Book 44 - Non Verbal

NON-VERBAL
COMMUNICATION SKILLS
Medical Research in Biblical Times

from the Viewpoint of Contemporary
Perspective
Liubov Ben-Nun
In order to maintain relationships effectively humans must
communicate with each other. In everyday life, there are many types
of communication including with work colleagues, family, neighbors,
and friends, some efficient and some inefficient.
Non-verbal communication is defined as not involving words of
speech: voluntary or involuntary non-verbal signals, such as smiling
or blushing. The present research deals with non-verbal
communication among humans, evaluating biblical verses associated
with this topic from a viewpoint of contemporary perspective.
About the Author

Dr. Liubov Ben-Nun, the Author of dozens Books and Articles that have
been published in scientific journals worldwide.
Professor Emeritus at Ben Gurion University of the Negev, Faculty of
Health Sciences, Beer-Sheva, Israel. She has established the "LAHAV"
International Forum for research into medicine in the Bible from the
viewpoint of contemporary medicine.
NOT FOR SALE

NON-VERBAL COMMUNICATION SKILLS
Liubov Ben-Nun
Professor Emeritus
Ben-Gurion University of the Negev,

Faculty of Health Sciences, Beer-Sheva, Israel
th
44 Book.
Published by B. N. Publication House, Israel. 2014.
Fax: +(972) 8 6883376 Mobile 050 5971592

E-Mail: L-bennun@smile.net.il
Distributed Worldwide
Technical Assistance: Carmela Ben-Nun-Moshe.
All rights reserved
NOT FOR SALE `
1
CONTENTS I
MY VIEW
PREFACE 2
FOREWORD 3
INTRODUCTION 4
THE BIBLICAL VERSES 8
CHARACTERISTICS OF NON-VERBAL COMMUNICATION 9
FACIAL EXPRESSIONS
GESTURES
PARALANGUAGE
PHYSICAL COMMUNICATION
KINESICS
PROXEMICS
EYE GAZE
HAPTICS
APPEARANCE
AESTHETIC COMMUNICATION
SIGNS AND SYMBOLS OF COMMUNICATION
EXPRESSION OF EMOTIONS 21
TACTILE CHANNEL
LISTENING AND COMPREHENSION 25
NOISY ENVIRONMENT
CHANGES IN BREATHING
LISTENING TO PARENTS
PASSIVE-LISTENING AND ACTIVE RESPONSE
RACE BIAS 32
TELEVISED NON-VERBAL BEHAVIOR 35
IDENTIFYING LEADERS 35
ROBOT INTERACTION 37
PHYSICIAN-PATIENT INTERACTION 37
EMPATHIC LISTENING
TRAUMATIC BRAIN INJURY
DEMENTIA
PATIENTS IN NURSING HOMES
TECHNOLOGISTS 56
DIETITIANS 56
MENTAL DISORDERS 58
PSYCHOTHERAPY
SILENCE IN PSYCHODYNAMIC PSYCHOTHERAPY
CLINICAL VIGNETTE
PEDIATRICS 73
DISCLOSING MEDICAL ERRORS 75
NURSES' NON-VERBAL COMMUNICATION 78
TEACHING 84
SUMMARY 93
ABBREVATIONS 99
1
L. Ben-Nun Non-verbal communication skills
MY VIEW
MEDICINE IN THE BIBLE

AS A RESEARCH CHALLENGE
This is a voyage along the well-trodden routes of contemporary
medicine to the paths of the Bible, from the time of the first man to
the period of the People of Israel. It covers the connection between
body and soul, and the unbroken link between our earliest ancestors,
accompanied by spiritual yearning and ourselves. Through the verses
of the Bible flows a powerful stream of ideas for medical research
combined with study of our roots and the Ancient texts.
It would not be too adventurous to state that if there is one book
in the world that all Jews are proud of, that is the Book of Books, the
greatest classic among all literary works, whose original language is
not Greek or Latin, but the Hebrew that I and other Israelis speak
every day, our mother tongue, the language of Eliezer Ben Yehuda.
The Bible exists as evidence in the Book of Books, open to all
humankind. For thousands of years it has been placed before us, still
as fresh as before, the history of peoples who have disappeared and
of the Jewish people, which has survived with its Holy Text that has
been translated into hundreds of languages and dialects, and remains
our eternal taboo.
Many people ask me about the connection between the Bible and
medical science. My reply is simple: the roots of science are buried
deep in the biblical period and I am just the archeologist and medical
researcher. This scientific medical journey to the earliest roots of the
nation in the Bible has been and remains moving, exciting and
enjoyable. It has created a kind of meeting in my mind between the
present and those Ancient times, through examining events frozen in
time.
Sometimes it is important to stop, to look back a little. In real
time, it is hard to study every detail, because time is passing as they
appear. However, when we look back we can freeze the picture and
examine every detail, see many events that we missed during that
fraction of a second when they occurred.
The Book of Books, the Bible, is not just the identity card of the
Jewish, but an essential source for the whole world.
2
PREFACE
The purpose of this research is to analyze the medical situations
and conditions referred to in the Bible, as we are dealing with a
contemporary medical record.
These are scientific medical studies incorporating verses from the

Bible, without no interpretation or historical descriptions of places.
Fundamentally, this Research is constructed purely from an

examination of passages from the Bible, exactly as written.
The research is part of a long series of published studies on the

subject of biblical medicine from a modern medical perspective.
This is not a laboratory research. The Research is built entirely on

a secular foundation. With due to respects to people faith, this
Research takes a modern look at medical practices. Each to his own
beliefs.
3
FOREWORD
In the health care professions, the results of miscommunication
and misunderstanding can be costly. Stress-related ailments and
burnout occur frequently. Managers therefore should examine
organizational communication strategies and offer ways of dealing
with stress, if necessary. One stress-reduction measure that can be
undertaken at little cost is bridge building. The bridge-building
process involves making a connection or link between people by
careful listening and attention to their interactions with another.
Bridge building may include persons from all organizational levels;
the only limits are participants' willingness to risk and their desire to
improve the work environment. One strategy for bridge building is
the story meeting. Because stories are a representative way of
addressing complex issues, they can provide a framework for
handling sensitive situations. Creating a story about a department or
work team allows persons to deal with inner frustrations in a
nonthreatening way and to consider creative outcomes to their
shared problem (1).
Because communication is something that is often taken for
granted, many people do not consciously think about communication
habits and behaviors. When patients are questioned concerning
important attributes of a doctor, they say they want someone who
respects and listens to them. In a time of increasing malpractice
litigation, physicians need to examine their communication skills. In
an increasingly more diverse world, social and cultural beliefs,
attitudes, and behaviors have a considerable effect on the health of
communities. Patient safety, satisfaction, and successful outcomes
rely on understanding the patient's medical and cultural needs. The
concept of becoming a "cultural anthropologist" is improbable, but
becoming aware of the demographics of the community in which the
physician serves will improve communication and lead to improved
patient and physician satisfaction, better patient compliance, and
improved health outcomes (2).
Effective communication is essential to practice and can result in
improved interpersonal relationships at the workplace. Effective
communication is shaped by basic techniques such as open-ended
questions, listening, empathy, and assertiveness. However, the
relationship between effective communication and successful
4
interpersonal relationships are affected by intervening variables. The

variables of gender, generation, context, collegiality, cooperation,
self-disclosure, and reciprocity can impede or enhance the outcome
of quality communication. It is essential to qualitatively assess the
degree to which each of these concepts affects communication and,
in turn, relationships at work (3).
Even though the English language is full of complex words that
help us to express ourselves and connect with each other through
speech, most communication between two human beings transpires
without the use of words. Humans begin communicating as soon as
their energy fields cross; and this exchange can lead to even greater
insight when it takes place in someone's home (4).
References
1. Ward JR. Communications bridges raise productivity, reduce stress.
Health Prog. 1987;68(2):71-2.
2. Lewis VO, McLaurin T, Spencer HT, et al. Communication for all your
patients. Instr Course Lect. 2012;61:569-80.
3. Grover SM. Shaping effective communication skills and therapeutic
relationships at work: the foundation of collaboration. AAOHN J. 2005;
53(4):177-82; quiz 186-7.
4. Anderson M. The unspoken exchange between two human beings.
Creat Nurs. 2011;17(4):198-200.
INTRODUCTION
Effective communication is an essential skill in general practice
consultations. The art of communication is the development of
effective skills and finding a style of communication that suits the
clinician and produces benefits for both patient and doctor. The
essential skills are required for effective communication with a
patient and clinicians should consider this communication as an art
that can be developed throughout a medical career. Good
communication can improve outcomes for patients and doctors, and
deserves equal importance as developing clinical knowledge and
procedural skill. A therapeutic patient-doctor relationship uses the
clinician as a therapeutic intervention and is part of the art of
communication. Despite all the technological advances of recent
5
decades, caring, compassionate, and healing doctors remain the best

therapeutic tool in medicine. The ability of a doctor to provide
comfort through their presence and their words is a fundamental
component of good medical care (1).
For many years, medical researchers have been studying
physician-patient interactions, and the results of these studies have
yielded 3 basic conclusions: physician-patient interactions have an
impact on patient health, patient and physician satisfaction,
adherence to medical recommendations, and malpractice risk;
communication is a core clinical skill and an essential component of
clinical competence; and appropriate training programs can
significantly change medical practitioners' communication
knowledge, skills, and attitudes (2).
Effective patient-provider communication is a critical aspect of the
delivery of high-quality patient care; however, research regarding the
conversational dynamics of an overall ED visit remains unexplored.
Identifying both patterns and relative frequency of utterances within
these interactions will help guide future efforts to improve the
communication between patients and providers within the ED
setting. The objective of this study was to analyze complete audio
recordings of ED visits to characterize these conversations and to
determine the proportion of the conversation spent on different
functional categories of communication. Patients at an urban
academic ED, Department of Emergency Medicine, Chicago, with 4
diagnoses (ankle sprain, back pain, head injury, and laceration) were
recruited to have their ED visits audio recorded from the time of
room placement until discharge. Patients were excluded if they were
age <18 years, were non-English-speaking, had significant history of
psychiatric disease or cognitive impairment, or were medically
unstable. Audio editing was performed to remove all silent downtime
and non-patient-provider conversations. Audiotapes were analyzed
using the RIAS. RIAS is the most widely used medical interaction
analysis system; coders assign each "utterance" (or complete
thought) spoken by the patient or provider to 1 of 41 mutually
exclusive and exhaustive categories. Descriptive statistics were
calculated for all 41 categories and then grouped according to RIAS
standards for "functional groupings." The percentage of total
utterances in each functional grouping is reported. Twenty-six audio
recordings were analyzed. Patient participants had a mean (SD) age
6
of 38.8 (16.0) years, and 30.8% were male. Intercoder reliability was
good, with mean intercoder correlations of 0.76 and 0.67 for all
categories of provider and patient talk, respectively. Providers
accounted for the majority of the conversation in the tapes (median
= 239 utterances, IQR = 168 to 308) compared to patients (median =
145 utterances, IQR = 80 to 198). Providers' utterances focused most
on patient education and counseling (34%), followed by patient
facilitation and activation (e.g., orienting the patient to the next steps
in the ED or asking if the patient understood; 30%). Approximately
15% of the provider talk was spent on data gathering, with the
majority (86%) focusing on biomedical topics rather than
psychosocial topics (14%). Building a relationship with the patient
(e.g., social talk, jokes/laughter, showing approval, or empathetic
statements) constituted 22% of providers' talk. Patients' conversation
was mainly focused in 2 areas: information giving (47% of patient
utterances: 83% biomedical, 17% psychosocial) and building a
relationship (45% of patient utterances). Only 5% of patients'
utterances were devoted to question asking. Patient-centeredness
scores were low. In conclusion, in this sample, both providers and
patients spent a significant portion of their talk time providing
information to one another, as might be expected in the fast-paced
ED setting. Less expected was the result that a large percentage of
both provider and patient utterances focused on relationship
building, despite the lack of traditional, longitudinal provider-patient
relationships (3).
The purpose of this article is to provide a commentary on non-
verbal communication in the physician-older patient interaction. A
literature review of physician-older patient communication yielded
several published studies on this topic. Non-verbal behaviors were
rarely examined in this body of literature even though the need to
adopt a more "biopsychosocial" model of care was mentioned in
several of the articles. The non-verbal communication literature was
also reviewed to determine whether aging had been a variable of
interest with regard to encoding (sending) and decoding
communication (receiving) skills. There have been very few studies
that have investigated the role of non-verbal communication in the
physician-older patient interaction. Selected encoding and decoding
characteristics for both physicians and patients are discussed with
the context of the aging process. In lieu of direct evidence linking
7
non-verbal behavior and physician-older patient communication,

possible implications are offered for the following characteristics:
expression of emotion, pain expression, gestures, gaze, touch,
hearing, and vocal affect. Three relevant outcomes (satisfaction with
care, QOL, and health status) are discussed within the non-verbal
behavior-aging framework. In conclusion, the connection between
non-verbal behavior and how physicians and older patients interact
with one another has not been rigorously examined. Identifying and
improving nonverbal communication will likely enhance the verbal
exchange in the medical encounter and may improve the older
patient's quality of care (4).
Communication is an important human characteristic. In order to
maintain relationships effectively humans must communicate with
each other. In everyday life, there are many types of communication
including with work colleagues, family, neighbors, and friends, some
efficient and some inefficient.
My previous research (5) deals with two biblical verses "Death and
life are in the power of the tongue" (Proverbs 18:21) and "A soft
tongue beaks the bone" (Proverbs 25:15) evaluating the following
questions: how do HCPs interact with each other? How do they
interact with their patients? How do they deliver difficult issues to
their patients? To their families? How do they handle conversations
related to difficult medical situations? Should medical students,
interns and HCPs be taught how to conduct effective conversations?
How to deliver difficult messages to the patients? The main message
of these verses is to show people that their ability to communicate is
of vital importance for their existence.
The present research studies non-verbal communication among
humans, evaluating other biblical verses associated with this topic.
References
1. Warnecke E. The art of communication. Aust Fam Physician. 2014;43
(3):156-8.
2. Shaw JR. Four core communication skills of highly effective
practitioners. Vet Clin North Am Small Anim Pract. 2006;36(2):385-96, vii.
3. McCarthy DM, Buckley BA, Engel KG, et al. Understanding patient-
provider conversations: what are we talking about? Acad Emerg Med. 2013;
20(5):441-8.
4. Irish JT. Deciphering the physician-older patient interaction. Int J
Psychiatry Med. 1997;27(3):251-67.
8
5. Ben-Nun L. Verbal communication as described in the Bible. Research

in Biblical Times from the Viewpoint of Contemporary Medicine. Ben-Nun L.
(ed.). Israel. 2014.
THE BIBLICAL VERSES

Communication between humans is a vital interaction in our life.
This research deals with biblical verses: "He who guards his mouth
and his tongue keeps his soul from troubles" (Proverbs 21:23). and "I
will keep a curb on my mouth, while the wicked man is before me"
(Psalms 39:2).
Communication is defined as the exchange information, or the use
of common system of symbols, signs, behavior for this; a verbal or
written message; a system of routes; techniques for the effective
transmission of information, ideas, etc. (1). Communication also
transfers information from one person to another (2).
Non-verbal communication is defined as not involving words of
speech: voluntary or involuntary non-verbal signals, such as smiling
or blushing (1).
Verses described above indicate non-verbal communication that is
an essential part of the human existence. These verses have a wide
range of implications for our everyday life dealing with
communication within a family, with friends, in society, at work, and
with patients. Since the author of this research is a medical doctor,
studying Medicine in the Bible, it is natural that this study
concentrates mainly on non-verbal communication in a variety of
medical situations. How can we deal with these verses in our
everyday life?
Reference
ND
1. The Penguin English Dictionary. 2 ED. Penguin Books. Robert Allen
Consultant ed. 2003. England.
2. Examples of Non Verbal Communication. Available 15 May 2014 at
yourdictionary.com/examples-of-non-verbal-communication.
9
CHARACTERISTICS OF NON-VERBAL
COMMUNICATION
An estimated 60 to 65 percent of interpersonal communication is
conveyed via non-verbal behaviors (1). Unfortunately, the emphasis
in the clinical setting is disproportionately placed on verbal
interactions. Many non-verbal behaviors are unconscious and may
represent a more accurate depiction of a patient's attitude and
emotional state. They can belie a patient's anxiety regarding a
specific topic discussed in therapy despite verbal assertions that the
subject is inconsequential and not causing distress. It is critically
important to consider a patient's non-verbal behaviors when
assessing risk of harm to self or others. Alternatively, non-verbal
behaviors may shed light on feelings of transference and counter-
transference between patient and physician (2).
All non-verbal behavior must be interpreted within context. Knapp
and Hall specifically address the issue of physicians' limited training in
non-verbal communication. Physicians can use this kind of
knowledge. However, it is important that physicians not only notice
cues but also that they draw appropriate interpretations from them
(3). Non-verbal cues cannot be interpreted in a vacuum. No single
behavior or gesture means the exact same thing in every conceivable
context. For example, consider the hand gesture of extending only
the index and middle fingers, spread apart in a V shape, while closing
the rest of the hand. This might signify a number, 2. In the United
States if the palm is facing the individual using this gesture it signifies
victory and if the palm is facing others it is identified as a symbol
meaning peace. In England, however, making the American V for
victory sign is an insult with sexual connotations. In London,
displaying the American peace sign instead represents victory (3).
Non-verbal communication is one of the key aspects of
communication and especially important in a high-context culture. It
has multiple functions: used to repeat the verbal message e.g. point
in a direction while stating directions; often used to accent a verbal
message e.g. verbal tone indicates the actual meaning of the specific
words, often complement the verbal message but also may
contradict, e.g. a nod reinforces a positive message (among
Americans); a wink may contradict a stated positive message;
10
regulate interactions (non-verbal cues covey when the other person

should speak or not speak); may substitute for the verbal message
(especially if it is blocked by noise, interruption, etc) - i.e. gestures
(finger to lips to indicate need for quiet), and facial expressions (i.e. a
nod instead of a yes) (4).
Non-verbal communication involves those non-verbal stimuli in a
communication setting that are generated by both the source
[speaker] and his or her use of the environment and have potential
message value for the source or receiver [listener] (5). It is sending
and receiving messages in a variety of ways without the use of verbal
codes (words). Non-verbal communication is both intentional and
unintentional. Most speakers/listeners are not conscious of this. It
includes touch, glance, eye contact (gaze), volume, vocal nuance,
proximity, gestures, facial expression, pause (silence), intonation,
dress, posture, smell, word choice and syntax, and sounds
(paralanguage) (4).
There are 2 basic categories of non-verbal language: non-verbal
messages produced by the body; non-verbal messages produced by
the broad setting (time, space, and silence) (4).
A substantial portion of our communication is non-verbal. Every
day, we respond to thousands on non-verbal cues and behaviors
including postures, facial expression, eye gaze, gestures, and tone of
voice. From our handshakes to our hairstyles, non-verbal details
reveal who we are and affect how we relate to other people (6).
Scientific research on non-verbal communication and behavior
began with the 1872 publication of Charles Darwin's The Expression
of the Emotions in Man and Animals. Since that time, there has been
an abundance of research on the types, effects and expressions of
unspoken communication and behavior. While these signals are often
so subtle that we are not consciously aware of them, research has
identified several different types of non-verbal communication. In
many cases, we communicate information in non-verbal ways using
groups of behaviors. For example, we might combine a frown with
crossed arms and unblinking eye gaze to indicate disapproval (6).
This exploratory study examined patterns of non-verbal
accommodation within health care interactions and investigated the
impact of communication skills training and gender concordance on
non-verbal accommodation behavior. The NAAS was used to code
the non-verbal behavior of physicians and patients within 45
11
oncology consultations. Cases were then placed in 1 of 7 categories

