focus interaction between the social worker and the nursing home residents. This focus is paramount in understanding the infantile verbal articulation we often see in nursing home. Perhaps it is best to use Goffman's (1990) own words to describe the fundamentals of his perspective. He writes: … society is organized on the principle that an individual who possesses certain social characteristics has a moral right to expect that others will value and treat him in an appropriate way.... An individual who implicitly or explicitly signifies that he has certain social characteristics ought in fact to be what he claims he is.... An individual projects a definition of the situation and thereby makes an implicit or explicit claim to be a person of a particular kind, he automatically exerts a moral demand upon the others, obligating them to value and treat him in the manner that persons of his kind have a right to expect. He also implicitly forgoes all claims to be things he does not appear to be and hence forgoes the treatment that would be appropriate for such individuals, The others find, then, that the individual has informed them as to what is and as to what they ought to see as the 'is' (p. 13). Role expectations are not only expectations of how individuals are to behave within the parameters of their role as nursing home resident, but are also expectations of how they are to be treated by occupants of those who perform the social worker role. The foundation of Goffman's difference with Blumer and Mead rests in his view of the paradoxical nature of human life. Fontana (1980) best describes this difference when she writes: "… realities are layered upon each other, intertwined, and confused to the point that the paramount reality is no longer a clear, solid entity" (p, 74). Yet, Goffman (1974) contends that there is an aspect of reality that is solid; there just seems to be more ambiguity than solidness. Again Fontana (1980) offers a good illustration when she writes: …the whole of reality is not, for Goffman, a granite monolith, but a fish net full of holes. We ourselves fill in the holes by constructing social scenes, and then are duped by our own construction into seeing the loss mesh of net and social construction that fills the holes as a solid wall. We reify, or take as concrete reality 'out-there'--what we ourselves have constructed out of social meanings (p. 74). This paradoxical nature of human drama is the key to understanding the acceptance of dementia among the elderly and is the major theme of the latter section of the paper. Since the major underlying assumptions of Goffman's perspective have been addressed, it is now important to examine and define terms that are utilized within his framework. The terms discussed here are NOT a conclusive list of all of Goffman's terminology; rather they are terms that facilitate an understanding of what we will refer to as the "dementia act." These terms are: 1) impression management; 2) front region and back region; and 3) maintaining face. Impression Management Goffman (1974; 1961; 1990; 1986; 1967; 1963) discusses impression management in most of his major publications. Although it is a dominant theme in his work, he offers no concise definition. However, it is obvious to any reader that by "impression management" Goffman was referring to the techniques by which the actor maintains a desired role. Goffman (1986) even uses examples from Emily Post to support his position (p.172). He suggests that etiquette is a prop that facilitates the social mask we wear. Actors attempt to project an image that they desire. Susan wanted an image of being cute to the residents; while Debbie desired an image of being reserved to both residents and staff. One assumes that the image one wants to project is one which "makes me look good." Susan received positive annual evaluations, but so did Debbie. As a result, both continued to maintain the role for both staff and residents. This assumption can be found in the work of some exchange theorists, but does not represent the work of Goffman. Impression management also includes the projecting of social images that are NOT desired for a particular act. People will project an act that "hurts" them. Why? Turner (2002) suggests it is because "Goffman tends to emphasize the process of the impression management, per se, and not the purposes or goals toward which action is directed" (401). Yet, Goffman does seem to address this issue via his assumption on the paradoxical nature of life and his term "maintaining face." Maintaining Face According to Goffman "maintaining face" is one behavioral occurrence that takes place within impression management. Goffman indicates that face may be defined as the social value a person claims for himself and others assume he has taken during that particular social interaction. He (1967) writes that: A person may be said to have, or be in, or maintained face when the line he effectively takes presents an image of him that is internally consistent, that is supported by judgments and evidence conveyed by other participants, and that is confirmed by evidence conveyed through impersonal agencies in the situation. In such times the person's face clearly is something that is not lodged in or on his body, but rather something that is diffusely located in the flow of events in the encounter and becomes manifest only when these events are read and interpreted for the appraisals expressed in them.... Given his attributes and the conventionalized nature of the encounter, he will find a small choice of faces will be waiting for him.... Thus while concern for face focuses the attention of the person on the current activity, he must, to maintain face in this activity, take into consideration his place in the social world beyond it.... once he takes on a self- image expressed through face he will be expected to live up to it. In different ways in different societies he will be required to show self-respect, abjuring certain actions because they are above or beneath him, while forcing himself to perform others even though they cost him dearly. By entering a situation in which he is given a face to maintain, a person takes on the responsibility of standing guard over. the flow of events as they pass before him. He must ensure that a particular expressive order is sustained--an order that regulates the flow of events, large or small, so that anything that appears to be expressed by them will be consistent with his face (p, 6-7). Goffman is suggesting that social circumstances place individuals in a position that they must maintain whether they want to or not. For example when an elderly person receives the medical diagnosis of dementia, one must maintain that image. “The doctor must know what he is talking about.” Front Region and Back Region Goffman continues to utilize his acting analogy with the following concepts. In a theatre the audience watches the play which takes place on the front stage--so everyone can see it clearly. However, the audience does not view the preparation of the play which takes place back stage. The audience does not see the mess, the errors, or the practices. Occasionally, the audience does have a chance to view an error or the covering up of an error. Goffman (1967; see pages 97- 113) discusses this in detail but for the purpose of this present paper, it is not relevant. Yet, it is important to note that Goffman (1961) suggests that the mentally ill clearly understand the image that they are to project to the medical' staff. Occasionally, they can be caught in their back region. They may not act the part of the mentally ill person until the nurse enters the room. At that point they are on front stage and they must perform according to the social script that defines mental illness. Goffman claims that he has observed the mentally ill in their back region. They do not act crazy there. Hochschild’s Extension total rewrite required Goffman (1974; 1961; 1990; 1986; 1967; 1963) focuses on the interaction “on” and “off” the “stage.” Within Goffman’s work, there is acknowledgement that the social actor may not be cognizant of one’s own actions or emotions. Profoundly impressed with Goffman’s work, Hochschild (2003) identified his primary focus as a potential weakness of his theory. She greatly improved his dramaturgical model by answering a critical question: Can a person who occupies a professional role be trained to acknowledge that interaction and emotion is controllable? The answer is YES. However, Hochschild does not contend that all interactive strategies are planned in advanced. For example, infantilization of elderly person may not be intentional elder abuse. In fact, it is more likely to be unintentional elder abuse. Unintentional abuse is just as damaging as intentional abuse. In fact, Brandl et. al (2006) acknowledges that unintentional abuse has been accepted part of the gerontological nomenclature on elder abuse. Unintentional abuse is more difficult to prove, but is still contrary to statutory standards.

