Book Reviews 115

when the policy of wholesale review and cutbacks began. After 1980, reversal rates for people whose benefits were terminated have been generally very high, in part because the terminations were often based on shoddy evidence and in part because legal advocacy increased. The relevant base for comparison of PUSH’s results would seem to be post- 1980 claims with legal representation. I have no doubt that the PUSH has been very successful in securing benefits for its clients, but the authors’ documentation of their enthusi- asm falls a bit short of solid analysis.

After describing PUSH, the authors go on to show that even the service projects and claims assistance provided by the most successful advocacy agency cannot ameliorate the larger problems of the disabled as long as society has a genera1 policy of treating them as second-class citizens. They provide a brief, probably idealized, view of public policy toward the disabled in England, Canada, France and Swe- den, to set the stage for the mainstreaming mode1 in the last chapter. They define “mainstreaming” as:

the provision of an appropriate occupational oppor- tunity for all disabled workers in the least restrictive environment, based on individualized employment programs that provide procedural safeguards and fair compensations, and aimed at providing disabled workers with access to, and constructive interactions with, social institutions (p. 10.5).

They explore the implications of such a policy through a variety of examples and public statements, and provide an impressionistic picture of what mainstreaming might mean.

PUSH sounds like an inspiring and effective organization. and one can only wish that its leaders are able to commu- nicate their ideas and experiences to other groups wanting to start similar projects. Unfortunately a $2 1 .OO hard-cover book, cast in the jargon of social work and policy analysis, may not be the best medium for this endeavor.

Massachusetts Institute of Technology

Cambridge, MA, U.S.A.

DEBORAH A. STONE

General Practice Revisited: A Second Study of Patients and Their Doctors, by ANN CARTWRIGHT and ROBERT ANDERSON. Tavistock, London, 1981. 227 pp. $28.95.

General Practice in the United Kingdom is coming under increasing scrutiny and criticism, not only by the public but also by its practitioners who care for 90% of the popu- lation’s ills, leaving the hospital service the remaining 10%.

This is an interesting book. It is a follow-up comparison of a study by Ann Cartwright in 1964 and titled “Patients and their Doctors”. In 1977 the format was the same. 836 people in England and Wales, randomly selected, were interviewed in their homes between April and July. The main aim was to describe the care given by the general practitioner (GP) service (also now called the Primary Care team) and the experiences and attitudes of patients and doctors to this care. Where appropriate, the-changes be- tween 1964 and 1977 are highlighted. Each interview lasted between l-2 hours. The patie&’ doctors (543) were sent postal questionnaires of which 67% were satisfactorily com- pleted and returned. There are nine chapters dealing with aims and methods, patients’ views, the GP system, doctor-patient relationships, health centres, ancilliary help, practitioner relationship with hospitals, variations between doctors and conclusions. There are also seven useful explanatory appendices.

In 1966 better remuneration and help in the organisation of genera1 practice led to much improved premises, the establishment of more health centres and doctors working largely in partnership. Now, in 1984, only 14% were on their own and 25% were in health centres. The authors were unable to identify any dramatic change in the consultation

rates or the average number of patients on each doctor’s list. However, by 1983 there has been a definite decline (2150) though not nearly as far as the 1700 patients per doctor being aimed at by general practitioners. There are inter- esting views on “trivial” consultations and the discovery that doctors’ attitudes and definitions are very variable. Some are happy to spend time discussing family and persona1 problems, while others believe them inappropriate and hence trivial. Personally, I do not believe patients have trivial complaints. To them so-called trivial complaints are real and potentially incapacitating. They are often caused by ignorance. To some doctors they may well appear to be trivia1 but today’s teaching is to be more understanding and caring.

Patients’ attitudes to prescribing are changing and through the media they have become more knowledgeable and discerning, but I don’t think as much as the American patient. British patients are still rather passive. However, many now may ask about side effects and doctors are learning to say “No” to a prescription or spend time explaining the natural history of disease and that therapy is not always necessary. The authors found that 90% of patients were satisfied or very satisfied with the service they receive, although many decried the decline in home visiting.

In the intervening years, the Primary Care team has been more widely and securely established, with the doctor working with nurses, health visitors, midwives and social workers as well as receiving backup from secretaries and receptionists. There is more of a community spirit about. Despite this, more patients have been going straight to casualty departments in hospital (emergency room) for minor injuries, accidents and some acute problems. This may be due to some doctors not giving 24 hour cover or not being available easily because of their home visits, hospital attachments and leisure time.

The major problem with this book is that the research was done 7 years ago. Much has happened in the intervening period. In fact the three suggestions made in the final chapter have all been accepted and now many practitioners do not automatically proffer a prescription. They also advise and counsel on persona1 and family problems. Receptionists are being trained, thus enhancing their relationships with the patients. Sickness certification arrangements have been changed and much improved.

But much more has happened. General practice is now a specialty with doctors undertaking a 3 year vocational course before being allowed to become a principal in primary care, rather like getting your American Board examination. This has given them more prestige, encour- aged higher standards of practice and postgraduate edu- cation. Moreover, a self audit has been stimulated particu- larly by the Royal College of General Practitioners. Doctors have much more open access to hospital facilities (but not beds), do more counselling and contraceptive work, as well as preventive care. They also get more money. Despite what I have said, it is sad to note that the number of prescriptions given to patients rises each year and I wonder whether this is not due to the potent and more useful drugs available now and the power of the pharmaceutical companies and their propaganda.