based on patterns of accommodation observed across the
interaction. Across all NAAS behavior categories, physician-patient
interactions were most frequently categorized as joint convergence,
followed closely by asymmetrical-patient convergence. Among
paraverbal behaviors, talk time, interruption, and pausing were most
frequently characterized by joint convergence. Among non-verbal
behaviors, eye contact, laughing, and gesturing were most frequently
categorized as asymmetrical-physician convergence. Differences
were predominantly insignificant in terms of accommodation
behavior between pre- and post-communication skills training
interactions. Only gesturing proved significant, with post-
communication skills training interactions more likely to be
categorized as joint convergence or asymmetrical-physician
convergence. No differences in accommodation were noted between
gender-concordant and nonconcordant interactions. The importance
of accommodation behavior in health care communication is
considered from a patient-centered care perspective (7).
Knapp and Hall (8) conceptualize these basic elements similarly,
referring to the communication environment, which includes both
physical and spatial elements, the individual's physical characteristics,
and body movement and position. They further subdivide the latter
element into gestures, posture, touching behaviors, facial
expressions, eye behavior and vocal behavior. Touching behaviors
include simple nervous habits, including playing with a tissue or
objects on the desk in session or clasping the hands together, as well
as behaviors designed to decrease anxiety or serve as self-soothing
methods, including rubbing the forehead, crossing the arms across
the body, or running the palms over the lap.
FACIAL EXPRESSIONS
Non-verbal communication includes facial expressions, gestures,
and eye contact. When someone is talking, changes in facial
expressions are noticed and respond accordingly. These include
raising eyebrows, yawning, sneering, rolling eyes, gaping, and
nodding. The meaning of these movements is pretty much the same
in all cultures (6).
12
Facial expressions are responsible for a huge proportion of non-

verbal communication. Consider how much information can be
conveyed with a smile or a frown. While non-verbal communication
and behavior can vary dramatically between cultures, the facial
expressions for happiness, sadness, anger and fear are similar
throughout the world (6). Non-verbal behaviors, in particular facial
expressions and paralanguage, can reveal significant information
pertaining to a patient's affective state (8).
In everyday life, people communicate not only with another
person but also in front of other people. How do people behave
during communication when observed by others? Effects of an
observer (presence vs. absence) and interpersonal relationship
(friends vs. strangers vs. alone) on facial behavior were examined.
Participants viewed film clips that elicited positive affect (film
presentation) and discussed their impressions about the clips
(conversation). Participants rated their subjective emotions and
social motives. Durations of smiles, gazes, and utterances of each
participant were coded. The presence of an observer did not affect
facial behavior during the film presentation, but did affect gazes
during conversation. Whereas the presence of an observer seemed
to facilitate affiliation in pairs of strangers, communication between
friends was exclusive and not affected by an observer (9).
Facial expression is one of the more straightforward non-verbal
behaviors to identify and interpret, and is one of the most studied
elements of non-verbal communication. Ekman and Friesen identified
several facial expressions of emotion that are relatively similar and
easily identifiable across cultures (10). The 6 classic emotions that are
recognized and understood by members of most cultures are
surprise, fear, disgust, anger, happiness, and sadness. (11). Ekman
and Friesen later developed a facial atlas that catalogs every facial
muscle and its role in each of these emotional states. This
information is the basis of an encoding system used to classify facial
expressions for research purposes (12). In clinical use, being able to
recognize and differentiate between similar expressions (e.g., fear
and sadness or disgust and anger) is important when treating
alexithymic patients who have difficulty articulating their feeling
state. The study of facial expression has been further refined in order
to detect emotional leakage via very subtle microexpressions or
fleeting, involuntary, non-verbal facial indicators of an emotion that
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someone attempts to conceal by voluntarily displaying another

affective state (12).
Previous studies investigated the effects of interpersonal
relationships on facial expressions by comparing friends with
strangers. This study examined facial expressions in the course of
relationship formation. Twenty pairs of female strangers met once a
week for 3 weeks watching film clips aimed to elicit a positive
emotions. Smiles and gazes during and after presentation of the film
clips were measured. Subjective emotions and social motives were
also measured. Smiling increased from Week 1 to Week 2, but did
not change from Week 2 to 3. The results support the theory of Berg
and Clark's (13) that relationships are differentiated very early on.
The score for "concern about partner's evaluation" on the social
motive questionnaire decreased from Week 1 to 2 suggesting that
decreasing avoidant social motives facilitates the expressions of
smiles in the course of relationship formation (14).
Previous studies have suggested that facial displays in the
presence of others are influenced by the relationship with
accompanying persons. In these studies, subjects participated with
friends or strangers, without any focus on social interactions
between partners. In the current study, pairs of friends or strangers
viewed film clips expected to elicit positive and negative affects; the
control group participated without partners. Synchronous smiles
between partners as a social interactive display, in addition to the
duration and the frequency of smiles and frowns were measured.
Subjective emotion and social motive were also measured. Smiles
were facilitated by the presence of a friend than a stranger or the
condition of lone participation, regardless of stimulus valence.
Synchronous smiles and the communication motive were also
enhanced with a friend than with a stranger. These results suggested
that the expression of smiles was facilitated by the communication
motive and social interactions between partners (15).
Processing of non-verbal social cues is essential to interpersonal
functioning and is particularly relevant to models of social anxiety.
This article provides a review of the literature on non-verbal social
cues processing from the perspective of social rank and affiliation
biobehavioral systems, based on functional analysis of human
sociality. The potential of this framework for integrating cognitive,
interpersonal, and evolutionary accounts of social anxiety was
14
examined. Whether non-verbal social cues are uniquely suited to

rapid and effective conveyance of emotional, motivational, and trait
information and whether various channels are differentially effective
in transmitting such information were evaluated. First, studies on
perception of non-verbal social cues through face, voice, and body
were reviewed. Studies that utilized information processing or
imaging paradigms to assess non-verbal social cues perception were
examined. This research demonstrated that social anxiety is
associated with biased attention to, and interpretation of, emotional
facial expressions and emotional prosody. Findings regarding body
and posture remain scarce. Studies on non-verbal social cues
expression pinpointed links between social anxiety and disturbances
in eye gaze, facial expressivity, and vocal properties of spontaneous
and planned speech. Again, links between social anxiety and posture
were understudied. Although cognitive, interpersonal, and
evolutionary theories have described different pathways to social
anxiety, all 3 models focus on interrelations among cognition,
subjective experience, and social behavior. Non-verbal social cues
processing and production comprise the juncture where these
theories intersect (16).
GESTURES
Gestures are many times an individuals way of communicating as
most people gesture when talking (4). Deliberate movements and
signals are an important way to communicate meaning without
words. Common gestures include waving, pointing, and using fingers
to indicate numeric amounts. Other gestures are arbitrary and
related to culture (6).
People move their hands as they talk - they gesture. Gesturing is a
robust phenomenon, found across cultures, ages, and tasks. Gesture
is found in individuals blind from birth. However, what purpose, if
any, does gesture serve? Gesture when it stands on its own,
substituting for speech and clearly serving a communicative function
is examined. When called upon to carry the full burden of
communication, gesture assumes a language-like form, with
structure at word and sentence levels. However, when produced
along with speech, gesture assumes a different form - it becomes
15
imagistic and analog. Despite its form, the gesture that accompanies
speech also communicates. Trained coders can glean substantive
information from gesture - information that is not always identical to
that gleaned from speech. Gesture can thus serve as a research tool,
shedding light on speakers' unspoken thoughts. The controversial
question is whether gesture conveys information to listeners not
trained to read them. Do spontaneous gestures communicate to
ordinary listeners? Or might they be produced only for speakers
themselves? These are not mutually exclusive functions - gesture
serves as both a tool for communication for listeners, and a tool for
thinking for speakers (17).
When speakers talk, they gesture. The goal of this review is to
investigate the contribution that these gestures make to how we
communicate and think. Gesture can play a role in communication
and thought at many time spans. In turn, gesture's contribution to
how language is produced and understood in the moment is
explored; its contribution to how we learn language and other
cognitive skills; and its contribution to how language is created over
generations, over childhood, and on the spot. The gestures speakers
produce when they talk are integral to communication and can be
harnessed in a number of ways. 1] Gesture reflects speakers'
thoughts, often their unspoken thoughts, and thus can serve as a
window onto cognition. Encouraging speakers to gesture can thus
provide another route for teachers, clinicians, interviewers, etc., to
better understand their communication partners. 2] Gesture can
change speakers' thoughts. Encouraging gesture thus has the
potential to change how students, patients, witnesses, etc., think
about a problem and, as a result, alter the course of learning,
therapy, or an interchange. 3] Gesture provides building blocks that
can be used to construct a language. By watching how children and
adults who do not already have a language put those blocks together,
we can observe the process of language creation. Our hands are with
us at all times and thus provide researchers and learners with an
ever-present tool for understanding how we talk and think (18).
Gesture has privileged access to information that children know
but do not say. As such, it can serve as an additional window to the
mind of the developing child, one that researchers are only beginning
to acknowledge. Gesture might, however, do more than merely
reflect understanding - it may be involved in the process of cognitive
16
change itself. This question will guide research on gesture as we

enter the new millennium. Gesture might contribute to change
through 2 mechanisms which are not mutually exclusive: [1]
indirectly, by communicating unspoken aspects of the learner's
cognitive state to potential agents of change (parents, teachers,
siblings, and friends); and [2] directly, by offering the learner a
simpler way to express and explore ideas that may be difficult to
think through in a verbal format, thus easing the learner's cognitive
burden. As a result, the next decade may well offer evidence of
gesture's dual potential as an illuminating tool for researchers and as
a facilitator of cognitive growth for learners themselves (19).
PARALANGUAGE
Paralanguage includes other mental status elements, such as
prosody, rate, rhythm, volume, tone, and pitch of speech (20).
Paralinguistics refers to vocal communication that is separate
from actual language. This includes factors such as tone of voice,
loudness, inflection and pitch, considering the powerful effect that
tone of voice can have on the meaning of a sentence. When said in a
strong tone of voice, listeners might interpret approval and
enthusiasm. The same words said in a hesitant tone of voice might
convey disapproval and a lack of interest (6).
PHYSICAL COMMUNICATION
Physical communication covers the personal kind of
communication, and includes a smile or frown, wink, touch, smell,
salute, gesture, and other bodily movements. Social conversation
uses many of these physical signals along with the spoken words (21).
Physical communication is the most used form of non-verbal
communication. A person that is aware of anothers non-verbal cues
will understand that person better. Even the way one is standing and
his/her position in a group of people can communicate. The amount
of distance between 2 persons will be interpreted in a certain way,
17
and the meaning will change according to the culture. It either can
mean an attraction, or can signal intensity. Standing side-to-side can
show cooperation, where a face-to-face posture may show
competition. A posture can communicate in a non-verbal way,
whether a person is folding his arms, slouching, crossing his legs, or
standing and sitting erect. Finally, any actual touching can convey
attraction or a level of intimacy. Examples of non-verbal
communication of this type include shaking hands, patting the back,
hugging, pushing, or other kinds of touch (6).
KINESICS
Kinesics includes how the body moves. This includes posture,
body movements, gestures, eye behaviors, and facial expressions.
Each refers to elements of the mental status examination in a
different guise (e.g., general appearance and behavior, psychomotor
functioning, eye contact, and affect) (20).
Posture and movement can convey a great deal of information.
Research on body language has grown significantly since the 1970's,
but popular media have focused on the over-interpretation of
defensive postures, arm-crossing, and leg-crossing, especially after
the publication of Julius Fast's book Body Language. While these non-
verbal behaviors can indicate feelings and attitudes, research
suggests that body language is far more subtle and less definitive that
previously believed (6).
PROXEMICS
People often refer to their need for "personal space," which is also
an important type of non-verbal communication. The amount of
distance we need and the amount of space we perceive as belonging
to us is influenced by a number of factors including social norms,
situational factors, personality characteristics and level of familiarity.
For example, the amount of personal space needed when having a
casual conversation with another person usually varies between 18
18
inches to 4 feet. On the other hand, the personal distance needed

when speaking to a crowd of people is around 10 to 12 feet (4).
Proxemics refers to how interpersonal relationships and behavior
are changed by the distance between 2 people (20).
EYE GAZE
Looking, staring and blinking can also be important non-verbal
behaviors. When people encounter people or things that they like,
the rate of blinking increases and pupils dilate. Looking at another
person can indicate a range of emotions, including hostility, interest
and attraction (6).
Eye contact is important in communicating non-verbally. A
persons emotion through their eyes can be read, and many times is
not the same emotion as their words are saying (4).
HAPTICS
Communicating through touch is another important non-verbal
behavior. There has been a substantial amount of research on the
importance of touch in infancy and early childhood. Harry Harlow's
classic monkey study demonstrated how the deprivation of touch
and contact impedes development. Baby monkeys raised by wire
mothers experienced permanent deficits in behavior and social
interaction. Touch can be used to communicate affection, familiarity,
sympathy and other emotions (6).
APPEARANCE
Our choice of color, clothing, hairstyles and other factors affecting
appearance are a means of non-verbal communication. Research on
color psychology has demonstrated that different colors can evoke
different moods. Appearance can also alter physiological reactions,
judgments and interpretations. The first impressions are important,
19
which is why experts suggest that job seekers dress appropriately for
interviews with potential employers (4).
AESTHETIC COMMUNICATION
Aesthetic communication occurs through creative expression.
This includes the arts: music, dance, theatre, crafts, art, painting, and
sculpture. Ballet is a great example of this, as there is dance and
music, but no spoken or sung words. Even in an opera, where there
are words, there are still facial expressions, costumes, posture, and
gestures (21).
SIGNS AND SYMBOLS OF COMMUNICATION

Signs are a more mechanical kind of non-verbal communication,
which includes signal flags or lights, a 21-gun salute, a display of
airplanes in formation, horns, and sirens (4).
Symbols of communication are used for religious or personal
status reasons, as well as to build self-esteem. This includes jewelry,
cars, clothing, and other things to communicate social status,
financial means, influence, or religion (4).
Assessment: an estimated 60 to 65 percent of interpersonal

communications are conveyed via non-verbal behaviors.
Unfortunately, the emphasis in the clinical setting is
disproportionately placed on verbal interactions. Many non-verbal
behaviors are unconscious and may represent a more accurate
depiction of a patient's attitude and emotional state.
Non-verbal communication includes physical communication: a
smile or frown, wink, smell, salute, posture and other bodily
movements, pause (silence); facial expressions: raising eyebrows,
yawning, sneering, rolling eyes, gaping, and nodding; gestures:
waving, pointing, and using fingers to indicate numeric amounts;
paralinguistics: vocal communication, separate from actual language,
and includes tone of voice, loudness, inflection and pitch; proxemics:
the need for "personal space"; eye gaze: looking, contact, staring and
20
blinking; haptics: communication through touch; appearance: choice

of color, clothing, hairstyles and other factors affecting appearance;
aesthetic communication: creative expression including music, dance,
theatre, crafts, art, painting, and sculpture; signs: signal flags or
lights, a 21-gun salute, a display of airplanes in formation, horns, and
sirens; symbols: jewelry, cars, and clothing.
References
1. Burgoon JK, Guerrero LK, Floyd K. Nonverbal Communication. Boston,
MA: Allyn and Bacon. 2009.
2. Philippot P, Feldman R, Coats E. The role of nonverbal behavior in
clinical settings. In: Philippot P, Feldman R, Coats E (eds.). Nonverbal
Behavior in Clinical Settings. New York, NY: Oxford University Press. 2003,
pp. 313.
3. Knapp ML, Hall JA. Nonverbal Communication in Human Interaction,
Seventh Edition. Wadsworth, Canada: Cengage Learning. 2010.
4. Non Verbal Communication. Available 15 May 2014 at
andrews.edu/~tidwell/bsad560/NonVerbal.html.
5. Samovar LA, Porter RE, McDaniel ER. Communication Between
Cultures. Cengage Learning. Social Science. 2009.
6. Kendra Cherry. Types of Nonverbal Communication. Available 16 May
2014 at psychology.about.com/.../nonverbalcommunication/.../nonverbal
types.htm.
7. D'Agostino TA, Bylund CL. Nonverbal accommodation in health care
communication. Health Commun. 2014;29(6):563-73.
8. Gretchen N. Foley, Julie P. Gentile. Nonverbal Communication in
Psychotherapy. Psychiatry (Edgmont). 2010;7(6):3844.
9. Yamamoto K, Suzuki N. Effect of an observer's presence on facial
behavior during dyadic communication. Percept Mot Skills. 2012;114(3):949-
63.
10. Ekman P, Friesen WV. Constants across cultures in the face and
emotion. J Personal Soc Psychol. 1971;17(2):124129.
11. Ekman P, Friesen WV. Unmasking the Face. Englewood Cliffs, NJ:
Prentice-Hall Inc. 1975.
12. FACS vs. F.A.C.E. The differences between FACS and F.A.C.E. Available
15 April 2010 at training paulekman.com/products/facs-vs-f-a-c-e/.
13. Berg JH, Clark MS. Differences in Social exchange between intimate
and other relationships. Gradually evolving or quickly apparent? In Derlega
VJ, Winstead BA (eds.). Friendship and Social Interaction. New York Springer-
Verlag. 1986.
14. Yamamoto K, Suzuki N. Facial expressions in the course of
relationship formation. Shinrigaku Kenkyu. 2008;78(6):567-74.
21
15. Yamamoto K, Suzuki N. The effects of personal relationships on facial

displays. Shinrigaku Kenkyu. 2005;76(4):375-81.
16. Gilboa-Schechtman E, Shachar-Lavie I. More than a face: a unified
theoretical perspective on nonverbal social cue processing in social anxiety.
Front Hum Neurosci. 2013 Dec 31;7:904. eCollection 2013.
17. Goldin-Meadow S. The role of gesture in communication and
thinking. Trends Cogn Sci. 1999;3(11):419-29.
18. Goldin-Meadow S, Alibali MW. Gesture's role in speaking, learning,
and creating language. Annu Rev Psychol. 2013;64:257-83.
19. Goldin-Meadow S. Beyond words: the importance of gesture to
researchers and learners. Child Dev. 2000;71(1):231-9.
20. Shea SC. Psychiatric Interviewing: The Art of Understanding, Second
Edition. Philadelphia, PA: Saunders. 1998.
21. Examples of Non Verbal Communication. examples. Available 15 May
2014 at yourdictionary.com/examples-of-non-verbal-communication.
EXPRESSION OF EMOTIONS
Relationship-centered care reflects both knowing and feeling: the
knowledge that physician and patient bring from their respective
domains of expertise, and the physicians and patient's experience,
expression, and perception of emotions during the medical
encounter. These processes are conveyed and reciprocated in the
care process through verbal and non-verbal communication. The
emotional context of care is especially related to non-verbal
communication and emotion-related communication skills, including
sending and receiving non-verbal messages and emotional self-
awareness are critical elements of high-quality care. Although non-
verbal behavior has received far less study than other care processes,
the current review argues that it holds significance for the
therapeutic relationship and influences important outcomes
including satisfaction, adherence, and clinical outcomes of care (1).
This study investigated the hypothesis that different emotions are
most effectively conveyed through specific, non-verbal channels of
communication: body, face, and touch. Experiment 1 assessed the
production of emotion displays. Participants generated non-verbal
displays of 11 emotions, with and without channel restrictions. For
both actual production and stated preferences, participants favored
22
the body for embarrassment, guilt, pride, and shame; the face for
anger, disgust, fear, happiness, and sadness; and touch for love and
sympathy. When restricted to a single channel, participants were
most confident about their communication when production was
limited to the emotion's preferred channel. Experiment 2 examined
the reception or identification of emotion displays. Participants
viewed videos of emotions communicated in unrestricted and
restricted conditions and identified the communicated emotions.
Emotion identification in restricted conditions was most accurate
when participants viewed emotions displayed via the emotion's
preferred channel. This study provides converging evidence that
some emotions are communicated predominantly through different
non-verbal channels. Further analysis of these channel-emotion
correspondences suggests that the social function of an emotion
predicts its primary channel: The body channel promotes social-
status emotions, the face channel supports survival emotions, and
touch supports intimate emotions (2).
Just as there are facial expressions that appear to be universally
understood, vocally expressed emotions are also readily identifiable
by members of different cultures (3). In fact, an individual often can
differentiate the appropriate emotional state of a speaker when the
words spoken have no contextual relationship to the emotion being
expressed, even if words are spoken in a foreign language (4). In
Pell's study (4), native Argentinean Spanish-speaking (and
monolingual) listeners accurately identified the emotion of joy 89
percent of the time and the feeling of anger 81 percent of the time
when spoken in pseudo-utterances, which are nonsense words
modeled after Spanish linguistic properties that removed any content
or contextual clues with which to identify the emotion. The same
listeners were fairly successful identifying emotions of speakers
talking in other languages. In fact, 77 percent of the listeners
correctly identified the feeling of anger when the words were spoken
in German, 74 percent accurately identified sadness spoken in
English, and 77 percent rightly identified sadness when spoken in
Arabic (4).
23
Assessment: non-verbal behavior is significant for the therapeutic