UTILITY OF GOFFMAN'S APPROACH

As noted at the beginning of this paper, gerontology is theoretically barren. The absence of theory produces service delivery in a random or chaotic manner. Thus, without theory, the success of intervention is inconsistent. Ultimately, practitioners are ineffectual in establishing a basis to contribution advances in intervention to other professionals. The bottom line is, theory advances our intervention strategies and our understanding of the best and most successful gerontological services. With the description of the interaction of Susan and Debbie toward the residents of the nursing home and an introduction to Goffman’s theory with contributions of Hochschild, we can begin to apply a synthesis to gerontological services. We can begin with key questions:  Where do professionals procure the social interaction scripts (i.e. infantilization) they employ for gerontological services?  How is the infantilization script perpetuated?  Employing Goffman’s framework, what can professionals do to eliminate the infantilization script among professional AND nonprofessional staff? Each of these questions will be addressed.

The employment of the infantilization script In institutional settings for the elderly, we have observed a pattern of infantilization as the basis for interaction between a staff member and an elder resident. Our observation includes aides, dietary staff, nurses, orderlies, physicians, social workers, and x-ray technicians. The question is where did the script for infantilization originate? The most confounding social factor is, we have never observed infantilization between an adult child and an aging or infirmed parent. These adult children interact with interact with their respective parents in a manner that is consistent with their upbringing. The pattern of interaction between adult child and aging parent does NOT appear to transfer to interaction between a professional and an aging client/patient. Professionals do not share a common interaction paradigm used with the parents as they would for an aging or infirmed patient/client? Of course, models of professional training models of professional training prohibit that level of familiarity. Transference and countertransference are cautions we continue to warn students during their professional education. On the other hand, we also train young professionals NOT to be demeaning. We can only hypothesize a cause through the work of Biddle….

The perpetuation of the infantilization script Lack of knowledge of fear of superiors Lack of family members objecting. Use Robert Jenkins

The Goffman/ Hochschild inspired solution to eliminate the infantilization script

Contemporary social gerontology's theoretical frameworks and empirical research have failed to address the social impact of dementia among American elderly. Goffman's frame of reference provides a refreshing social view of this so-called medical disorder. The importance of Goffman’s contribution rests within his ability to redefine traditional medical nomenclature. Perhaps his definitions are more meaningful. Goffman's focus is on the individuals who perform the dementia act, while the physician's focus is more on the label. Blumer’s interest and focus on the interaction rather than on the actor decreases the chances of understanding the motives. The subjective appreciation of the motives behind the dementia act is bound to take us closer to understanding the social forces related to the phenomena. Perhaps Goffman's contribution is the roadmap he provides. He introduces us to the concept of the "back region." Most of the answers to our questions rest there. That is, one cannot define the demented person to be demented by merely observing his front region behavior. There seem to be three avenues. First, one can conduct interviews and observe. Goffman would frown on this. The observer would be defined by the actor as an outsider--the audience. The dementia act must go on in order to continue to achieve the social sanctions. Second, one can become a participant observer who is defined by the total institution as insignificant to the patient's care. When a housekeeping staff person enters a patient's room, he is not even noticed by the professional health care staff. Even those who are defined as dementia realize janitors are not health care providers. Janitors are spoken to by patients but they are not defined as being part of the medical establishment. Due to their status within the total institution, they perhaps would be admitted to the back stage. Of the entire staff, they assume the greatest amount of intersubjectivity with the patients. They do not necessarily assume that a dementia patient cannot comprehend social and verbal intercourse because janitors and maids do not have access to the charts. If patients believe that the housekeeping staff have no special behavioral expectations, theoretically (according to Goffman) the housekeeping staff would have the greatest assess to the patients' back stage behavior. The most effective manner to uncover the questions related to dementia is to actually take up the act in a total institution. To examine the accuracy of Goffman's theoretical framework, one would need to admit oneself into a care facility for the aged. This would require more than an act but also plenty of makeup. The goal of such a search would be to enter the back region of those who partake of the dementia act. If Goffman's analogy is an accurate one then the major questions outlined within this paper have a chance of being answered. Lastly, there is an ex post facto observation. Prior to reading Goffman, I had the privilege to observe two radically different styles of social service delivery within the framework of the same total institution for the elderly. The first social worker complied with all of Goffman's expectation of the act of the total institutional staff. She was kind and tolerant with patients' slowness and had no expectation of behavioral improvement. She spoke to them in a loud clear and overly-cheerful voice. The dementia patients liked her and appreciated her thoughtfulness. Some staff saw her as speaking to the institutionalized elderly in a child-like or condescending manner. Again, her act seemed to conform to institutional expectations. When she left her job, another social worker filled the position. She had a different style of operation. She, like the first social worker, was kind and well-liked by the institutionalized patients. Interestingly, the second social worker had little effect change when she clocked-in. Her approach to the institutionalized patients was identical to her approach to staff and everyday social interaction. She did not speak to the patients in a child-like manner; her expectations of patients were similar to non-institutionalized adults. In a few short weeks, nurses, the administrator and I noticed some differences in the lucidness of patients inflicted with dementia. For the first time, I heard two of them speak coherent English. A miracle? Goffman would suggest not. The performance of the dementia act was no longer an effective mode to receive social sanction. The play acquired a new director; thus, the actors had to change their roles. To deal with the new social worker, new techniques of impression management had to be institutionalized. The rules for "maintaining face" changed. The patients can no longer sit and expect to be treated like children. Acting like children did not achieve anything socially meaningful. Some supportive but non-scholarly research written within the dramaturgical framework is the work of Patty Moore (Baker, 1984). Employed as an industrial designer, Moore (1985) used make-up to look like a woman in her 80's. Baker (1984) writes: …Ironically, one of Moore's first forays as an old woman was to attend an Ohio gerontology conference. Among both the male and female gerontologists, people who had devoted their careers to the elderly, Moore found herself totally ignored. No one wanted to talk to her. Several months later, dressed as a middle-class old woman, she was mugged in a New York City park. When she dressed as a "bag lady," children laughed at her and pelted her with stones. (When she appeared as a wealthy woman of the same age, however, she found that she was accorded far more respect.) During her experiences, Moore discovered that "people either condescended or they totally dismissed me." Until she became "old," she hadn't realized just how much attention she had always received for being young and pretty (p, 154). Such descriptions open the door to creative qualitative research methods. Yet to proceed, one must begin with the construction of propositions. DEVELOPMENT OF PROPOSITIONS