American doctors may have a little difficulty with this book if unfamiliar with the British National Health Service system. It describes a very excellent piece of research which is not only fascinating and illuminating but certainly edu- cational. It makes one ask an ever recurring question, “How am I doing?’

Boston G.P. Vocalional Training Scheme FRANK WALT Lincolnshire, England

Nonverbal Behavior: A Functional Perspective, by MILES L. PATTERSON. Springer, New York, 1983. 216 pp. DM 68; approx. USS26.40

116 Book Reviews

The stated purpose of this book is to provide a comprehen- sive theoretical integration of the field of nonverbal behav- ior research. Such integration is needed, says the author, because existing theoretical perspectives (1) focus only on a few behaviors at a time, (2) neglect the variety of functions that can be served by nonverbal expressions and/or (3) inadequately address the role of “predisposing variables” in social interaction. To remedy these shortcomings, Patterson advances a “sequential functional model” that is said to contrast with “the common ‘channel’ approach”,

meant for other colleagues in the field. However, the use of colloquial language and rather simplified illustrations in substantive chapters (e.g. Chapters 5-7) imply that the volume is intended as a lower level introduction to the field. I anticipate that this work will have greatest appeal to other cognitively oriented social psychologists who share Pat- terson’s assumptions.

The contrast is most evident in the book’s organization. Rather than devote chapters to particular channels of communication (e.g. gaze, touch, facial expression and body orientation) this author subdivides his subject matter ac- cording to “the functional bases for nonverbal behavior”: Providing information, regulating interaction, expressing intimacy, exercising social control and facilitating service and task goals. Five of the nine chapters are addressed to these functions. Of the remaining four, Chapter 1 defines the author’s terms, Chapter 2 describes his theoretical model, Chapter 8 (oddly) discusses “antecedent influences” on functions described in Chapters 2-7 and Chapter 9 offers an overview of problems and prospects posed by the model the author advances.

Beyond the organization of book chapters, Patterson’s departures from existing theoretical perspectives are appar- ent in his definitions of terms. For example, in Chapter 1, he defines a “functional” analysis as one that classifies nonverbal actions according to “the apparent purpose underlying an actor’s behavior”. Of course, as others (e.g. Paul Ekman and Don McKay) have noted, the distinction between goal-directed communication and merely “indica- tive” behavior is not always an easy one to sustain. But despite difficulties with its operationalization, Patterson employs this distinction because “it is assumed that most people are sensitive to an indicative versus communicative, or spontaneous versus goal-directed distinction” and be- cause adequate analyses of actors’ purposes can be garnered “from the objective assessment of intraindividual or inter- individual consistencies across time and circumstances”.

For others than these, the book is likely to pose major problems. First, Patterson’s theoretical integration of exist- ing research is nowhere as comprehensive as readers might reasonably expect it to be. For example, his discussion of conversational turn-taking (Chapter 4) might have benefitted from broader consideration of theoretical ad- vances in the field of conversation analysis (e.g. works by Harvey Sacks, Emmanuel Schegloff, Gail Jefferson and their colleagues). His analyses of intimacy (Chapter 5) and social control (Chapter 6) all but ignore Nancy Henley’s classic synthesis of these dimensions of nonverbal behavior (es- pecially odd, given that Mayo and Henley have a book in the same series as his). Readers of this journal may find his discussion of relations between medical practitioners and patients (Chapter 7) particularly perplexing. There, he skirts three decades of research on doctor-patient communication to cite Desmond Morris’s observation that male physicians used to be barred from attending births due to proscriptions against cross-sex intimacy (“The result”, according to Pat- terson, “was that unskilled and frequently superstitous women served as midwives, causing unnecessary risks to mother and child”).

Another significant departure from existing work lies in Patterson’s use of “nonverbal involvement behaviors” as an organizing construct for his theoretical model. Bypassing Erving GofTman’s classic discussion of “involvement obli- gations”, Patterson’s notion is one that “overlaps with proxemics, intimacy, and immediacy, but it is more compre- hensive than each of those constructs”. His tentative list offers evidence of its comprehensiveness: Interpersonal dis- tance, gaze, touch, body orientation, lean, facial expressive- ness, talking duration, interruptions, postural openness, relational gestures, head nods and paralinguistic cues (e.g. intonation, speech rate and speech volume.)

Second, and apart from the issue of the book’s compre- hensiveness, Patterson’s “sequential functional model” rests on questionable assumptions. For example, race and gender are described as “personal factors” (along with personality differences) that figure as antecendent influences on the model’s operation. Not only does this misrepresent the impact of such variables, but it prevents us from under- standing how they become salient features of face-to-face interaction. Moreover, as Patterson himself notes, infer- ences regarding the functions of nonverbal behaviors are “often uncertain”. His solution to this problem- conducting “objective” observations of behaviors across a range of persons and circumstances-appears to confuse reliability and validity. Finally, as in the case of other “functional” analyses (especially those in social science), it is always reasonable to ask “functional for whom?” While it may be convenient for organizational purposes to discuss intimacy and social control as if they were unrelated to one another, this tactic hinders our assessment of dynamics between the two (and obscures considerable evidence to the contrary).

The intended audience for this book is unclear. Levels of Sociology Board abstraction evidenced in Patterson’s theoretical discussions University of California (especially Chapter 2) would suggest that the volume is Santa Crux, CA, U.S.A.

CANDACE WEST