relationship and influences important outcomes including
satisfaction, adherence, and clinical outcomes of care.
Some emotions are communicated predominantly through
different non-verbal channels. The body channel promotes social-
touch is related to intimate emotions.
References
1. Roter DL, Frankel RM, Hall JA, Sluyter D. The expression of emotion
through nonverbal behavior in medical visits. Mechanisms and outcomes. J
Gen Intern Med. 2006;21 Suppl 1:S28-34.
2. App B, McIntosh DN, Reed CL, Hertenstein MJ. Nonverbal channel use
in communication of emotion: how may depend on why. Emotion. 2011;
11(3):603-17.
3. Scherer KR, Banse R, Walkbott H. Emotional interferences from vocal
expression correlate across languages and cultures. J Cross-Cultur Psychol.
2001;32:7692.
4. Pell MD, Monetta L, Paulmann S, Kotz S. Recognizing emotions in a
foreign language. J Nonverb Behav. 2009;33:107120.
TACTILE CHANNEL
Participants in the current study were allowed to touch an
unacquainted partner on the whole body to communicate distinct
emotions. Of interest was how accurately the person being touched
decoded the intended emotions without seeing the tactile
stimulation. The data indicated that anger, fear, disgust, love,
gratitude, and sympathy were decoded at greater than chance levels,
as well as happiness and sadness, 2 emotions that have not been
shown to be communicated by touch to date. Moreover, fine-grained
coding documented specific touch behaviors associated with
different emotions (1).
Good communication skills are integral to successful doctor-
patient relationships. Communication is verbal or non-verbal, and
touch is a significant component, which has received little attention
in the primary care literature. Touch may be procedural (part of a
clinical task) or expressive (contact unrelated to a
24
procedure/examination). The aim of this study was to explore GPs'

and patients' experiences of using touch in consultations. In this
qualitative study conducted in urban and semi-rural areas of north-
west England, participating GPs recruited registered patients with
whom they felt they had an ongoing relationship. Data were
collected by semi-structured interviews and subjected to constant
comparative qualitative analysis. All participants described the
importance of verbal and non-verbal communication in developing
relationships. Expressive touch was suggested to improve
communication quality by most GPs and all patients. GPs reported a
lower threshold for using touch with older patients or those who
were bereaved, and with patients of the same sex as themselves. All
patient responders felt touch on the hand or forearm. GPs described
limits to using touch, with some responders rarely using anything
other than procedural touch. By contrast, most patient responders
believed expressive touch was acceptable, especially in situations of
distress. All GP responders feared misinterpretation in their use of
touch, but patients were keen that these concerns should not
prevent doctors using expressive touch in consultations. In
conclusion, expressive touch improves interactions between GPs and
patients. Increased educational emphasis on the conscious use of
expressive touch would enhance clinical communication and, hence,
perhaps patient wellbeing and care (2).
Assessment: anger, fear, disgust, love, gratitude, and sympathy

are decoded at greater than chance levels, as well as happiness and
sadness, 2 emotions that are communicated by touch.
Expressive touch improves interactions between GPs and patients.
References
1. Hertenstein MJ, Holmes R, McCullough M, Keltner D. The
communication of emotion via touch. Emotion. 2009;9(4):566-73.
2. Cocksedge S, George B, Renwick S, Chew-Graham CA. Touch in
primary care consultations: qualitative investigation of doctors' and
patients' perceptions. Br J Gen Pract. 2013;63(609):e283-90.
25
LISTENING AND COMPREHENSION

This article presents the author's personal reflection on how her
nursing practice was enhanced because of losing her voice.
Surprisingly, being unable to speak appeared to improve the
nurse/patient relationship. Patients responded positively to a quiet
approach and silent communication. Indeed, the skilled use of non-
verbal communication through silence, facial expression, touch and
closer physical proximity appeared to facilitate active listening, and
helped to develop empathy, intuition and presence between the
nurse and patient. Quietly 'being with' patients and communicating
non-verbally was an effective form of communication. It is suggested
that effective communication is dependent on the nurse's ability to
listen and utilize non-verbal communication skills. In addition,
reflection on practical experience can be an important method of
uncovering and exploring tacit knowledge in nursing (1).
The concept of listening is acknowledged as an essential
component of effective communication by many disciplines. Listening
has always been considered a crucial component of nursing care, and
its benefits have been documented in nursing literature. Certain
characteristics that are essential to listening have been identified in
the reviewed literature. These defining attributes include empathy,
silence, attention to both verbal and non-verbal communication, and
the ability to be non-judgmental and accepting. In addition, listening
is a deliberate act that requires a conscious commitment from the
listener. Although listening is considered an important nursing
intervention, it has not received the same consideration as other
nursing skills. Very few tools are available to measure the concept of
listening, and no tools are available to measure the patients'
perception of nurses' listening skills. Research aimed at theory
development should incorporate the concept of listening as an
integral component of nursing care. Such research provides a
framework for the use of listening as it pertains to nursing practice.
Finally, research is necessary for the development and validation of
tools that may be used to evaluate the effectiveness of listening from
both the nurses and patients' perspectives (2).
26
The activities involved in mediating reinforcement for a speaker's

behavior constitute only 1 phase of a listener's reaction to verbal
stimulation. Other phases include listening and understanding what a
speaker has said. It is argued that the relative subtlety of these
activities is reason for their careful scrutiny, not their complete
neglect. Listening is conceptualized as a functional relation obtaining
between the responding of an organism and the stimulating of an
object. A current instance of listening is regarded as a point in the
evolution of similar instances, whereby one's history of perceptual
activity may be regarded as existing in one's current interbehavior.
Understanding reactions are similarly analyzed; however, they are
considerably more complex than listening reactions due to the
preponderance of implicit responding involved in reactions of this
type. Implicit responding occurs by way of substitute stimulation, and
an analysis of the serviceability of verbal stimuli in this regard is
made. Understanding is conceptualized as seeing, hearing, or
otherwise reacting to actual things in the presence of their "names"
alone. The value of an inferential analysis of listening and
understanding is also discussed, with the conclusion that unless some
attempt is made to elaborate on the nature and operation of these
activities, the more apparent reinforcement mediational activities of
a listener are merely asserted without an explanation for their
occurrence (3).
As we celebrate the 50th anniversary of the publication of B. F.
Skinner's Verbal Behavior, it may be important to reconsider the role
of the listener in the verbal episode. Although by Skinner's own
admission, Verbal Behavior was primarily about the behavior of the
speaker, his definition of verbal behavior as "behavior reinforced
through the mediation of other persons" (4) focused on the behavior
of the listener. However, because many of the behaviors of the
listener are fundamentally no different than other discriminated
operants, they may not appropriately be termed listening. Even
Skinner noted that the behavior of the listener often goes beyond
simply mediating consequences for the speaker's behavior, implying
that the listener engages in a repertoire of behaviors that is itself
verbal. Listening involves subvocal verbal behavior. Some of the
forms and functions of the listener's verbal behavior include echoic
and intraverbal behavior. In conclusion, there may be no functional
distinction between speaking and listening (5).
27
In conversation, women have a small advantage in decoding non-

verbal communication compared to men. Whether sex differences
existed in visual attention during a related listening task were
evaluated, and if so, if the differences existed among attention to
high-level aspects of the scene or to conspicuous visual features.
Using eye-tracking and computational techniques, direct evidence
that men and women orient attention differently during
conversational listening were presented. The eyes of 15 men and 19
women who watched and listened to 84 clips featuring 12 different
speakers in various outdoor settings were tracked. At the fixation
following each saccadic eye movement, the type of object that was
fixated was analyzed. Men gazed more often at the mouth and
women at the eyes of the speaker. Women more often exhibited
"distracted" saccades directed away from the speaker and towards a
background scene element. Examining the multi-scale center-
surround variation in low-level visual features (static: color, intensity,
orientation, and dynamic: motion energy), men consistently selected
regions which expressed more variation in dynamic features, which
can be attributed to a male preference for motion and a female
preference for areas that may contain non-verbal information about
the speaker. In sum, significant differences arise from different
integration strategies of visual cues in selecting the final target of
attention. These findings have implications for studies of sex in non-
verbal communication, as well as for more predictive models of visual
attention (6).
The purpose of this experiment was to investigate whether
classroom reverberation influences second-language (L2) listening
comprehension. Moreover, whether individual differences in baseline
L2 proficiency and in WMC modulate the effect of reverberation
time on L2 listening comprehension was investigated. The results
showed that L2 listening comprehension decreased as reverberation
time increased. Participants with higher baseline L2 proficiency were
less susceptible to this effect. WMC was also related to the effect of
reverberation (although just barely significant), but the effect of
WMC was eliminated when baseline L2 proficiency was statistically
controlled. Taken together, the results suggest that top-down
cognitive capabilities support listening in adverse conditions (7).
28
Assessment: the skilled use of non-verbal communication through

silence, facial expression, touch and closer physical proximity
facilitates active listening, and helps to develop empathy, intuition
and presence between the nurse and patient.
The defining attributes include empathy, silence, attention to
both verbal and non-verbal communication, and the ability to be
non-judgmental and accepting.
Listening is conceptualized as a functional relation obtaining
between the responding of an organism and the stimulating of an
object. Understanding is conceptualized as seeing, hearing, or
otherwise reacting to actual things in the presence of their "names"
alone.
Listening involves subvocal verbal behavior. Some of the forms
and functions of the listener's verbal behavior include echoic and
intraverbal behavior. There may be no functional distinction between
speaking and listening.
High second-language proficiency protects against the effects of
reverberation on listening comprehension.
References
1. Kacperek L. Non-verbal communication: the importance of listening.
Br J Nurs. 1997;6(5):275-9.
2. Shipley SD. Listening: a concept analysis. Nurs Forum. 2010;45(2):125-
34.
3. Parrott LJ. Listening and understanding. Behav Anal. 1984;7(1):29-39.
4. Skinner B. F. Verbal behavior. Cambridge, MA: Prentice Hall. 1957.
5. Schlinger HD. Listening is behaving verbally. Behav Anal. 2008;31(2):
145-61.
6. Shen J, Itti L. Top-down influences on visual attention during listening
are modulated by observer sex. Vision Res. 2012;65:62-76.
7. Srqvist P, Hurtig A, Ljung R, Rnnberg J. High second-language
proficiency protects against the effects of reverberation on listening
comprehension. Scand J Psychol. 2014;55(2):91-6.
29
NOISY ENVIRONMENT
Multi-talker conversations challenge the perceptual and cognitive
capabilities of older adults and those listening in their L2. In older
adults, these difficulties could reflect declines in the auditory,
cognitive, or linguistic processes supporting speech comprehension.
The tendency of L2 listeners to invoke some of the semantic and
syntactic processes from their L1 may interfere with speech
comprehension in L2. These challenges might also force them to
reorganize the ways in which they perceive and process speech,
thereby altering the balance between the contributions of bottom-up
vs. top-down processes to speech comprehension. Younger and older
L1s as well as young L2s listened to conversations played against a
babble background, with or without spatial separation between the
talkers and masker, when the spatial positions of the stimuli were
specified either by loudspeaker placements (real location), or
through use of the precedence effect (virtual location). After listening
to a conversation, the participants were asked to answer questions
regarding its content. Individual hearing differences were
compensated for by creating the same degree of difficulty in
identifying individual words in babble. Once compensation was
applied, the number of questions correctly answered increased when
a real or virtual spatial separation was introduced between babble
and talkers. There was no evidence that performance differed
between real and virtual locations. The contribution of vocabulary
knowledge to dialog comprehension was larger in the virtual
conditions than in the real whereas the contribution of reading
comprehension skill did not depend on the listening environment but
rather differed as a function of age and language proficiency. The
acoustic scene and the cognitive and linguistic competencies of
listeners modulate how and when top-down resources are engaged
in aid of speech comprehension (1).
Reference
1. Avivi-Reich M, Daneman M, Schneider BA. How age and linguistic
competence alter the interplay of perceptual and cognitive factors when
listening to conversations in a noisy environment. Front Syst Neurosci. 2014
Feb 25;8:21.
30
CHANGES IN BREATHING
The current paper extends previous work on breathing during

speech perception and provides supplementary material regarding
the hypothesis that adaptation of breathing during perception "could
be a basis for understanding and imitating actions performed by
other people" (1). The experiments were designed to test how the
differences in reader breathing due to speaker-specific
characteristics, or differences induced by changes in loudness level or
speech rate influence the listener breathing. Two readers (a male and
a female) were pre-recorded while reading short texts with normal
and then loud speech (both readers) or slow speech (female only).
These recordings were then played back to 48 female listeners. The
movements of the rib cage and abdomen were analyzed for both the
readers and the listeners. Breathing profiles were characterized by
the movement expansion due to inhalation and the duration of the
breathing cycle. Both loudness and speech rate affected each
reader's breathing in different ways. Listener breathing was different
when listening to the male or the female reader and to the different
speech modes. However, differences in listener breathing were not
systematically in the same direction as reader differences. The
breathing of listeners was strongly sensitive to the order of
presentation of speech mode and displayed some adaptation in the
time course of the experiment in some conditions. In contrast to
specific alignments of breathing previously observed in face-to-face
dialog, no clear evidence for a listener-reader alignment in breathing
was found in this purely auditory speech perception task. The results
and methods are relevant to the question of the involvement of
physiological adaptations in speech perception and the basic
mechanisms of listener-speaker coupling (2).
Reference
1. Paccalin C, Jeannerod M. Changes in breathing during observation of
effortful actions. Brain Res. 2000;862:194200.
2. Rochet-Capellan A, Fuchs S. Changes in breathing while listening to
read speech: the effect of reader and speech mode. Front Psychol. 2013 Dec
9;4:906.
31
LISTENING TO PARENTS
The purpose of this study was to increase understanding of the
experience of parenting kindergarten-aged children who were
anxious. Twenty-three in-depth interviews were conducted with
parents of kindergarten-aged children who expressed interest in a
parent-focused early intervention program for child anxiety offered
in a local elementary school. Key concerns of the parents included
their children's separation anxiety, social anxiety, and oppositional
behavior. The child's anxiety was identified as a stressor on the child,
the parent, and the family. Parents utilized a range of parenting
responses although they tended to be reactive and did not have a
consistent strategy for managing the anxiety. A salient parenting
struggle was whether or not to push the child to face challenging
situations although there were few descriptions of overprotection or
overcontrol. The findings suggest greater attention be given to the
strengths of parents of children who are anxious and the ways in
which parents may be a positive factor in mitigating the effects of
child anxiety. Implications for intervention are discussed (1).
Reference
1. Hiebert-Murphy D, Williams EA, Mills RS, et al. Listening to parents:
the challenges of parenting kindergarten-aged children who are anxious.
Clin Child Psychol Psychiatry. 2012;17(3):384-99.
PASSIVE-LISTENING AND ACTIVE RESPONSE

Comprehension of narrative stories plays an important role in the
development of language skills. In this study, brain activity elicited by
a passive-listening version and an active-response version of a
narrative comprehension task was compared by using independent
component analysis on functional MRI data from 21 adolescents
(ages 14-18 years). Differences in functional network connectivity
engaged by 2 versions of the task were explored and the relationship
between the online response time and the strength of connectivity
between each pair of independent components were investigated.
32
Despite of similar brain region involvements in auditory, temporo-

parietal, and fronto-parietal language networks for both versions, the
active-response version engages some additional network elements
including the left dorsolateral prefrontal, anterior cingulate, and
sensorimotor networks. These additional involvements are likely
associated with working memory and maintenance of attention,
which can be attributed to the differences in cognitive strategic
aspects of the 2 versions. Significant positive correlation between the
online response time and the strength of connectivity, and between
an independent component in left inferior frontal region and an
independent component in sensorimotor region were found. An
explanation for this finding is that longer reaction time indicates
stronger connection between the frontal and sensorimotor networks
caused by increased activation in adolescents who require more
effort to complete the task (1).
Reference
1. Wang Y, Holland SK. Comparison of functional network connectivity
for passive-listening and active-response narrative comprehension in
adolescents. Brain Connect. 2014;4(4):273-85.
RACE BIAS
A voluminous literature has examined how primates respond to
non-verbal expressions of status, such as taking the high ground,
expanding one's posture, and tilting one's head. This research was
extended to human intergroup processes in general and interracial
processes in particular. Perceivers may be sensitive to whether racial
group status is reflected in group members' non-verbal expressions
of status. Whether people who support the status hierarchy would
prefer racial groups whose members exhibit status-appropriate non-
verbal behavior to racial groups whose members do not exhibit such
behavior was evaluated. People who reject the status quo should
exhibit the opposite pattern. These hypotheses were supported in 3
studies using self-report (Study 1) and reaction time (Studies 2 and 3)
measures of racial bias and 2 different status cues (vertical position
and head tilt). For perceivers who supported the status quo, high-
33
status cues (in comparison with low-status cues) increased

preferences for White people over Black people. For perceivers who
rejected the status quo, the opposite pattern was observed (1).
Compared with more explicit racial slurs and statements, biased
facial expressions and body language may resist conscious
identification and thus produce a hidden social influence. In 4
studies, race biases can be subtly transmitted via televised non-
verbal behavior. Characters on 11 popular television shows exhibited
more negative non-verbal behavior toward black than toward status-
matched white characters. Critically, exposure to prowhite (versus
problack) non-verbal bias increased viewers' bias even though
patterns of non-verbal behavior could not be consciously reported.
These findings suggest that hidden patterns of televised non-verbal
behavior influence bias among viewers (2).
Previous research suggests that automatic prejudice directly
manifests in non-verbal behavior. The authors offer a more complex
picture of the relation between automatic processes and non-verbal
behavior by suggesting that any discomfort that appears in non-
verbal behavior stems not from negative attitudes per se but from
discordance between automatically activated attitudes toward Blacks
and the specific evaluations. White participants for whom estimates
of automatic prejudice were available provided videotaped
evaluations of several individuals, including 2 matched Black and
White males. Discordance between general racial attitudes and
evaluations of specific targets is manifested in discomfort-related
non-verbal behavior. Moreover, nave Black judges, but not White
judges, doubted the sincerity of individuals characterized by
discordance (3).
The main objective of this study was to examine the joint
influence of physician race and patient race on non-verbal
communication displayed by primary care physicians during medical
interviews with patients 65 years or older. Video-recordings of visits
of 209 patients 65 years old or older to 30 primary care physicians at
3 clinics located in the Midwest and Southwest Columbia, US, were
included. Duration of physicians' open body position, eye contact,
smile, and non-task touch, coded using an adaption of the Non-verbal
Communication in Doctor-Elderly Patient Transactions form. African
American physicians with African American patients used more open
body position, smile, and touch, compared to the average across
34
other dyads (adjusted mean difference for open body

position=16.55, p<0.001; smile=2.35, p=0.048; touch=1.33,
p<0.001). African American physicians with white patients spent less
time in open body position compared to the average across other
dyads, but they also used more smile and eye gaze (adjusted mean
difference for open body position=27.25, p<0.001; smile=3.16,
p=0.005; eye gaze=17.05, p<0.001). There were no differences
between white physicians' behavior toward African American vs.
white patients. In conclusion, race plays a role in physicians' non-
verbal communication with older patients. Its influence is best
understood when physician race and patient race are considered
jointly (4).
Assessment: race plays a role in non-verbal communication. Any

discomfort that appears in non-verbal behavior stems not from
negative attitudes per se but from discordance between
automatically activated attitudes toward Blacks and the specific
evaluations. Discordance between general racial attitudes and
evaluations of specific targets is manifested in discomfort-related
non-verbal behavior.
References
1. Weisbuch M, Slepian ML, Eccleston CP, Ambady N. Nonverbal
expressions of status and system legitimacy: an interactive influence on race
bias. Psychol Sci. 2013;24(11):2315-21.
2. Weisbuch M, Pauker K, Ambady N. The subtle transmission of race
bias via televised nonverbal behavior. Science. 2009;326(5960):1711-4.
3. Olson MA, Fazio RH. Discordant evaluations of Blacks affect nonverbal
behavior. Pers Soc Psychol Bull. 2007;33(9):1214-24.
4. Stepanikova I, Zhang Q, Wieland D, et al. Non-verbal communication
between primary care physicians and older patients: how does race matter?
J Gen Intern Med. 2012;27(5):576-81
35
TELEVISED NON-VERBAL BEHAVIOR