If a theory cannot be tested, most social scientists would suggest that it lacks trustworthiness. Thus, in contemporary social science, it is vital that theories be tested. Following are a series of propositions which are delineated from the body of this paper. These propositions need to be tested in order to determine if Goffman's dramaturgical is fruitful. It is important to note that these propositions were constructed within the context of what Goffman's call the "total institution." Thus, the proposition are only applicable to nursing facilities and not to elders who live in the community.

1. Qualitative behavioral differences exist for institutionalized elderly between two types of social interaction: a) elderly social interaction with nursing home staff (front region); b) elderly social interaction with other institutionalized elderly (back region). 2. Elderly patients in an institutionalized setting will act more lucid (back region) in the presence of other institutionalized elderly than they will the staff. 3. Elderly patients in an institutionalized setting who are treated in a non-adult manner will be less lucid (front region) then elderly patients in an institutionalized setting who are treated in an adult manner. 4. There is a quantitative difference in the amount of time that staff devotes to elderly who rebel against their "dementia" label compared with those who comply with the label expectations. 5. The amount of time that staff will spend with elderly patients who rebel against their dementia label is filled with negative social sanctions, while the amount of time that staff spends with elderly patients who do not rebel against their dementia label is filled with neutral and some positive social sanctions.

Great support for Goffman’s dramaturgical model will be derived if research confirms these propositions.

CONCLUSION

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Volume In Press, Issue 0, 2012, Pages 1-9 DOI: http://dx.doi.org/10.5127/jep.022411

Abstract The aim of the present study was to examine whether expertise in the field of psychiatry undermines the efficacy of the Structured Inventory of Malingered Symptomatology (SIMS) to detect feigned psychosis. Participants without psychiatric expertise (n = 24) and those with psychiatric expertise (n = 23) were asked to fill out the SIMS twice. On one occasion they had to fill out the SIMS honestly, the other occasion they were requested to complete the SIMS imagining they had decided to malinger psychosis because they were standing trial for a serious offence and wanted to avoid legal responsibility. Participants with psychiatric expertise engaged in less flagrant feigning on the SIMS than those without expertise. However, when asked to malinger psychosis, most participants were classified by the SIMS as malingerers, regardless of their expertise in the field of psychiatry. This indicates that psychiatric expertise does not imply a sophisticated form of feigning that evades detection by the SIMS.