The extent to which non-verbal behavior contributes to culturally
shared attitudes and beliefs was examined. In Study 1, especially slim
women elicited especially positive non-verbal behaviors in popular
television shows. In Study 2, exposure to this non-verbal bias caused
women to have especially slim cultural and personal ideals of female
beauty and to have especially positive attitudes toward slim women.
In Study 3, individual differences in exposure to such non-verbal bias
accounted for substantial variance in pro-slim attitudes, anti-fat
attitudes, and personal ideals of beauty, even after controlling for
several third variables. In Study 4, regional differences in exposure to
non-verbal bias accounted for substantial variance in regional
unhealthy dieting behaviors, even after controlling for several third
variables (1).
Reference
1. Weisbuch M, Ambady N. Unspoken cultural influence: exposure to
and influence of nonverbal bias. J Pers Soc Psychol. 2009; 96(6):1104-19.
IDENTIFYING LEADERS
Research investigating the influence and character of non-verbal
leader displays has been carried out in a systematic fashion since the
early 1980s, yielding growing insight into how viewers respond to the
televised facial display behavior of politicians. The major streams of
research in this area considers the key ethological frameworks for
understanding dominance relationships between leaders and
followers and the role non-verbal communication plays in politics and
social organization. The analysis focuses on key categories of facial
display behavior by examining an extended selection of published
experimental studies considering the influence of non-verbal leader
behavior on observers, the nature of stimuli shown to research
participants, range of measures employed, and make-up of
participant pools (1).
36
Subject/observers were accurate in identifying emergent

leadership hierarchies on 4 leadership dimensions when provided
records of target groups' meetings containing only verbal
communications, only non-verbal communications, or both types of
behavior. With knowledge of participation rates controlled by
covariance, the subject/observers' accuracy scores retained
significance in 3 of the information conditions demonstrating the
presence of verbal and non-verbal leadership cues independent of
participation rates. The value of verbal and non-verbal
communications to identifying leaders varied with the type of
leadership hierarchy. The findings are presumed to hold for leader
selection as well. The question is of why a group member has
emerged to fulfill a leadership role in a group be studied from the
point of view of group members' selecting leaders or permitting
emergence rather than leaders emitting behaviors (2).
A 2 X 3 design was used to assess effects of non-verbal
communication and sensory modality of presentation of stimuli on
107 undergraduates' perception of leadership. Non-verbal
communication and modality of presentation had a significant effect
on perception of leadership. These results suggest that non-verbal
cues should be seen as essential in impression-formation (3).
Assessment: the value of verbal and non-verbal communications

to identifying leaders varied with the type of leadership hierarchy.
Non-verbal communication and modality of presentation has a
significant effect on perception of leadership. Non-verbal cues are
essential in impression-formation.
Reference
1. Stewart PA, Salter FK, Mehu M. Taking leaders at face value: ethology
and the analysis of televised leader displays. Politics Life Sci. 2009;28(1):48-
74.
2. Stein RT. Identifying emergent leaders from verbal and nonverbal
communications. J Pers Soc Psychol. 1975;32(1):125-35.
3. Gitter AG, Black H, Goldman A. Role of nonverbal communication in
the perception of leadership. Percept Mot Skills. 1975;40(2):463-6.
37
ROBOT INTERACTION
How do humans coordinate their intentions, goals and motor
behaviors when performing joint action tasks? Recent experimental
evidence suggests that resonance processes in the observer's motor
system are crucially involved in our ability to understand actions of
others to infer their goals and even to comprehend their action-
related language. In this paper, a control architecture for human-
robot collaboration that exploits this close perception-action linkage
as a means to achieve more natural and efficient communication
grounded in sensorimotor experiences is presented. The architecture
is formalized by a coupled system of dynamic neural fields
representing a distributed network of neural populations that encode
in their activation patterns goals, actions and shared task knowledge.
The verbal and non-verbal communication skills of the robot in a joint
assembly task in which the human-robot team has to construct toy
objects from their components were validated. The experiments
focus on the robot's capacity to anticipate the user's needs and to
detect and communicate unexpected events that may occur during
joint task execution (1).
Reference
1. Bicho E, Louro L, Erlhagen W. Integrating verbal and nonverbal
communication in a dynamic neural field architecture for human-robot
interaction. Front Neurorobot. 2010 May 21;4. pii: 5.
PHYSICIAN-PATIENT INTERACTION
The physician-patient interview is the key component of all health
care, particularly of primary medical care. This review sought to
evaluate existing primary-care-based research studies to determine
which verbal and non-verbal behaviors on the part of the physician
during the medical encounter have been linked in empirical studies
with favorable patient outcomes. The literature was reviewed from
1975 to 2000 for studies of office interactions between primary care
physicians and patients that evaluated these interactions empirically
38
using neutral observers who coded observed encounters, videotapes,

or audiotapes. Each study was reviewed for the quality of the
methods and to find significant relations between specific physician
behaviors and patient outcomes. In examining non-verbal behaviors,
because of a paucity of clinical outcome studies, outcomes were
expanded to include associations with patient characteristics or
subjective ratings of the interaction by observers. Fourteen studies
of verbal communication and 8 studies of non-verbal communication
met inclusion criteria. Verbal behaviors positively associated with
health outcomes included empathy, reassurance and support,
various patient-centered questioning techniques, encounter length,
history taking, explanations, both dominant and passive physician
styles, positive reinforcement, humor, psychosocial talk, time in
health education and information sharing, friendliness, courtesy,
orienting the patient during examination, and summarization and
clarification. Non-verbal behaviors positively associated with
outcomes included head nodding, forward lean, direct body
orientation, uncrossed legs and arms, arm symmetry, and less mutual
gaze. In conclusion, existing research is limited because of lack of
consensus of what to measure, conflicting findings, and relative lack
of empirical studies (especially of non-verbal behavior). Nonetheless,
medical educators should focus on teaching and reinforcing
behaviors known to be facilitative, and to continue to understand
how physician behavior can enhance favorable patient outcomes,
such as understanding and adherence to medical regimens and
overall satisfaction (1).
The goal of this paper is to show that non-verbal aspects in the
physician-patient interaction play an important role. Interpersonal
judgment relies mostly on non-verbal and appearance cues of the
social interaction partner. This is also true for the physician-patient
interaction. Moreover, physicians and patients tend to mirror some
of their non-verbal behavior and complement each other on other
aspects of their non-verbal behavior. Non-verbal cues emitted by the
patient can contain important information for the doctor to use for
treatment and diagnosis decisions. In conclusion, the way the
physician behaves non-verbally affects patient outcomes, such as, for
instance, patient satisfaction. Affilliative non-verbal behavior (e.g.,
eye gaze and proximity) of the physician is related to higher patient
satisfaction. However, how different physician non-verbal behaviors
39
are related to patient satisfaction and depend on personal attributes

of the physician such as gender, for instance. Physician training could
profit from incorporating knowledge about physician and patient
non-verbal behavior (2).
The relationship between physicians' non-verbal communication
skills (their ability to communicate and to understand facial
expression, body movement and voice tone cues to emotion) and
their patients' satisfaction with medical care was examined in 2
studies. The research involved 71 residents in internal medicine and
462 of their ambulatory and hospitalized patients. Standardized,
reliable and valid measures of non-verbal communication skills were
administered to the physicians. Their scores on these tests were
correlated with ratings they received from a sample of their patients
on measures of satisfaction with the technical aspects and the
socioemotional aspects (or art) of the medical care they received.
While the non-verbal communication skills of the physicians bore
little relationship to patients' ratings of the technical quality of care,
measures of these skills did predict patient satisfaction with the art of
medical care received. Across both samples, physicians who were
more sensitive to body movement and posture cues to emotion (the
channel suggested by non-verbal researchers as the one in which
true affect can be perceived) received higher ratings from their
patients on the art of care than did less sensitive physicians. In
addition, physicians who were successful at expressing emotion
through their non-verbal communications tended to receive higher
ratings from patients on the art of care than did physicians who were
less effective communicators (3).
The main objective of this observational study was to examine the
association of physician non-verbal communication with SP
satisfaction in the context of the "quality" of the interview (i.e.,
information provided and collected, communication skills). One
university-based internal medicine residency program was included.
Participants were 59 internal medicine residents. The 59 residents
were recruited to participate in 3 SP encounters. The scenarios
included: 1] a straightforward, primarily "medical" problem (chest
pain); 2] a patient with more psychosocial overlay (a depressed
patient with a history of sexual abuse); and 3] a counseling encounter
(HIV risk factor reduction counseling). Trained SPs rated physician
non-verbal behaviors (body lean, open versus closed body posture,
40
eye contact, smiling, tone of voice, nod, and facial expressivity) in the
3 encounters. Multiple regression approaches were used to
investigate the association of physician non-verbal behavior with
patient satisfaction in the context of the "quality" of the interview (SP
checklist performance, and measures of verbal communication skills),
controlling for physician characteristics (gender, and postgraduate
year). Non-verbal communication skills were an independent
predictor of standardized patient satisfaction for all 3 patient
stations. The effect sizes were substantial, with non-verbal
communication predicting 32% of the variance in patient satisfaction
for the chest pain station, 23% of the variance for the depression-
sexual abuse station, and 19% of the variance for the HIV counseling
station. In conclusion, better non-verbal communication skills are
associated with greater patient satisfaction in a variety of different
types of clinical encounters with SPs. Formal instruction in non-verbal
communication is important addition to residency (4).
There are several measurement tools to assess verbal dimensions
in clinical encounters; by contrast, there is no established tool to
evaluate physical non-verbal dimensions in geriatric encounters. The
present paper describes the development of a tool to assess the
physical context of examination rooms in doctor-older patient visits.
Salient features of the tool were derived from the medical literature
and systematic observations of videotapes and refined during current
research. The tool consists of 2 main dimensions of examination
rooms: 1] physical dimensions comprising static and dynamic
attributes that become operational through the spatial configuration
and can influence the manifestation of 2] kinesic attributes. In
conclusion, details of the coding form and inter-rater reliability are
presented. The usefulness of the tool is demonstrated through an
analysis of 50 National Institute of Aging videotapes. Physicians in
examination rooms with no desk in the interaction, no height
difference and optimal interaction distance were observed to have
greater eye contact and touch than physicians' in examination rooms
with a desk, similar height difference and interaction distance. The
tool can enable physicians to assess the spatial configuration of
examination rooms (through Parts A and B) and thus facilitate the
structuring of kinesic attributes (Part C) (5).
41
Physician and patient gender both influence medical

communication. Non-verbal behavior is generally under-researched
in the medical encounter but plays an important role for patient
outcomes such as satisfaction. This article aims at identifying how
specific physician non-verbal behaviors predict analogue patient
satisfaction depending on physician and patient gender. Eleven
physicians in a real medical encounter were videotaped and analogue
patients indicated their satisfaction with each physician while viewing
the videotapes. One hundred sixty-three university students
participated (analogue patients). From the videotapes, 17 physician
non-verbal behaviors (related to face, body, and voice/speech), 2
physician appearance cues, 2 characteristics of the examination
room, and 1 patient behavior were coded. For each analogue patient,
the correlation between each of these coded characteristics and the
patient's satisfaction was calculated, across all physicians and across
male and female physicians separately. There was no main effect for
patient gender but most coded characteristics showed different
relations to patient satisfaction according to physician gender.
Analogue patients were most satisfied with female physicians who
behaved in line with the female gender role (e.g., more gazing, more
forward lean, and softer voice) while still stressing their
professionalism (laboratory coat, medically-looking, and examination
room). For male physicians, satisfaction was high for a broader range
of behaviors, partly related to their gender role (e.g., louder voice,
and more distance to patient). In conclusion, to be satisfied, patients
expect female and male physicians to show different patterns of non-
verbal behavior. Awareness of these gender-specific expectations
should be taken into account in medical training (6).
During doctor-patient interactions, many messages are
transmitted without words, through non-verbal communication. The
aim of this study was to elucidate the types of non-verbal behaviors
perceived by patients interacting with family GPs and to determine
which cues are perceived most frequently. This study included in-
depth interviews with patients of family GPs conducted at 9 family
practices in different regions of Poland. At each practice site,
interviews were performed with 4 patients who were scheduled
consecutively to see their family doctor. Twenty-four of 36 studied
patients spontaneously perceived non-verbal behaviors of the family
GP during patient-doctor encounters. They reported 48 non-verbal
42
cues. The most frequent features were tone of voice, eye contact,
and facial expressions. Less frequent were examination room
characteristics, touch, interpersonal distance, GP clothing, gestures,
and posture. In conclusion, non-verbal communication is an
important factor by which patients spontaneously describe and
evaluate their interactions with a GP. Family GPs should be trained to
better understand and monitor their own non-verbal behaviors
towards patient (7).
A field study of 28 residents in family practice was conducted.
Physicians' self-reports of empathy, self-monitoring ability, and
affective communication skill as well as their objectively measured
non-verbal communication skills were examined as predictors of
patient satisfaction, appointment noncompliance, and physician
workload (schedule density). Physicians completed the Hogan
Empathy Scale, Snyder Self-Monitoring Scale, Affective
Communication Test, short form of the Profile of Non-verbal
Sensitivity, and a non-verbal encoding task. Patient satisfaction with
communication, affective care, and technical care was assessed using
a 25-item, visit-specific satisfaction scale. Appointment records were
used to determine the number of patients seen by each physician
and the compliance of patients with scheduled appointments. Results
indicated that the 3 self-report measures were unrelated to the
measures of patient noncompliance and patient satisfaction, but self-
reported affective communication ability was significantly correlated
with physician workload. Objectively measured physician sensitivity
to audio communication predicted patient compliance: more
sensitive physicians experienced fewer un-rescheduled appointment
cancellations (8).
Recent empirical findings document the role of non-verbal
communication in cross-cultural interactions. As ethnic minority
health disparities in the US continue to persist, physician competence
in this area is important. Physicians' abilities to decode non-verbal
emotions across cultures were examined, the hypothesis being that
there is a relationship between physicians' skill in this area and their
patients' satisfaction and outcomes. First part tested Caucasian and
South Asian physicians' cross-cultural emotional recognition ability.
Physicians completed a balanced forced multiple-choice test of
decoding accuracy judging emotions based on facial expressions and
vocal tones. In the second part, patients reported on satisfaction and
43
health outcomes with their physicians using a survey. Physicians,

regardless of their ethnicity, were more accurate at rating Caucasian
faces and vocal tones. South Asian physicians were no better at
decoding the facial expressions or vocal tones of South Asian
patients, who were less likely to be satisfied with the quality of care
provided by their physicians and to adhere to their physicians'
recommendations. Implications include the development of cultural
sensitivity training programs in medical schools, continuing medical
education and public health programs (9).
Assessment: non-verbal behaviors such as head nodding, forward

lean, direct body orientation, uncrossed legs and arms, arm
symmetry, eye gaze and proximity are associated with higher patient
satisfaction.
Patients are most satisfied with female physicians who behave in
line with the female gender role (e.g., more gazing, more forward
lean, and softer voice) while still stressing their professionalism
(laboratory coat, medical-looking, and examination room). For male
physicians, satisfaction is high for a broader range of behaviors,
partly related to their gender role such as louder voice, and more
distance to patient.
Non-verbal communication is an important factor by which
patients spontaneously describe and evaluate their interactions with
a GP.
References
1. Beck RS, Daughtridge R, Sloane PD. Physician-patient communication
in the primary care office: a systematic review. J Am Board Fam Pract. 2002;
15(1):25-38.
2. Mast MS. On the importance of nonverbal communication in the
physician-patient interaction. Patient Educ Couns. 2007;67(3):315-8.
3. DiMatteo MR, Taranta A, Friedman HS, Prince LM. Predicting patient
satisfaction from physicians' nonverbal communication skills. Med Care.
1980;18(4):376-87.
4. Griffith CH 3rd, Wilson JF, Langer S, Haist SA. House staff nonverbal
communication skills and standardized patient satisfaction. J Gen Intern
Med. 2003;18(3):170-4.
5. Gorawara-Bhat R, Cook MA, Sachs GA. Nonverbal communication in
doctor-elderly patient transactions (NDEPT): development of a tool. Patient
Educ Couns. 2007;66(2):223-34.
44
6. Mast MS, Hall JA, Kckner C, Choi E. Physician gender affects how
physician nonverbal behavior is related to patient satisfaction. Med Care.
2008;46(12):1212-8.
7. Marcinowicz L, Konstantynowicz J, Godlewski C. Patients' perceptions
of GP non-verbal communication: a qualitative study. Br J Gen Pract. 2010;
60(571):83-7.
8. DiMatteo MR, Hays RD, Prince LM. Relationship of physicians'
nonverbal communication skill to patient satisfaction, appointment
noncompliance, and physician workload. Health Psychol. 1986;5(6):581-94.
9. Coelho KR, Galan C. Physician cross-cultural nonverbal
communication skills, patient satisfaction and health outcomes in the
physician-patient relationship. Int J Family Med. 2012;2012:376907.
EMPATHIC LISTENING
As part of the epistemological transition from positivistic to
relativistic science that had begun earlier in the twentieth century,
Kohut attempted to update psychoanalytic thinking in formulating
the empathic mode of observation (1-4). The purpose of this paper is
to reassess, through a conceptual and historical lens, the
considerable controversy generated by the empathic perspective.
The author specifically addresses constructivist philosophical
underpinnings, the use and impact of the analyst's subjectivity, the
inclusion of unconscious processes, the need for additional listening
perspectives, and the influence of theoretical models in the
organization of empathically acquired data (5).
Empathy, the ability to communicate an understanding of a
client's world, is a crucial component of all helping relationships. It is
important to focus on the failure of measures of empathy to reflect
clients' views about the ability to offer empathy. It is argued that, if
clients are able to perceive the amount of empathy in helping
relationships, they are able to advise professionals about how to
offer empathy. There are the inconclusive research evidence that
existing courses have enabled professionals to offer empathy, and
the disagreement about how empathy is best taught (6).
Empathy is crucial to all forms of helping relationships. While
most studies cited are more than a decade old, the relationship
45
between empathy and helping remains unchallenged in the 1990s.

Additionally, while there is confusion about whether empathy is a
personality dimension, an experienced emotion, or an observable
skill, empathy involves an ability to communicate an understanding
of a client's world. Finally, a definition of empathy considered to be
relevant to clinical nursing is introduced, which includes the need to
understand client's distress, and to provide supportive interpersonal
communication. It is argued that there is a need to revisit the role of
empathy in the context of current health care delivery (7).
This paper includes a discussion about the origins of items on a
measure of cognitive-behavioral empathy. This scale was originally
produced by the author as a teaching tool for an empathy education
program (for registered nurses) and subsequently developed into a
quantitative measure of empathy. The instrument is being used as
part of a triangulated approach for data collection on research into
the effectiveness of an educational program about registered nurses'
empathy. Antecedents of the initial item pool for the scale stem from
theoretical views about empathy, the professional experience of
others, and the researcher's experience with clients. While this scale
has undergone some investigation for reliability and validity, this
work will only be summarized briefly. The major focus for the paper
is clients' reports of interpersonal conditions which they perceive as
being helpful, or unhelpful, in respect of building therapeutic nurse-
client relationships (8).
Empathy as a characteristic of patient-physician communication in
both general practice and clinical care is considered to be the
backbone of the patient-physician relationship. Although the value of
empathy is seldom debated, its effectiveness is little discussed in
general practice. Effects include patient satisfaction and adherence,
feelings of anxiety and stress, patient enablement, diagnostics
related to information exchange, and clinical outcomes. The aim of
this systematic literature search was to review the existing literature
concerning all studies published in the last 15 years on the
effectiveness of physician empathy in general practice. Searches of
PubMed, EMBASE, and PsychINFO databases were undertaken, with
citation searches of key studies and papers. Original studies
published in English between July 1995 and July 2011, containing
empirical data about patient experience of GPs' empathy, were
included. Qualitative assessment was applied using Giacomini and
46
Cook's criteria (9,10). After screening the literature using specified

selection criteria, 964 original studies were selected; of these, 7 were
included in this review after applying quality assessment. There is a
good correlation between physician empathy and patient satisfaction
and a direct positive relationship with strengthening patient
enablement. Empathy lowers patients' anxiety and distress and
delivers better clinical outcomes. In conclusion, although only a small
number of studies could be used in this search, the general outcome
seems to be that empathy in the patient-physician communication in
general practice is of unquestionable importance (11).
Evidence based largely on self-report data suggests that factors
associated with medical education erode the critical human quality of
empathy. These reports have caused serious concern among medical
educators and clinicians and have led to changes in medical curricula
around the world. This study aims to provide a more objective index
of possible changes in empathy across the spectrum of clinical
exposure, by using a behavioral test of empathic accuracy in addition
to self-report questionnaires. Moreover, non-medical groups were
used to control for maturation effects. Three medical groups
(n=320) representing a spectrum of clinical exposure, and 2 non-
medical groups (n=220) matched for age, sex and educational
achievements completed self-report measures of empathy, and tests
of empathic accuracy and interoceptive sensitivity. Between-group
differences in reported empathy related to maturation rather than
clinical training/exposure. Conversely, analyses of the "eyes" test
results specifically identified clinical practice, but not medical
education, as the key influence on performance. The data from the
interoception task did not support a link between visceral feedback
and empathic processes. In conclusion, clinical practice, but not
medical education, impacts on empathy development and seems
instrumental in maintaining empathetic skills against the general
trend of declining empathic accuracy with age (12).
The aim of this pilot prospective study was to investigate the
relationships between GPs empathy, patient enablement, and
patient-assessed outcomes in primary care consultations in an area
of high socio-economic deprivation in Scotland. This prospective
study was carried out in a 5-doctor practice in an area of high
socioeconomic deprivation in Scotland. Patients' views on the
consultation were gathered using the CARE Measure and the PEI.
47
Changes in main complaint and well-being 1 month after the contact

consultation were gathered from patients by postal questionnaire.
The effect of GP empathy on patient enablement and prospective
change in outcome was investigated using structural equation
modeling. Of 323 patients who completed the initial questionnaire at
the contact consultation, 136 (42%) completed and returned the
follow-up questionnaire at 1 month. Confirmatory factor analysis
confirmed the construct validity of the CARE Measure, though
omission of 2 of the 6 PEI items was required in order to reach an
acceptable global data fit. The structural equation model revealed a
direct positive relationship between GP empathy and patient
enablement at contact consultation and a prospective relationship
between patient enablement and changes in main complaint and
well-being at 1 month. In conclusion, in a high deprivation setting, GP
empathy is associated with patient enablement at consultation, and
enablement predicts patient-rated changes 1 month later. Further
larger studies are desirable to confirm or refute these findings. Ways
of increasing GP empathy and patient enablement need to be
established in order to maximize patient outcomes. Consultation
length and relational continuity of care are known factors: the
benefit of training and support for GPs needs to be further
investigated (13).
The objective of this study was to measure acupuncture patients'
perceptions of practitioner empathy at the initial consultation and its
relationship with patient enablement, and prospectively reported
changes in symptoms. Fifteen acupuncturists asked consecutive new
patients to complete a questionnaire within 2 days of the first
consultation. The questionnaire included the CARE measure (a
consultation process measure), the PEI, a consultation outcome
measure, and the MYMOP, a patient-centered symptom, well-being
and activity outcome measure. A postal follow-up questionnaire was
completed at 8 weeks, which repeated these measures. Fifty-two
patients (58% of all new patients) completed the initial
questionnaire. Of these, 41 (79%) completed the follow-up
questionnaire. From a multiple regression analysis, which controlled
for known confounders, empathy was found to be associated with
enablement at the initial consultation (Beta coefficient=0.16, 95% CI
0.02-0.31, p=0.03) and empathy-predicted changes in health
outcome (MYMOP) at 8 weeks (Beta=0.07, 95% CI 0.004-0.13,
48
p=0.04). In conclusion, patients' perception of practitioner empathy

was associated with patient enablement at initial consultation and
predicted changes in health outcome at 8 weeks. The empathy of
practitioners, as perceived by patients, has a direct impact on patient
enablement and health outcome (14).
Patient 'enablement' is a term closely aligned with
'empowerment' and its measurement in a general practice
consultation has been operationalised in the widely used PEI, a
patient-rated measure of consultation outcome. The aim of the study
is to assess the factors influencing patient enablement in GP
consultations in areas of high and low deprivation. A questionnaire
study was carried out on 3,044 patients attending 26 GPs (16 in areas
of high socio-economic deprivation and 10 in low deprivation areas,
in the west of Scotland). Patient expectation (confidence that the
doctor would be able to help) was recorded prior to the consultation.
PEI, GP empathy (measured by the CARE), and a range of other
measures and variables were recorded after the consultation. Data
analysis employed multi-level modeling and multivariate analyses
with the PEI as the dependant variable. Although numerous variables
showed a univariate association with patient enablement, only 4
factors were independently predictive after multilevel multivariate
analysis; patients with multimorbidity of 3 or more long-term
conditions (reflecting poor chronic general health), and those
consulting about a long-standing problem had reduced enablement
scores in both affluent and deprived areas. In deprived areas,
emotional distress (GHQ-caseness) had an additional negative effect
on enablement. Perceived GP empathy had a positive effect on
enablement in both affluent and deprived areas. Maximal patient
enablement was never found with low empathy. In conclusion,
although other factors influence patient enablement, the patients'
perceptions of the doctors' empathy is of key importance in patient
enablement in general practice consultations in both high and low
deprivation settings (15).
49
Assessment: empathy, the ability to communicate an

understanding of a client's world, is a crucial component of all
relationships.
The empathy of practitioners, as perceived by patients, has a
direct impact on patient enablement and health outcome.
The patients' perceptions of the doctors' empathy is of key
importance in patient enablement in general practice consultations
in both high and low deprivation settings.
References
1. Kohut H. Introspection, empathy and psychoanalysis. J Americ
Psychoanalysis Assn. 1959;7:459-83.
2. Kohut H. The restoration of the self. New York International Press.
1977.
3. Kohut H. Introspection, empathy and the semicircle of mental health.
Intern J Psycho-Anal. 1982;63:359-407.
4. Kohut H. How does analysis cure? Goldberg A, Stepansky P (eds.).
Chicago: The University of Chicago Press. 1984.
5. Fosshage JL. The use and impact of the analyst's subjectivity with
empathic and other listening/experiencing perspectives. Psychoanal Q.
2011;80(1):139-60.
6. Reynolds WJ, Scott B, Jessiman WC. Empathy has not been measured
in clients' terms or effectively taught: a review of the literature. J Adv Nurs.
1999;30(5):1177-85.
7. Reynolds WJ, Scott B. Empathy: a crucial component of the helping
relationship. J Psychiatr Ment Health Nurs. 1999;6(5):363-70.
8. Reynolds B. The influence of clients' perceptions of the helping
relationship in the development of an empathy scale. J Psychiatr Ment
Health Nurs. 1994;1(1):23-30.
9. Gliacomi MK, Cook DJ. Are the results of the study valid? Users' guide
to the medical literature. XXIII. Qualitative research in the health care.
JAMA. 2000a; 284:357-362.
10. Gliacomi MK, Cook DJ. What are the results and how they do help
me care for my patients? Users' guide to the medical literature. XXIII.
Qualitative research in the health care. JAMA. 2000b; 284:478-482.
11. Derksen F, Bensing J, Lagro-Janssen A. Effectiveness of empathy in
general practice: a systematic review. Br J Gen Pract. 2013;63(606): e76-84.
12. Handford C, Lemon J, Grimm MC, Vollmer-Conna U. Empathy as a
function of clinical exposure - reading emotion in the eyes. PLoS One. 2013;
8(6):e65159.
13. Mercer SW, Neumann M, Wirtz M, et al. General practitioner
empathy, patient enablement, and patient-reported outcomes in primary
50
care in an area of high socio-economic deprivation in Scotland - a pilot

prospective study using structural equation modeling. Patient Educ Couns.
2008;73(2):240-5.
14. Price S, Mercer SW, MacPherson H. Practitioner empathy, patient
enablement and health outcomes: a prospective study of acupuncture
patients. Patient Educ Couns. 2006;63(1-2):239-45.
15. Mercer SW, Jani BD, Maxwell M, et al. Patient enablement requires
physician empathy: a cross-sectional study of general practice consultations
in areas of high and low socioeconomic deprivation in Scotland. BMC Fam
Pract. 2012 Feb 8;13:6.
TRAUMATIC BRAIN INJURY

Individuals who have had a TBI often have difficulty processing
non-verbal communication. The published research in this area has
focused on a TBI patient's ability to recognize facial expression, vocal
intonation, and postural expression (1,2). This study compared the
non-verbal processing skills of brain-injured patients versus non-
injured controls in all 3 domains. The stimuli were photographs of
facial and postural expressions and audio recordings of intonational
expressions. The results indicated that persons with TBI have
particular difficulty recognizing non-verbal communication resulting
from vocal intonations. In conclusion, the TBI patients had difficulty
processing tonality, therefore, it is reasonable to suggest that
clinicians, friends, and family members should emphasize the explicit
verbal content of spoken language when speaking to a person with
TBI (3).
Discursive abilities of severe brain injured patient are always
impaired: loss of flexibility, lack of cohesion and coherence, often
more elliptic. The objective is to verify non-verbal abilities of these
patients by pragmatic analysis. Four men were examined more than
7 years after severe TBI. Non-verbal Pragmatic Protocol (4) was done
allowing to a qualitative and quantitative measurement of
paralinguistic behavior: prosody and quality of speech, facial
expression, posture, gaze, and gesture. Two conditions were
recorded: dual (descriptive discourse) and group (conversational
discourse). Associated impairments such as cognitive and
51
dysexecutive functioning were also investigated. Impoverishment

(loss of ability) or impaired inadequacity was observed in all patients.
Paralinguistic competence of conversational discourse was worse
than descriptive one. Facial expression, gaze functioning, and
referential gesture were more often impaired. Maladjustment could
be interpretated in reference with dysexecutive syndrome. In
conclusion, in spite of the lack of information about the range of
normal pragmatic behavior, it seems that brain injured patients have
poor non-verbal abilities during discourse. Rehabilitation training of
communication skills would integrate this fact in order to improve
interactivity and social relationship (5).
Following post-traumatic impairment in executive function, failure
to adjust to communication situations often creates major obstacles
to social and professional reintegration. The analysis of pathological
verbal communication has been based on clinical scales since the
1980s, but that of non-verbal elements has been neglected, although
their importance should be acknowledged. The aim of this research
was to study non-verbal aspects of communication in a case of
executive-function impairment after TBI. During the patient's
conversation with an interlocutor, all non-verbal parameters,
including coverbal gestures, gaze, posture, proxemics and facial
expressions, were studied in as much an ecological way as possible,
to closely approximate natural conversation conditions. Such an
approach highlights the difficulties such patients experience in
communicating, difficulties of a pragmatic kind, that have so far been
overlooked by traditional investigations, which mainly take into
account the formal linguistic aspects of language. The analysis of the
patient's conversation revealed non-verbal dysfunctions, not only on
a pragmatic and interactional level but also in terms of enunciation.
Moreover, interactional adjustment phenomena were noted in the
interlocutor's behavior. In conclusion, the 2 inseparable aspects of
communication, verbal and non-verbal, should be equally assessed in
patients with communication difficulties; highlighting distortions in
each area might bring about an improvement in the rehabilitation of
such people (6).
52
Assessment: TBI patients have particular difficulty recognizing

non-verbal communication resulting from vocal intonations. These
patients have difficulty processing tonality, therefore, clinicians,
friends, and family members should emphasize the explicit verbal
content of spoken language when speaking to a person with TBI.
Verbal and non-verbal communication should be equally assessed
in patients with communication difficulties; highlighting distortions in
such people.
References
1. Croker V, McDonald S. Recognition of emotion from facial expression
following traumatic brain injury. Brain Inj. 2005;19(10):787-99.
2. Hopkins MJ, Dywan J, Segalowitz SJ. Altered electrodermal response
to facial expression after closed head injury. Brain Inj. 2002;16(3):245-57.
3. Bird J, Parente R. Recognition of nonverbal communication of
emotion after traumatic brain injury. NeuroRehabilitation. 2014;34(1):39-43.
4. Prutting CA, Kirchner DM. A clinical appraisal of the pragmatic aspects
of language. J Speech Hear Disord. 1987;52(2):105-19.
5. Aubert S, Barat M, Campan M, et al. Non verbal communication
abilities in severe traumatic brain injury. Ann Readapt Med Phys. 2004;
47(4):135-41.
6. Sainson C. Non-verbal communication and executive function
impairment after traumatic brain injury: a case report. Ann Readapt Med
Phys. 2007;50(4):231-9.
DEMENTIA
This review underlines the importance of non-verbal
communication in Alzheimer's disease. A social psychological
perspective of communication is privileged. Non-verbal behaviors
such as looks, head nods, hand gestures, body posture or facial
expression provide a lot of information about interpersonal attitudes,
behavioral intentions, and emotional experiences. Therefore, they
play an important role in the regulation of interaction between
individuals. Non-verbal communication is effective in Alzheimer's
disease even in the late stages. Patients still produce non-verbal
signals and are responsive to others. Nevertheless, few studies have
been devoted to the social factors influencing the non-verbal
53
exchange. Misidentification and misinterpretation of behaviors may

have negative consequences for the patients. Thus, improving the
comprehension of and the response to non-verbal behavior would
increase first the quality of the interaction, then the physical and
psychological well-being of patients and that of caregivers. The role
of non-verbal behavior in social interactions should be approached
from an integrative and functional point of view (1).
In later stages of Alzheimer's disease, many people will engage in
noise-making (screaming and other kinds of sounds), often
experienced as interruptive by others. A problem with the noise-
making is the difficulty in understanding the meaning of the noise.
This study addresses 2 questions: to what extent is noise-making
responsive to the ongoing interaction and is noise-making regarded
as meaningless behavior by other participants? The analysis of
selective examples shows that noises may be fitted into the
conversational interaction to a certain degree and in some instances
is responsive to interaction. The co-participants tend to treat the
noises as meaningful. In conclusion, if utterances and responses in
interaction are treated as if they are meaningful, they will become
meaningful in their consequences for all participants (2).
Assessment: in Alzheimer's disease, non-verbal behaviors such as

looks, head nods, hand gestures, body posture or facial expression
provide a lot of information about interpersonal attitudes, behavioral
intentions, and emotional experiences. They play an important role in
the regulation of interaction between individuals. Non-verbal
communication is effective in Alzheimer's disease even in the late
stages. Patients still produce non-verbal signals and are responsive to
others. If non-verbal vocalization such as utterances and responses
in interaction are treated as if they are meaningful, they will become
meaningful.
References
1. Schiaratura LT. Non-verbal communication in Alzheimer's disease.
Psychol Neuropsychiatr Vieil. 2008;6(3):183-8.
2. Hydn LC. Non-verbal vocalizations, dementia and social interaction.
Commun Med. 2011;8(2):135-44.
54
PATIENTS IN NURSING HOMES

Aging of the population is a growing problem in all developed
societies. The older people need more health and social services, and
their QOL in there is getting more and more important. This study
aimed at determining the characteristics of non-verbal
communication of the older people living in old people's homes. The
sample consisted of 267 residents of the old people's homes, aged
65-96 years, and 267 caregivers from randomly selected 27 old
people's homes. Three types of non-verbal communication were
observed and analyzed using univariate and multivariate statistical
methods. In face expressions and head movements about 75% older
people looked at the eyes of their caregivers, and about 60% were
looking around, while laughing or pressing the lips together was
rarely noticed. The differences between genders were insignificant
while significant differences among different age groups were
observed in dropping the eyes (p=0.004), and smiling (0.008). In hand
gestures and trunk movements, majority of older people most often
moved forwards and clenched fingers, while most rarely they stroked
and caressed their caregivers. The differences between genders were
significant in leaning on the table (p=0.001), and changing the
position on the chair (0.013). Significant differences among age
groups were registered in leaning forwards (p=0.006), and pointing to
the others (p=0.036). In different modes of speaking and
paralinguistic signs almost 75% of older people spoke normally, about
70% kept silent, while they rarely quarreled. The differences between
genders were insignificant while significant differences among age
groups were observed in persuasive speaking. In Slovenia, older
people in old people's homes communicated significantly less
frequently with hand gestures and trunk movements than with face
expressions and head movements or different modes of speaking and
paralinguistic signs. The caregivers should be aware of this and pay a
lot of attention to these 2 groups of non-verbal expressions. Their
importance should be constantly emphasized during the educational
process of all kinds of health-care professionals as well (1).
This study aimed at determining the characteristics of non-verbal
communication of caregivers in Slovene nursing homes. The cross-
sectional study was performed on 267 randomly selected caregivers
from 27 randomly selected nursing homes. Facial expressions/head
55
movements, hand gestures/trunk movements, and modes of

speaking/paralinguistic signals were observed. The caregivers
manifested altogether 11,324 non-verbal communication
expressions. Those definitely reflecting positive attitude prevailed
and accounted for 59.3% of all expressions, whereas those definitely
reflecting negative attitude were very rare and accounted for 9.1% of
all expressions, at a ratio of 6.5:1 (p<0.001). Differences were highly
significant between genders (men manifested negative attitude
expressions significantly more frequently, 11.8%) and professions
(social helpers manifested positive attitude expressions significantly
less frequently, 56.4%; other professionals manifested negative
attitude expressions significantly less frequently, 5.4%) (p<0.001).
The results were similar within groups of non-verbal communication
expressions. Although this study showed that caregivers in Slovene
nursing homes use positive attitude expressions more frequently
than negative there is a reason for concern due to a general decline
in positive values and beliefs in Slovene society. Promoting positive
attitude towards non-verbal communication among new generations
of caregivers in nursing homes need to become one of the most
important contents of their life-long learning and training (2).
Assessment: in Slovenia, older people in old people's homes

communicate less frequently with hand gestures and trunk
movements than with face expressions and head movements or
different modes of speaking and paralinguistic signs.
Positive attitude towards non-verbal communication among new
generations of caregivers in nursing homes needs to become one of
the most important contents of their life-long learning and training.
References
1. Zaletel M, Kovacev AN, Sustersic O, Kragelj LZ. Non-verbal
communication of the residents living in homes for the older people in
Slovenia. Coll Antropol. 2010;34(3):829-40.
2. Zaletel M, Kovacev AN, Mikus RP, Kragelj LZ. Nonverbal
communication of caregivers in Slovenian nursing homes. Arch Gerontol
Geriatr. 2012; 54(1):94-101.
56
TECHNOLOGISTS
Although the amount of time a technologist spends with a patient
may be brief, the attitude and approach he uses with that patient is
of utmost importance. By being sensitive to the often unspoken
thoughts and feelings of the patient, the technologist can respond
with the words, touch, or facial expression that will let the patient
know he is recognized as a human being and his needs are
understood and are being responded to with empathetic concern (1).
Reference
1. Ireland SJ, Hansen EU. Brief encounter: origin of patient
communication. Radiol Technol. 1978;50(1):33-6.
DIETITIANS
Little is known about how dietitians conduct their communication
with individual patients in the process of nutrition education. To
study this issue, both practitioners' and patients' perceptions of
dietitians' skills were examined in the first phase of a 2-phase study.
The resulting narratives were used to develop a questionnaire to
survey Australian dietitians involved in clinical practice. A purposive
sample of dietitians in 1 state (n=46; 12%), working in hospital,
community or private practice, and a quota of their adult patients
(n=34), were interviewed. In the second stage, Australian dietitians
(n=258; 16%) responded to a national survey in 2006, which asked
about educational strategies, communication skills, and professional
attributes. Descriptive statistics were used to compare response
distributions, and nonparametric statistics were used to examine
between-group relationships. Criterion for item acceptance was
established as 70% agreement. Triangulation of results revealed
strong agreement between data sources. Four main communication
competencies were established: interpersonal communication skill,
non-verbal communication, professional values, and counseling skill.
There was insignificant difference in practice by work category or
experience. The communication competencies, together with 26
57
accompanying skills, are described. In conclusion, an understanding

of this guide to communication practice might help enhance
dietitian-patient relations (1).
Although client communications are affected by clients'
assumptions about professionals' characteristics drawn from dress
attire, little is known about how this dialogue operates in dietetics.
The present study aimed to describe how dietitians and their clients
interpret this dialogue and to explore the implications for practice. A
purposive quota sample of dietitians (n=46) from 21 health services
in 1 state of Australia and a quota of their adult patients (n=34) were
interviewed about dietitians' nutrition education roles. Semi-
structured interviews were transcribed and identified themes
developed into a questionnaire to survey Australian dietitians.
Analysis used frequencies and non-parametric statistics (p<0.05).
Triangulation of the results obtained from the studies revealed a
strong agreement between data sources. Dietitians' dress attire was
perceived as a key source of non-verbal communications by dietetics
clients. This was recognized by 75% of the 256 dietitians who were
surveyed nationally. Dietitians favored a professional style (i.e. skirt
or slacks, with top). Many clients rejected formal dress (i.e. suit, high
heels) as being a potential communication barrier. Some clients
viewed dietitians' bodily size/shape as a role model. Implications of
dietitians' presentation (i.e. how you look) were important to both
clients and dietitians. In conclusion, dress style is implicated in non-
verbal communication dialogues between the dietitian and client. As
a matter of competence and to maintain congruency in
communication, dietitians should be aware of their clients'
preferences for formality of dress, and conduct their attire
accordingly (2).
Assessment: an understanding of communication practice might

help enhance dietitian-patient relations. Dietitian dress style is
implicated in non-verbal communication dialogues between the
dietitian and client.
58
References
1. Cant RP, Aroni RA. Exploring dietitians' verbal and nonverbal
communication skills for effective dietitian-patient communication. J Hum
Nutr Diet. 2008;21(5):502-11.
2. Cant RP. Communication competence within dietetics: dietitians' and
clients' views about the unspoken dialogue - the impact of personal
presentation. J Hum Nutr Diet. 2009;22(6):504-10.
MENTAL DISORDERS
Ethology is relevant to clinical psychiatry for 2 different reasons.
Ethology may contribute significantly to the development of more
accurate and valid methods for measuring the behavior of persons
with mental disorders. Ethology, as the evolutionary study of
behavior, may provide psychiatry with a theoretical framework for
integrating a functional perspective into the definition and clinical
assessment of mental disorders. This article describes an ethological
method for studying the non-verbal behavior of persons with mental
disorders during clinical interviews and reviews the results derived
from the application of this method in studies of patients who had a
diagnosis of schizophrenia or depression. The findings emerging from
current ethological research in psychiatry indicate that the
ethological approach is not limited simply to a mere translation into
quantitative and objective data of what clinicians already know on
the basis of their judgment or the use of rating scales. Rather, it
produces new insights on controversial aspects of psychiatric
disorders. Although the impact of ethology on clinical psychiatry is
still limited, recent developments in the fields of ethological and
Darwinian psychiatry can revitalize the interest of clinical
psychiatrists for ethology (1).
This paper provides an example of a mental health research
partnership underpinned by empowerment principles that seeks to
foster strength among community organizations to support better
outcomes for consumers, families and communities. It aims to raise
awareness among researchers and service providers that
empowerment approaches to assist communities to address mental
health problems are not too difficult to be practical but require long-
59
term commitment and appropriate support. A collaborative research

strategy that has become known as the Priority Driven Research
Partnership emerged through literature review, consultations, Family
Wellbeing Program delivery with community groups and activities in
2 discrete Indigenous communities. Progress to date on 3 of the 4
components of the strategy is described. The following key needs
were identified in a pilot study and are now being addressed in a
research-based implementation phase: 1] gaining 2-way
understanding of perspectives on mental health and promoting
universal awareness; 2] supporting the empowerment of careers,
families, consumers and at-risk groups through existing community
organizations to gain greater understanding and control of their
situation; 3] developing pathways of care at the primary health
centre level to enable support social and emotional wellbeing as well
as more integrated mental health care; 4] accessing data to enable an
ongoing process of analysis/sharing/planning and monitoring to
inform future activity. In conclusion, one of the key learning to
emerge in this project so far is that empowerment through
partnership becomes possible when there is a concerted effort to
strengthen grassroots community organizations. These include social
health teams and men's and women's groups that can engage local
people in an action orientation (2).
This study characterized psychiatrist and patient communication
behaviors and affective voice tones during pharmacotherapy
appointments with depressed patients at 4 community-based mental
health clinics where psychiatrists provided medication management
and other mental health professionals provided therapy ("split
treatment"). Audio recordings of 84 unique pairs of psychiatrists and
patients with a depressive disorder were analyzed with the RIAS,
which identifies 41 discrete speech categories that can be grouped
into composites representing broad conceptual communication
domains. Cluster analysis identified psychiatrist communication
patterns. On average, 53% of psychiatrist talk was devoted to
partnering and relationship building, and 67% of patient talk was
about biomedical subjects, such as depression symptoms, and
psychosocial information giving. Psychiatrist communication patterns
were characterized by 2 clusters, a biomedical-centered cluster that
emphasized biomedical questions (p<0.001) and education or
counseling (p<0.001) and a patient-centered cluster focused on
60
psychosocial and lifestyle questions (p<0.001) and information giving

(p<0.001). The patient-centered cluster was associated with patients'
expression of distress, anger, or other negative affects (p=0.002). In
conclusion, psychiatrists devoted much of their talk to partnering and
relationship building while maintaining a focus on symptoms or
psychosocial issues. However, patient behaviors did not reflect a
similar level of partnering (3).
This paper employs a rhetorical form designed to clarify and
sharpen the focus of the very special stance required, which must be
painstakingly learned under careful supervision, in order to
effectively tune in to communications coming from the unconscious
of the patient. This is the hardest task that must be mastered to
become truly empathic and sensitive in dyadic relationships, a unique
expertise that marks the psychiatrist as a genuine specialist in
medical practice. Regardless of theoretical orientation, neither the
form or content of any therapeutic intervention can be appropriate
unless it is empathically based. Clinical vignettes illustrate the lack of
such empathy, and readings are suggested that enhance our
approach to learning this skill, borrowing especially from Kohut and
Bion. The great importance of the often ignored "background" of the
patient's communication is emphasized, and is illustrated from the
field of music in the work of John Cage and Anton Webern. The
congruence between this clinical psychiatric problem and the main
thrust of Continental philosophy, which attempts to put man back in
touch with himself, is described. Suggestions are offered to
supervisors how to develop these skills in the novice. Finally, a
discussion is presented of the effect on the professional and personal
life of the therapist who has not developed these skills, emphasizing
the dangers of "burn-out" in therapists and the implicit philosophy of
life in a money-oriented practice of psychotherapy. The dangers of
not attending to such matters even during residency training are
pointed out, in an attempt to raise the consciousness level of the
therapist to the extreme importance of background practices both in
the patient and the therapist (4).
Non-verbal behavior is very similar. Sometimes the facial
expression, appearance, eye contact and body movements match the
verbal expression of the patient. On the other hand, the non-verbal
behavior may send a contrary or incongruent message relative to a
patient's verbal communication. These inconsistencies may represent
61
the patient's unconscious feelings or unstated thoughts and require

further exploration in order to conduct effective psychotherapy. The
inappropriate or blunted affect and disorganized behavior seen in
patients with schizophrenia make it challenging the psychiatrist to
understand the patient's internal emotional experience (5).
Non-verbal behaviors can be of critical importance in identifying
and evaluating the risk of dangerousness to self or others. A patient
who denies any history of self-injurious behavior yet has multiple
linear scars on his or her forearms would be considered at elevated
risk for future self-harm or accidental completed suicide. A patient
who is upset about being involuntarily admitted to the hospital may
exhibit his or her anger through non-verbal behavior. He or she may
raise the volume of the voice, clench the jaw, and tighten the hands
into fists. The psychiatrist may recognize these as signs of agitation
and take pre-emptive action to prevent the situation from escalating.
If the patient has dilated pupils and appears diaphoretic this may
further warn the psychiatrist of an increased risk for impulsive or
violent behavior (5).
A psychiatrist can rely on both visual (i.e., facial expressions) and
auditory (i.e., paralanguage) output to discern a patient's emotional
state. However, there are occasions where one or the other variable
is missing from the equation. For example, the non-verbal patient will
still be able to express a feeling state via facial expression or hand
gestures. There are patient-physician interactions lacking the benefit
of being able to see the patient. If the patient states he is not angry
during a telephone conversation with the psychiatrist, but his voice
rises in volume and takes on a harsher tone, the physician may
reasonably infer that the patient is angry about something but is
either unable or unwilling to recognize his emotional state or is
reluctant to share his true feelings at that point in time (5).
Assessment: Ethology may contribute significantly to the

development of more accurate and valid methods for measuring the
behavior of persons with mental disorders. Ethology, as the
evolutionary study of behavior, may provide psychiatry with a
theoretical framework for integrating a functional perspective into
the definition and clinical assessment of mental disorders.
Listening, sharing understanding and facilitating consumer, family
and community empowerment through a priority driven partnership
62
in Far North Queensland becomes possible when there is a concerted

effort to strengthen grassroots community organizations.
Psychiatrist and depressed patient communication is
characterized by a biomedical-centered cluster that emphasize
biomedical questions and education or counseling and a patient-
centered cluster focused on psychosocial and lifestyle questions and
information giving. The patient-centered cluster is associated with
patients' expression of distress, anger, or other negative effects.
Communications coming from the unconscious of the patient are
the hardest task that must be mastered to become truly empathic
and sensitive in dyadic relationships, a unique expertise that marks
the psychiatrist as a genuine specialist in medical practice.
References
1. Troisi A. Ethological research in clinical psychiatry: the study of
nonverbal behavior during interviews. Neurosci Biobehav Rev. 1999;23(7):
905-13.
2. Haswell-Elkins M, Reilly L, Fagan R, et al. Listening, sharing
understanding and facilitating consumer, family and community
empowerment through a priority driven partnership in Far North
Queensland. Australas Psychiatry. 2009;17 Suppl 1:S54-8.
3. Cruz M, Roter D, Cruz RF, et al. Psychiatrist-patient verbal and
nonverbal communications during split-treatment appointments. Psychiatr
Serv. 2011;62(11):1361-8.
4. Chessick RD. Psychoanalytic listening II. Am J Psychother.
1985;39(1):30-48.
PSYCHOTHERAPY
Communication is the essence of the process of psychotherapy.
Understanding the parameters of communication can form the
foundations for the development of psychotherapeutic skills in the
student therapist. Using learning objectives within the context of
teaching psychotherapy, the process of communication in individual
psychotherapy is explored. With the aim of offering a practical
framework to assist in the analysis of the communication process
63
involved in individual psychotherapy, the following concepts are first

examined. 1] channels of communication; 2] modes of functioning; 3]
interaction between channels of communication and modes of
functioning. Following this exploration, the learning objectives in
communication are discussed. Using clinical examples, the
relationship between the communication process and other concepts
of individual psychotherapy are illustrated (1).
In psychotherapy, use is made of both verbal and non-verbal
variants of communications between the psychotherapist and the
patient. The first ones have been studied in a sufficiently detailed
manner whereas non-verbal interactions have been elaborated
insufficiently. The process of psychotherapy (proceeding from non-
verbal prerequisites) is estimated by the author as a combination of
non-verbal actions of the patient and the doctor. At the same time,
special attention is to the feeling of distance, postures, gestures,
smiles, empathy, definite movements, body incline, free or
constrained postures, and so forth. Non-verbal communication can
successfully be used not only in psychotherapy but also in
psychodiagnosis and psychotherapy (2).
Non-verbal behaviors of the psychiatrist greatly affect the
dialogue in psychotherapy. Just as the psychiatrist is observing the
patient in the office, the patient is observing the psychiatrist. Non-
verbal behavior plays a significant role in establishing the therapeutic
alliance in any patient-physician interaction. In psychotherapy
settings, it is critically important to the formation of rapport between
the patient and psychiatrist. Rapport is the essential groundwork that
must be laid between both parties in order for them to continue
building a strong therapeutic alliance in which to work together
toward mutual goals. Rapport is influenced by 3 non-verbal behavior
elements: attentiveness, positivity-negativity, and coordination (3).
Attentiveness refers to each individual's capability for focusing
attention on the interaction occurring between the patient and
psychiatrist in the here and now. If a patient feels the psychiatrist is
distracted or uninterested in what he or she is saying, this
undermines rapport. The psychiatrist can display interest in the
patient by giving undivided attention to the conversation at hand and
encourage further communication with non-verbal behaviors such as
making eye contact and nodding (3).
64
Positivity-negativity refers to how interacting individuals are

responding to each another. Are they enjoying one another's
company and showing this through non-verbal behaviors such as
smiling, laughing, leaning forward in their chairs, and adopting open
postures? Or are they uncomfortable with one another and
displaying indifference or hostility and creating physical distance or
barriers between one another? (3).
Coordination refers to the similarity in the non-verbal behavior of
the patient and psychiatrist. This can be conceptualized by thinking
about how one person mirrors another's behavior. Examples include
making eye contact at the same moment, returning a smile, or
adopting and changing position in tandem with the patient (3).
This article explores what professionals regard as important skills
and attitudes for generating inter-agency network meetings involving
intra- and interprofessonal work. More specifically, what they
understand as promoting or impeding dialogue and how this is
related to their professional backgrounds were examined. The
professionals participated in a project using an open dialogue
approach in order to increase the use of inter-agency network
meetings with young people suffering from mental health problems.
In this explorative case study, empirical data was collected through
interviews conducted with 2 focus groups, the first comprising HCPs
and the second professionals from the social and educational sectors.
Content analysis was used, where the main category that emerged
was dialogue. To illustrate the findings achieved in the focus groups,
observations of inter-agency network meetings are included. The
findings describe the significance and challenges of listening and
authenticity in the professionals' reflections. The HCPs expressed
worries concerning their capacities for open and transparent
dialogues, while the other professionals' emphasized the usefulness
of particular techniques. Inter-agency network meetings may be
improved if more awareness is placed on the significance of meeting
atmosphere, dwelling on specific topics, dealing with silence and
understanding how authentic self-disclosure in reflections can
promote the personal growth of the participants (4).
The mental status examination is the objective portion of any
comprehensive psychiatric assessment and has key diagnostic and
treatment implications. This includes elements such as a patient's
baseline general appearance and behavior, affect, eye contact, and
65
psychomotor functioning. Changes in these parameters from session

to session allow the psychiatrist to gather important information
about the patient. In psychiatry, much emphasis is placed on not only
listening to what patients communicate verbally but also observing
their interactions with the environment and the psychiatrist. In a
complimentary fashion, psychiatrists must be aware of their own
non-verbal behaviors and communication, as these can serve to
either facilitate or hinder the patient-physician interaction (5).
There are multiple layers of context to consider. First, a
psychiatrist should take into consideration the environment in which
an interaction is taking place. During an initial interview, patients
may seem anxious about talking to a complete stranger about their
problems or appear distracted as they take in the novelty of the
psychotherapist's office. Crossing one's arms across the chest might
mean the patient is not open to pursuing a particular avenue of
exploration; however, in another case it might simply be indicative of
the office temperature being too cold for comfort. Second,
psychiatrists must consider a particular individual's typical
presentation and usual mental status examination. Some individuals
are naturally more expressive in terms of general animation,
gestures, and affect. Others may carefully control and modulate their
feelings. Certain cultures have different rules as to when it is
acceptable to express a particular emotion and to what degree.
Third, it is helpful to look at non-verbal behaviors globally rather than
center on the minutiae. Instead of focusing on any one single
gesture, it is more effective and useful to accurately interpret several
behaviors that occur simultaneously. Finally, a psychiatrist must
reflect on the interaction occurring between patient and physician in
real time. The psychiatrist's own non-verbal actions may in turn
affect a patient's behavior (5).
Another aspect of the mental status examination involves
comparison of a patient's stated mood versus his or her perceivable
affect. If a patient states he or she feels depressed and appears
sad, tearful, and uninterested in maintaining personal grooming and
demonstrates psychomotor retardation, the psychiatrist would
conclude the affect is congruent with the stated mood. Conversely, if
an individual states he feels depressed yet appears euthymic,
smiling, laughing, and enthusiastically interactive, the conclusion
would be that the affect is incongruent with the stated mood. This
66
does not necessarily mean the patient in question is not feeling

depressed, but the psychiatrist would take note of the inconsistency
and explore further through interview and continued observation of
the patient (5).
Once in the interview room, there are a number of observable,
non-verbal behaviors that produce information about the patient.
One should take notice of where the patient chooses to sit, posture
during the interview, whether eye contact is maintained, and how
the patient reacts to interpretations beyond simple verbal
acknowledgment. Over time, the psychiatrist becomes attuned to the
patient's baseline appearance, attitude, and behavior. Some of these
non-verbal behaviors may point the psychiatrist in the direction of a
specific diagnosis (6).
The initial mental status examination can provide valuable
information about a patient and begins when a new patient is first
seen in the waiting area. However, it takes time to accurately identify
a particular individual's baseline. A first impression may be influenced
by anxiety about coming to see the psychiatrist. What is the patient's
posture? Is the patient nervous and fidgeting or appearing calm and
relaxed? Does the patient appear depressed or easily startled, for
example when a door slams shut? Is there a gait disturbance as the
patient walks into the office? (5).
When aspects of the mental status examination change, it is
important that the psychiatrist explore this further in order to
determine the significance of the shift from baseline. A departure
from a patient's normal baseline appearance and behavior should
always be noted. Precisely because non-verbal communication is
often unconscious, these behaviors might be a more accurate
reflection of a patient's internal emotional state (2). Changes in non-
verbal behavior that occur during the therapeutic interaction may
alert the psychiatrist that a patient is not yet able to tolerate
discussion of a particular issue (7).
Assessment: in psychotherapy, use is made of both verbal and

non-verbal variants of communications between the psychotherapist
and the patient. Non-verbal communication can successfully be used
not only in psychotherapy but also in psychodiagnosis and
psychotherapy.
67
Non-verbal behavior plays a significant role in establishing the

therapeutic alliance in any patient-physician interaction. In
psychotherapy settings, it is critically important to the formation of
rapport between the patient and psychiatrist.
A patient's baseline general appearance and behavior, affect, eye
contact, and psychomotor functioning. Changes in these parameters
from session to session allow the psychiatrist to gather important
information about the patient. Much emphasis is placed on not only
listening to what patients communicate verbally but also observing
their interactions with the environment and the psychiatrist. In a
complimentary fashion, psychiatrists must be aware of their own
non-verbal behaviors and communication, as these can serve to
either facilitate or hinder the patient-physician interaction.
There are a number of observable, non-verbal behaviors that
produce information about the patient. One should take notice of
where the patient chooses to sit, posture during the interview,
whether eye contact is maintained, and how the patient reacts to
interpretations beyond simple verbal acknowledgment.
References
1. Watters WW, Bellissimo A, Rubenstein JS. Teaching individual
psychotherapy: learning objectives in communication. Can J Psychiatry.
1982;27(4):263-9.
2. Trubitsyna LV. Nonverbal communication in psychotherapy. Zh
Nevropatol Psikhiatr Im S S Korsakova. 1990;90(12):59-62.
3. Tickle-Degnen L, Gavett E. Changes in nonverbal behavior during the
development of therapeutic relationships. In: Philippot P, Feldman R, Coats
E (eds.). Nonverbal Behavior in Clinical Settings. New York, NY: Oxford
University Press. 2003, pp. 75110.
4. Holmesland AL, Seikkula J, Hopfenbeck M. Inter-agency work in Open
Dialogue: the significance of listening and authenticity. J Interprof Care.
2014;28(5):433-9
6. American Psychiatric Association. Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American
Psychiatric Press Inc. 2000.
7. Philippot P, Feldman R, Coats E. The role of nonverbal behavior in
clinical settings. In: Philippot P, Feldman R, Coats E, editors. Nonverbal
Behavior in Clinical Settings. New York, NY: Oxford University Press. 2003.
pp. 313.
68
SILENCE IN PSYCHODYNAMIC PSYCHOTHERAPY

Eighty-one therapists responded to a mailed survey about their
use of silence during a specific event in therapy and about their
general attitudes about using silence in therapy. For the specific
event, therapists used silence primarily to facilitate reflection,
encourage responsibility, facilitate expression of feelings, not
interrupt session flow, and convey empathy. During silence,
therapists observed the client, thought about the therapy, and
conveyed interest. In general, therapists indicated that they would
use silence with clients who were actively problem solving, but they
would not use silence with very disturbed clients. Therapists learned
about using silence mostly through clinical experience (1).
Moments of silence in the therapy hour, on the part of the client
or therapist, can communicate important psychodynamic
information, as well as deeply facilitate the therapeutic encounter.
The client may be communicating emotional and relational messages
of need and meaning. The therapist can use silence to communicate
safety, understanding and containment. However, if this intervention
is not skillfully and sensitively employed by the practitioner, the
client may feel the therapist's quietness as distance, disinterest, and
disengagement, leading to breaches in the trust and safety of the
therapeutic alliance (2).
Assessment: for the specific event, therapists can use silence to

facilitate reflection, encourage responsibility, facilitate expression of
feelings, not interrupt session flow, and convey empathy. During
silence, therapists observed the client, thought about the therapy,
and conveyed interest. The therapist can use silence to communicate
safety, understanding and containment.
References
1. Hill CE, Thompson BJ, Ladany N. Therapist use of silence in therapy: a
survey. J Clin Psychol. 2003;59(4):513-24.
2. Lane RC, Koetting MG, Bishop J. Silence as communication in
psychodynamic psychotherapy. Clin Psychol Rev. 2002;22(7):1091-104.
69
CLINICAL VIGNETTE (1)

Mrs. Jones was a 44-year-old married woman who initially
presented with a chief concern of worsening anxiety for the past
several months. Mrs. Jones reported being bothered by increasing
worry, poor sleep, feelings of fatigue, and a decreased ability to
focus. Her symptoms were especially intense in her occupational
setting as a receptionist in a busy medical office. She decided to seek
treatment after an argument with a patient, with whom she was
really snippy, which resulted in one of the female physicians in the
practice pulling her aside to ask if everything was okay. Mrs. Jones
was genuinely surprised when this doctor mentioned that she
seemed irritable lately. When she thought about this comment
later, she realized she had increased her smoking from a half pack
daily to nearly a full pack per day. She reported having always been
a worrier but had never before received mental health services. Her
only experience with psychotropic medication was zolpidem
(Ambien) prescribed by her primary care physician after she
complained of insomnia earlier in the year. She acknowledged feeling
uncomfortable about seeing a psychiatrist because you might think
I'm crazy. During the initial consultation, Mrs. Jones's eye contact
was fleeting and her palm was sweaty upon shaking hands with the
psychiatrist. She chose a seat on the couch, the furthest position
away from the psychiatrist, and pulled a pillow onto her lap. Her
speech was soft and somewhat rapid. She appeared nervous, fidgety,
and kept rubbing the back of her neck. When this repeated gesture
was brought to her attention by the psychiatrist, she reported
frequent headaches and neck pain.
Mrs. Jones's behavior indicated she was anxious about the
appointment. She put the maximum amount of physical distance
available between herself and the psychiatrist. Furthermore, she
hid behind the pillow as a sort of protective barrier and had a
difficult time sustaining eye contact.
It would be prudent to see if behaviors change after the patient
becomes more comfortable with the psychiatrist. If they do not
dissipate over time, a psychiatrist might conclude that this level of
anxiety is actually the patient's baseline mental state. Commenting
on Mrs. Jones's neck-rubbing behavior elicited a report of muscle
tension and further validated the psychiatrist's tentative assessment.
70
Jones was initially unable to pinpoint a reason for her worsening

anxiety. I don't know why I'm so keyed up, she replied when asked.
When the psychiatrist inquired about major life changes or stressors,
she was insistent there was nothing in particular that was troubling
her and crossed her arms over her chest, zipping up her cardigan in
the process. Mrs. Jones described her childhood as normal and
good and denied any history of abuse, trauma, or neglect. She
reported a relatively stable marriage for the past 24 years and said
there was no increase in marital conflict recently. She described her
husband as supportive and had no complaints about their
relationship, yet made diminished eye contact when her marriage
was the topic of discussion. She had 2 children, a 17-year-old son
preparing to graduate from high school in a matter of months and a
24-year-old daughter who was enrolled in graduate school several
states away. Mrs. Jones reported close and non-conflicted
relationships with both of them. The psychiatrist noted that nearly
every time her son came up in discussion, Mrs. Jones would take her
cigarette lighter out of her pocket and twirl it around in her hand. He
was planning on enlisting in the military after graduation and Mrs.
Jones was not supportive of this decision.
There was a strong non-verbal reaction whenever her marital
relationship was mentioned. Mrs. Jones's diminished eye contact, the
crossing of her arms, and the zipping up of her sweater literally serve
to close herself off from the psychiatrist. Despite denying any
concerns about her marriage, the psychiatrist concluded from her
behavior that there was something threatening to the patient about
that topic. Perhaps Mrs. Jones would be more open to discussing this
at a future time. In other instances, non-verbal behavior may help
direct the psychiatrist to an issue needing further exploration even if
the patient states the topic involved is unimportant or irrelevant.
The touching of the cigarette lighter was an indicator of discomfort,
as smoking is one of the ways Mrs. Jones attempted to cope with her
anxiety.
Over the course of psychotherapy, Mrs. Jones became more
comfortable in sessions. Her eye contact improved and her fidgeting
decreased. She began sitting on the end of the couch closer to the
psychiatrist. During one appointment, Mrs. Jones spontaneously
shared more about her employment situation. She had worked in the
same medical office for many years. It was a busy practice and she
71
had greatly enjoyed her job until the last several months. When
describing her work, she appeared happy and excited until she stated
that a new male physician had recently joined the staff. At this point,
Mrs. Jones's facial expression transformed and she appeared
subdued. The psychiatrist also noted she reverted to her anxious
mannerisms seen at initial presentation, so the psychiatrist invited
Mrs. Jones to discuss whatever she was comfortable sharing.
Mrs. Jones indicated the new physician had been flirting with her
and it was making her uncomfortable. In one case, the physician gave
her an unsolicited neck massage. She reported feeling frozen and
trapped at the time. Mrs. Jones did not reciprocate this physician's
feelings but felt unsure how to deal with the unwanted attention
without causing a problem in the office. Once, she told the physician
she was not interested, but he joked about it and did not appear to
take her concerns seriously. When sharing this information with the
psychiatrist, Mrs. Jones's voice became soft and meek. Mrs. Jones put
her hand to her eyebrow, covering one side of her face, looked at the
floor and became uncharacteristically silent. The psychiatrist inquired
if she somehow felt ashamed about the interactions with this
physician. Mrs. Jones immediately started to cry and admitted she
had never disclosed the flirtation to anyone else. She felt very guilty
for not telling her husband about the interactions at work. In
addition, Mrs. Jones felt she must have done something to lead him
on as the physician was continuing this behavior despite her
noninterest. She reported that the issues at her job reminded her of
an incident in her adolescence where she had been sexually
assaulted by a boyfriend after attempting to break off the
relationship. It was my fault then, and it's my fault now.
Mrs. Jones displayed a significant and rapid shift in facial
expression from happy to sad when the topic of the new male
physician in her office arose. The psychiatrist picked up on this as
well as the return of her fidgeting and gently encouraged Mrs. Jones
to share what was on her mind. Mrs. Jones then appeared ashamed
and embarrassed, indicated by her downcast eyes and by covering
her face, yet she was unable to freely talk about this emotional state
as evidenced by her silence. Again, the psychiatrist recognized the
change in her non-verbal behavior and made an interpretation
regarding the patient's visible affect. This facilitated Mrs. Jones's
sharing more details about the situation at work as well as a
72
traumatic past event that likely had considerable influence on how

she felt about and navigated the difficult position she faced.
When the treating psychiatrist reviewed details of the previous
appointment by referring to process notes and a videotape of that
session, she concluded the psychotherapy had stalled. When Mrs.
Jones mentioned the topic of previous sexual abuse, the treating
psychiatrist observed that she herself appeared uncomfortable and
subtly leaned back in the chair and crossed her own legs and arms.
Immediately after this, Mrs. Jones had abruptly changed the subject,
stating But you don't want to hear about all that.
Reflecting on her own behavior, the treating psychiatrist realized
that she did not comment on this and subsequently Mrs. Jones
discussed more superficial topics. She noted Mrs. Jones had
appeared considerably less animated and engaged in the session
after the topic shifted to more mundane events. The psychiatrist
reflected on how she felt during this particular session. She realized
that she had been unsure how to explore the sexual assault at that
point because the patient appeared uncomfortable. She wondered if
she might have been projecting her own concerns and discomfort
about addressing such an anxiety-provoking topic onto Mrs. Jones.
The psychiatrist realized she did not respond verbally to Mrs. Jones's
comment about not wanting to hear further information about the
sexual assault, but had communicated her own anxiety non-verbally.
The psychiatrist had not recognized that the patient was responding
to the psychiatrist's own discomfort and corresponding non-verbal
behavior.
The psychiatrist unconsciously displayed signals of discomfort that
Mrs. Jones identified even though no words to that effect were
exchanged. While the patient's reading of the psychiatrist's non-
verbal communication may have been conscious or unconscious, it
likely contributed to the patient's comment regarding the psychiatrist
not wanting to hear any more about the past sexual assault. The
psychiatrist missed an empathic opportunity to regroup and reassure
the patient that she was open to listening to whatever Mrs. Jones
wished to share. Through careful review of the process notes and
videotape, the treating psychiatrist became aware of this and was
able to utilize the information in subsequent sessions, facilitating the
patient's exploration of the past abuse at the next appropriate
opportunity.
73
In conclusion, this clinical vignette indicates that non-verbal

behavior contributes significantly to all interpersonal communication
but unfortunately is often only a peripheral area of focus in the
psychotherapeutic setting. While listening carefully to the patient is
obviously a fundamental aspect of psychotherapy, there may be
additional diagnostic and therapeutic information to be gained from
watching the non-verbal behaviors expressed by a patient. Non-
verbal signals can alert a psychiatrist to important affective states
that may otherwise be overlooked or denied. They can also help
identify how comfortable a patient is with a given topic of discussion.
This information can then be used to guide the psychotherapy in a
manner that is tolerable and therapeutic for the patient. Being aware
of our own non-verbal behavior and how it may affect interactions
with patients is central to improving our ability to establish rapport
and maintain a strong therapeutic alliance.
Reference
PEDIATRICS
The objective of this study was to test the independent
association of adult language input, television viewing, and adult-
child conversations on language acquisition among infants and
toddlers. Two hundred seventy-five families of children aged 2 to 48
months who were representative of the US census were enrolled in a
cross-sectional study of the home language environment and child
language development (phase 1). Of these, a representative sample
of 71 families continued for a longitudinal assessment over 18
months (phase 2). In the cross-sectional sample, language
development scores were regressed on adult word count, television
viewing, and adult-child conversations, controlling for socioeconomic
attributes. In the longitudinal sample, phase 2 language development
scores were regressed on phase 1 language development, as well as
phase 1 adult word count, television viewing, and adult-child
74
conversations, controlling for socioeconomic attributes. In fully

adjusted regressions, the effects of adult word count were significant
when included alone but were partially mediated by adult-child
conversations. Television viewing when included alone was
significant and negative but was fully mediated by the inclusion of
adult-child conversations. Adult-child conversations were significant
when included alone and retained both significance and magnitude
when adult word count and television exposure were included. In
conclusion, television exposure is not independently associated with
child language development when adult-child conversations are
controlled. Adult-child conversations are robustly associated with
healthy language development. Parents should be encouraged not
merely to provide language input to their children through reading or
storytelling, but also to engage their children in 2-sided conversations
(1).
Research in children with language problems has focused on
verbal deficits, and we have less understanding of children's deficits
with non-verbal sociocognitive skills which have been proposed to be
important for language acquisition. This study was designed to
investigate elicited non-verbal imitation in children with specific
language delay. It is argued that difficulties in non-verbal imitation,
which do not involve the processing of structural aspects of language,
indicate sociocognitive deficits. Participants were German-speaking
typically developing children (n=60) and children with specific
language delay (n=45) aged 2-3 years. A novel battery of tasks
measured their ability to imitate a range of non-verbal target acts to
a greater or lesser extent to involve sociocognitive skills (body
movements, instrumental acts on objects, and pretended acts).
Significant group differences were found for all body movement and
pretended act tasks, but not for the instrumental act tasks. The
poorer imitative performance of the specific language delay sample
was not explained by motor or non-verbal cognitive skills. It appeared
that the nature of the task affected children's imitation performance.
It is argued that the ability to establish a sense of connectedness with
the demonstrator was at the core of children's imitation difficulty in
the specific language delay sample (2).
Verbal-nonverbal correspondence training is a behavioral
approach recommended in the development of adaptive behaviors
and the reduction of problem behaviors. Research findings involve 4
75
verbal-non-verbal correspondence-training techniques and illustrate

the potential utility of these techniques in general pediatric settings.
Particular emphasis is placed on strategies pediatricians could
employ to teach patients how to use these techniques effectively to
decrease problem behaviors at home (e.g., ADHD, refusing to take
the prescribed medication, and eating problems) among children
seen in outpatient pediatric settings (3).
Assessment: effects of adult word count are significant when

included alone and are partially mediated by adult-child
conversations.
The poorer imitative performance of the specific language delay in
children is not explained by motor or non-verbal cognitive skills. The
nature of the task affects children's imitation performance. There is
utility of verbal-nonverbal correspondence-training techniques in
outpatient pediatric settings.
References
1. Zimmerman FJ, Gilkerson J, Richards JA, et al. Teaching by listening:
the importance of adult-child conversations to language development.
Pediatrics. 2009;124(1):342-9.
2. Dohmen A, Chiat S, Roy P. Nonverbal imitation skills in children with
specific language delay. Res Dev Disabil. 2013;34(10):3288-300.
3. Paniagua FA. Utility of verbal-nonverbal correspondence-training
techniques in outpatient pediatric settings. Psychol Rep. 2004;94(1):317-26.
DISCLOSING MEDICAL ERRORS

Medical errors are prevalent, but physicians commonly lack the
training and skills to disclose them to their patients. Existing research
has yielded a set of verbal messages physicians should communicate
during error disclosures. However, considering the emotional
message contents, patients likely derive much of the meaning from
physicians' non-verbal behaviors. The purpose of this study was to
test the causal effects of physicians' non-verbal communication on
error disclosure outcomes. At a university hospital in the
Southeastern United States, 318 patients were randomly assigned to
76
3 treatment groups. The first group watched a video vignette of a

verbally and non-verbally competent error disclosure by a person
acting as a physician. The second group was exposed to a verbally
competent but non-verbally incompetent error disclosure. The third
group read an error disclosure transcript. Then, all patients
responded to measures of closeness, trust, forgiveness, satisfaction,
distress, empathy, and avoidance. Holding the verbal message
content constant, physician non-verbal involvement was significantly
associated with higher patient ratings of closeness, trust, empathy,
satisfaction, and forgiveness, and with lower ratings of patient
emotional distress and avoidance. These associations were not
affected by patient predispositions such as sex, ethnicity, religion and
previous experiences with medical errors. In conclusion, non-verbal
communication has a significant effect on error disclosure outcomes
and thus should be considered as an important component of future
research and disclosure training efforts (1).
The purpose of this study was to test causal effects of physicians'
non-verbal involvement on medical error disclosure outcomes.
Hospital outpatients (n=216) Lugano, Switzerland were randomly
assigned to 2 experimental treatment groups. The first group
watched a video vignette of a verbally effective and non-verbally
involved error disclosure. The second group was exposed to a
verbally effective but non-verbally uninvolved error disclosure. All
patients responded to 7 outcome measures. Patients in the non-
verbally uninvolved error disclosure treatment group perceived the
physician's apology as less sincere and remorseful compared to
patients in the involved disclosure group. They also rated the
implications of the error as more severe, were more likely to ascribe
fault to the physician, and indicated a higher intent to change doctors
after the disclosure. In conclusion, non-verbal involvement during
medical error disclosures facilitates more accurate patient
understanding and assessment of the medical error and its
consequences on their health and QOL. In the context of disclosing
medical errors, non-verbal involvement increases the likelihood that
physicians will be able to continue caring for their patient. Thus,
providers are advised to consider adopting this communication skill
into their medical practice (2).
Existing investigations on medical error disclosures have neglected
the fact that a disproportionately large amount of the meaning in
77
messages is derived from non-verbal cues. This study provides an

empirical assessment of the verbal and non-verbal messages
physicians communicate when disclosing medical errors to SPs. Sixty
hypothetical error disclosures by a volunteer sample of attending
physicians were videotaped, coded, and statistically analyzed.
Physicians used friendly, smooth, approaching and invested non-
verbal styles as they disclosed medical errors to SPs. Female
physicians smiled more and were more attentive to patients than
male physicians, and physicians tended to exhibit more positive
affect in the form of facial pleasantness toward angry female patients
than toward angry male patients. Furthermore, physicians touched
and smiled at patients more frequently at the beginning and at the
end of their error disclosures, and displayed decreased attentiveness
and interactional fluency. In conclusion, future research needs to
examine which disclosure styles patients perceive as competent, and
to assess their causal impacts on objective and relational disclosure
outcomes. This study provides an important baseline understanding
of medical error disclosures that is essential for the successful
implementation of empirically based training programs (3).
Assessment: non-verbal communication has a significant effect on

error disclosure outcomes. Non-verbal involvement during medical
error disclosures facilitates more accurate patient understanding and
assessment of the medical error and its consequences on their health
and QOL. Non-verbal involvement increases the likelihood that
physicians will be able to continue caring for their patient.
References
1. Hannawa AF. "Explicitly implicit": examining the importance of
physician nonverbal involvement during error disclosures. Swiss Med Wkly.
2012 May 9;142:w13576.
2. Hannawa AF. Disclosing medical errors to patients: effects of
nonverbal involvement. Patient Educ Couns. 2014;94(3):310-3.
3. Hannawa AF. Shedding light on the dark side of doctor-patient
interactions: verbal and nonverbal messages physicians communicate during
error disclosures. Patient Educ Couns. 2011;84(3):344-51.
78
NURSES' NON-VERBAL COMMUNICATION

The purpose of this analysis was to examine whether nurses'
listening behavior, especially the coordination of their non-verbal
involvement activities with those of their patients, communicates
information about patient-nurse relationships. Participants were 126
college women who responded to a 30-item instrument measuring
relational information that was communicated to them by nurses'
behavior in videotaped segments of interactions between a
patient/actress and 12 nurses. Participants' responses to 2
consecutive interaction segments were selected for this analysis. The
research team coded the patient's and nurses' listening activities, and
they calculated coordination and activity rates for all interaction
segments. Multiple regression analysis revealed that nurses' verbal
listening activities, such as reflection, their non-verbal involvement
activities, and their simultaneous coordination of non-verbal
involvement activities with those of the patient predicted relational
information dimensions of trust/receptivity, depth/similarity/
affection, composure, and non-formality. Thus, nurses' listening
behavior, including coordination, may contribute to patient-nurse
communication (1).
Nursing involves deep human interpersonal relationships between
nurses and patients. However, in modern Korea, the nurse-patient
relationship tends to be ritualistic and mechanistic. Patients usually
express the hope that nurses be more tender and kind. Patients
expect nurses to express their warmth especially through non-verbal
behavior. This study was conducted to identify patients' preferences
for nurse's non-verbal expressions of warmth. Through the
confirmation of these preferences, nurses may learn how to enhance
their interpersonal relationships with patients. Subjects for the study
were 73 patients who had been admitted to a university teaching
hospital for at least 3 days and agreed to be interviewed by the
investigator. The interactions for non-verbal expressions of warmth
during nursing rounds and administration of oral medication were
studied. The interview schedule was especially designed by the
investigator to measure the nurse's posture, the distance between
the nurse and the patient, the nurse's eye contact, facial expression,
hand motion and head nodding. The results of this study are
summarized as follows: 1] Patient's preferences for nurse's non-
79
verbal expressions of warmth during nursing rounds. Preferred

nurse's posture was sitting (50.7%) or standing (49.3%) opposite to
the patient. Preferred distance between the nurse and the patient
was close to the bed (93.2%), less than 1 meter. Preferred eye
contact was directed to the patient's eyes or their affected part
(41.1%). Preferred facial expression was a smile (97.3%). Preferred
hand motions were light gestures (41.1%). Patients preferred head
nodding which approved their own opinions (69.9%). 2] Patient's
preferences for nurse's non-verbal expressions of warmth during
administration of oral medication. Preferred nurse's posture was
standing and waiting to confirm that the medication had been taken
(58.9%). Preferred distance from the patient was at arm's length, 0.5-
1 meter (64.4%). Patients preferred direct eye contact (58.9%), a
smile (94.5%), and that the nurse put the medicine directly into the
patient's hand (64.4%). Whether the nurse nodded her head or not
was not considered important. 3] The relation of general
characteristics and patient's preferences for nurse's non-verbal
expressions of warmth during nursing rounds and administration of
oral medication. During nursing rounds, the age of subjects (p=0.010)
and the standard of education (p=0.026) were related to the distance
between the nurse and the patient. The sick hospital ward related to
the eye contact (p=0.017) and facial expression (p=0.010) )2).
Because of language barriers and cultural differences, IEN face
documented communication challenges in health care delivery. Yet, it
is unknown how and to what extent nonverbal behaviors affect
patient care because of research gap in the existing nursing
literature. This was an exploratory study evaluating non-verbal
communication behaviors of IEN interacting with SPs in a controlled
clinical setting through videotape analysis. Participants included 52
IEN from 2 community hospitals in the same hospital system in a
southwestern metropolitan area in the United States. Twelve non-
verbal behaviors were rated using a 4-point Likert scale with 4
indicating the best performance by the research team after watching
videos of SP-IEN interactions. The global communication
performance was also ranked in 4 areas: genuineness, spontaneity,
appropriateness, and effectiveness. The relationships between these
4 areas and the non-verbal behaviors were explored. Finally, a
qualitative analysis of 2 extreme cases was conducted and
supplemented the quantitative findings. The IEN received average
80
scores under 2 in 5 out of the 12 non-verbal behaviors. They were

"hugging" (1.06), "lowering body position to patient's level" (1.07),
"leaning forward" (1.26), "shaking hands" (1.64), and "therapeutic
touch" (1.66). The top 3 scores were for "no distractive movement,"
"eye contact," and "smile" (3.80, 3.73, and 3.57, respectively). The
average overall global impression score was 2.98. The average score
for spontaneity was 2.80, which was significantly lower than the
scores for genuineness (3.15), appropriateness (3.11), but
comparable to the average score for effectiveness (2.85). Finally,
therapeutic touch, interpersonal space, eye contact, smiling, and
hugging were all significantly correlated with 1 or more of the global
impression scores, with therapeutic touch showing moderate
correlations with all of the scores as well as the overall global
impression score. The IEN non-verbal behaviors in areas such as
hugging, lowering body position to patient's level, leaning forward,
shaking hands, and therapeutic touch have room for improvement.
Targeted interventions focusing on norms and expectations of non-
verbal behaviors in the US health care setting are called for to
improve quality of care (3).
This article describes non-verbal communication, its nursing
assessment and its use with people who have a learning disability. A
nursing diagnosis of altered non-verbal communication is outlined
and a new diagnosis is proposed of potential for enhanced non-
verbal communication. It is important to use and encourage non-
verbal communication for people who have limited verbal
comprehension. Nurses are considered an important focus for
change (4).
This study explores the occurrence of non-verbal communication
in nurse-elderly patient interaction in 2 different care settings: home
nursing and a home for the elderly in the Netherlands. In a sample of
181 nursing encounters involving 47 nurses, a study included
videotaped nurse-patient communication. Six non-verbal behaviors
were observed: patient-directed eye gaze, affirmative head nodding,
smiling, forward leaning, affective touch and instrumental touch.
With the exception of instrumental touch, these non-verbal
behaviors are important in establishing a good relationship with the
patient. To study the relationship between non-verbal and verbal
communication, verbal communication was observed using an
adapted version of RIAS, which distinguishes socio-emotional and
81
task-related communication. The results demonstrated that nurses

use mainly eye gaze, head nodding and smiling to establish a good
relation with their patients. The use of affective touch is mainly
attributable to nurses' personal style. Compared to nurses in the
community, nurses in the home for the elderly more often display
non-verbal behaviors' such as patient-directed gaze and affective
touch (5).
This article critically synthesized current literature regarding
communication between nurses and people with an intellectual
disability who communicate non-verbally. The unique context of
communication between the intellectual disability individuals was
studied. Communication as a concept was explored in depth. Issues
included knowledge of the person with intellectual disability,
mismatch of communication ability, and knowledge of
communication arose as predominant themes. A critical review of the
importance of communication in nursing practice followed. The
paucity of literature relating to intellectual disability nursing and non-
verbal communication indicated a need for research (6).
This is the first of 2 articles presenting the findings of a qualitative
study which explored the experiences of RNIDs of communicating
with people with an intellectual disability who communicate non-
verbally. The article reports and critically discusses the findings in the
context of the policy and service delivery discourses of person-
centeredness, inclusion, choice and independence. Arguably, RNIDs
are the profession who most frequently encounter people with an
intellectual disability and communication impairment. The results
suggest that the communication studied is both complicated and
multifaceted. An overarching category of 'familiarity/knowing the
person' encompasses discrete but related themes and subthemes
that explain the process: the RNID knowing the service-user; the
RNID/service-user relationship; and the value of experience. People
with an intellectual disability, their families and disability services are
facing a time of great change, and RNIDs will have a crucial role in
supporting this transition (7).
The aim of this study was to ascertain what methods of
communication nurses use during interactions with patients nearing
the end of their lives, with a particular focus on non-verbal
communication. A questionnaire containing 24 questions was
completed by 95 nurses working in 1 of 5 hospices in Poland. A total
82
of 48% of the sample reported frequently using non-verbal

communication consciously and with a certain aim, and a further 37
(39%) reported that they sometimes use it. The sample's responses
indicate that for patients the best form of touch is holding hands. In
addition, 63% of the respondents stated that they had been educated
in communicating with palliative care patients, but only 56% thought
that nurses' communication knowledge and skills were satisfactory,
and 50% would like to undergo training in communication skills
specific to palliative care. In conclusion, most nurses are aware of
the importance of non-verbal communication to their interactions
with palliative care patients, but a substantial proportion think that
they need to be better educated in theoretical and practical aspects
of communication (8).
Assessment: nurses' verbal listening activities, such as reflection,

their non-verbal involvement activities, and their simultaneous
coordination of non-verbal involvement activities with those of the
patient predicted relational information dimensions of
trust/receptivity, depth/similarity/affection, composure, and non-
formality.
communication challenges in health care delivery. The IENs' non-
verbal behaviors in areas such as hugging, lowering body position to
patient's level, leaning forward, shaking hands, and therapeutic touch
have place for improvement. Targeted interventions focusing on
norms and expectations of non-verbal behaviors in the US health
care setting are called for to improve quality of care.
Nurses use mainly eye gaze, head nodding and smiling to establish
a good relation with their patients. The use of affective touch is
mainly attributable to nurses' personal style. Compared to nurses in
the community, nurses in the home for the elderly more often
display non-verbal behaviors such as patient-directed gaze and
affective touch.
Non-verbal communication is important between nurses and
people with an intellectual disability. People with an intellectual
disability, their families and disability services are facing a time of
great change, and RNIDs will have a crucial role in supporting this
transition. The RNID is ideally located and key to supporting the
implementation of the policies and strategies due to their highly
83
developed and proficient skill set as well as experience of

communicating with people with an intellectual disability who
communicate non-verbally.
Most nurses are aware of the importance of non-verbal
communication to their interactions with palliative care patients, but
a substantial proportion think that they need to be better educated
in theoretical and practical aspects of communication.
References
1. Gilbert DA. Coordination in nurses' listening activities and
communication about patient-nurse relationships. Res Nurs Health. 2004;
27(6):447-57.
2. Kim HS, Kim MS. Patients' preferences for nurses' nonverbal
expressions of warmth during nursing rounds and administration of oral
medication. Kanho Hakhoe Chi. 1990;20(3):381-98.
3. Xu Y, Staples S, Shen JJ. Nonverbal communication behaviors of
internationally educated nurses and patient care. Res Theory Nurs Pract.
2012;26(4):290-308.
4. Chambers S. Use of non-verbal communication skills to improve
nursing care. Br J Nurs. 2003;12(14):874-8.
5. Caris-Verhallen WM, Kerkstra A, Bensing JM. Non-verbal behaviour in
nurse-elderly patient communication. J Adv Nurs. 1999;29(4):808-18.
6. Martin AM, O'Connor-Fenelon M, Lyons R. Non-verbal communication
between nurses and people with an intellectual disability: a review of the
literature. Part I. J Intellect Disabil. 2010;14(4):303-14.
7. Martin AM, Connor-Fenelon MO, Lyons R. Non-verbal communication
between Registered Nurses Intellectual Disability and people with an
intellectual disability: an exploratory study of the nurse's experiences. Part
2. J Intellect Disabil. 2012;16(1):61-75.
8. Kozowska L, Doboszynska A. Nurses' nonverbal methods of
communicating with patients in the terminal phase. Int J Palliat Nurs. 2012;
18(1):40-6.
84
TEACHING
The VCE may function as an important support for medical
students in or prior to clinical practice to train and ease
communication and socioemotional interactions with patients. This
study was designed to investigate the dynamics and congruence of
interpersonal behaviors and socioemotional interaction exhibited
during the learning experience in a VCE, and to evaluate which
interaction design characteristics contribute most to the behavioral
and affective engagement in medical students. Thirty medical
students (sixth semester) participated voluntarily in an exploratory
observational study with a highly interactive VP case based on a
trustworthy VP encounter with a natural and realistic dialogue
interface. Students worked collaboratively in pairs. They were
videotaped for further behavioral analysis and self-reported (in both
a survey and an interview) personal opinions, perceptions and
attitudes about the VCE. A mixed methods approach was applied. All
participants demonstrated an adequate, respectful and relevant
clinical case management and to obtain psychosocial history. The
collaborative workspace played its role and led to dynamic and
engaged discussions fostering thus shared understanding. The results
suggest that the VCE studied was perceived as a meaningful,
intrinsically motivational and activating learning environment, and
was found to socially and emotionally engage learners. VCEs have the
potential to support the development of relevant and congruent
interpersonal communication skills in trainees. In conclusion, by
taking advantage of socioemotional interaction, VCEs promote not
only critical reflection skills or strategy-selection skills, but also
develop listening and non-verbal skills, induce self-awareness and
target coping behaviors. If applied in early medical education, this
learning approach may facilitate clinical encounters at an early stage
and contribute to responsible clinical decision-making (1).
A therapist's non-verbal behavior may communicate emotion and
feelings toward a client. Thus, skilled utilization of appropriate non-
verbal cues should facilitate many non-behavioral therapies. A 2 X 2 X
2 factorial experiment investigated the therapy-facilitating effects of
3 theoretical dimensions of non-verbal communication: Immediacy,
potency or status, and responsivity. A reenacted client-centered
therapy session was videotaped. Verbal content was held constant,
85
but all combinations of the 3 non-verbal dimensions were portrayed.

A total of 118 male and female non-participant observers rated the
therapist's interpersonal skills (empathy, warmth, and genuineness)
and effectiveness. The results disclosed that the non-verbal cues of
immediacy (close therapist-client distance and eye contact)
significantly improved ratings of the therapist's interpersonal skills
and effectiveness. Thus, the study demonstrated that a therapist's
non-verbal behavior is a basis for interpretations of empathy,
warmth, genuiness, and effectiveness. These findings were
interpreted in terms of the therapist's non-verbal cues
communicating liking and acceptance of the client (2).
The heath communication curriculum at the Trinidad campus of
the University of the West Indies was developed out of practices
advocated in large Western countries. Many students and tutors
observed that the non-verbal skills advocated in these approaches
did not fit the complex cultural dynamics of the Caribbean. A study
was developed to understand the problems Caribbean students faced
with these non-verbal communication practices. Thirty-six students
representing different Caribbean territories were randomly selected
from the 2 compulsory communication skills courses: Communication
Skills for Health Personnel and Communication Skills for the Health
Professions class list. These students participated in 4 focus group
discussions. The focus group discussions questions were formulated
on the non-verbal skills advanced in the Calgary-Cambridge Guide to
the doctor-patient interview. The findings supported the view that
recommended non-verbal skills were in conflict with expected
doctor-patient behavior in different Caribbean territories. Students
felt that non-verbal communication needed to be treated with
greater cultural sensitivity. These findings stimulated changes to the
health communication program (3).
Virtual Reality technology offers great possibilities for Cognitive
Behavioral Therapy of fear of public speaking: Clients can be exposed
to virtual fear-triggering stimuli (exposure) and are able to role-play
in virtual environments, training social skills to overcome their fear.
Usually, prototypical audience behavior (neutral, social and anti-
social) serves as stimulus in virtual training sessions, although there is
significant lack of theoretical basis on typical audience behavior. This
study deals with the design of a realistic virtual presentation
scenario. An audience (consisting of 18 men and women) in an
86
undergraduate seminar was observed during 3 frontal lecture

sessions. Behavior frequency of 4 non-verbal dimensions (eye
contact, facial expression, gesture, and posture) was rated by means
of a quantitative content analysis. Results show audience behavior
patterns which seem to be typical in frontal lecture contexts, like
friendly and neutral face expressions. Additionally, combined and
even synchronized behavioral patterns between participants who sit
next to each other (like turning to the neighbor and start talking)
were registered. The gathered data serve as empirical design basis
for a virtual audience to be used in virtual training applications that
stimulate the experiences of the participants in a realistic manner,
thereby improving the experienced presence in the training
application (4).
While non-verbal communication is an essential part of a
physician's interpersonal skills, it has attracted relatively little
attention in medical education. The aim of this study was to develop
a program for teaching non-verbal communication skills, and to
examine whether it would improve student's awareness and
performance of this communication. A total of 106 preclerkship
medical students were randomly assigned to 14 groups for a
communication skills training session before an OSCE. Five faculty
members served as session facilitators, of whom 3 provided the
original program (n=67) and 2 provided the non-verbal
communication intervention program (n=39). After the training
session, students wrote their goals for the OSCE medical interview,
which were analyzed for content. The student's performance of non-
verbal communication was evaluated based on the video recording of
the OSCE. Students in non-verbal communication group were
significantly more likely to write goals related to non-verbal
communication, but insignificant differences were found in the non-
verbal communication evaluations at the OSCE. In conclusion, the
intervention was effective in increasing student's awareness of non-
verbal communication, but it was insufficient to change the actual
performance (5).
Communication skills and the psychosocial dimensions of patient
care are currently considered core competencies in medical schools.
Communication skills programs have focused on verbal
communication rather than the non-verbal communication. The aim
of this study was to present a training program aimed to decode
87
patients' non-verbal clues for second year medical students

implemented at the School of Medicine of the Autonomous
University of Barcelona. This study included a description of a
theoretical framework, principles, general and specific goals, learning
settings, strategies, skills, and assessment tools. A model of training
for preclinical medical students in decoding patients' non-verbal clues
is shown. The students have shown satisfaction with the program. In
conclusion, the detection of patients' non-verbal clues can be
regarded as a humanistic skill that can be defined, trained, and
evaluated. The program can be transferable to other institutions on
health sciences and adapted to other academic levels or, even,
clinical specialties (6).
Physicians have been reported to have difficulty in communicating
with their patients. An element of this communication gap is
proposed be related to the educational curriculum and the selection
process of medical schools, in particular, with the emphasis on
scientific methodology reducing exposure to humanistic values. This
hypothesis was tested by measuring non-verbal receptive abilities in
2 groups. Thirty medical students were compared with 30 college
students who were not science majors but were age-, sex- and race-
matched. The nonscience majors were better at perceiving non-
verbal cues than medical students. Male nonscience majors had
higher scores than male medical students while similar results were
seen when female nonscience majors were compared with female
medical students. Finally, medical students planning to practice as
primary care specialists had higher scores than those interested in
specialties which do not involve direct or prolonged patient care (7).
This study examines the reliability and validity of the RCS-O using
a random sample of 80 videotaped interactions of medical students
interviewing SPs. The RCS-O is a 34-item instrument designed to
measure the non-verbal communication of physicians interacting
with patients. The instrument was applied and examined in 2
different interview scenarios. In the first scenario (year 1), the
medical student's interview objective is to demonstrate patient-
centered interviewing skills as the SP presents with a psychosocial
concern. In the second scenario (year 3), the student's interview
objective is to demonstrate both doctor-centered and patient-
centered skills as the SP presents with a case common in primary
care. In the year 1 scenario, 19 of the 34 RCS-O items met acceptable
88
levels of inter-rater agreement and reliability. In the year 3 scenario,

26 items met acceptable levels of inter-rater agreement and
reliability. Factor analysis indicated that in both scenarios each of the
4 primary relational communication dimensions was salient:
intimacy, composure, formality, and dominance. Measures of
correlation and differences involving the RCS-O dimensions and
structural features of the interviews (e.g., number of questions asked
by the medical student) are examined (8).
The objective of this study conducted in one US medical school
was to examine the relation of medical students' non-verbal
sensitivity to their gender and personal traits, as well as to their
communication and impressions made during a SP visit. This study
included 275 third-year medical students. The design included
psychometric testing, questionnaire, and observation. Non-verbal
sensitivity and attitudes were measured using standard instruments.
Communication during the SP visit was measured using trained
coders and analogue patients who viewed the videotapes and rated
the favorability of their impressions of the student. Non-verbal
sensitivity was higher in female than male students (p<0.001) and
was positively correlated with self-reported patient-centered
attitudes (p<0.01) and ability to name one's own emotions (p<0.05).
It was associated with less distressed (p<0.05), more dominant
(p<0.001), and more engaged (p<0.01) behavior by the SP, and with
more liking of the medical student (p<0.05) and higher ratings of
compassion (p<0.05) by the analogue patients. Correlations between
non-verbal sensitivity and other variables were generally stronger
and different for male than female students, but non-verbal
sensitivity predicted analogue patients' impressions similarly for male
and female students. In conclusion, medical students' non-verbal
sensitivity was related to clinically relevant attitudes and behavioral
style in a clinical simulation (9).
This study was designed to look at the challenges of SPs while in
role and to use the findings to enhance training methods. The study
investigated the effect of improvisations and multiple-task
performance on the ability of SPs to observe and evaluate another's
communication behaviors and its associated mental workload.
Twenty SPs participated in a 2 types of interview (with and without
improvisations)-by-2 types of observation (passive and active) within-
groups design. The results indicated that both active observations
89
and improvisations had a negative effect on the SP' ability to observe

the learner, missing more than 75% of non-verbal behaviors during
active improvisational encounters. Moreover, SPs experienced the
highest mental demand during active improvisational encounters. In
conclusion, the need to simultaneously portray a character and
assess a learner may negatively affect the ability of SPs to provide
accurate evaluations of a learner, particularly when they are required
to improvise responses, underscoring the need for specific and
targeted training (10).
Significant information exchange occurs between a doctor and
patient through non-verbal communication such as gestures, body
position, and eye gaze. In addition, empathy is an important trust-
building element in a physician: patient relationship. Previous work
validates the use of VPs to teach and assess content items related to
history-taking and basic communication skills. The purpose of this
study was to determine whether more complex communication skills,
such as non-verbal behaviors and empathy, were similar when
students interacted with a VP or SP. Medical students (n=84) at the
University of Florida and the Medical College of Georgia underwent a
videotaped interview with either a SP or a highly interactive VP with
abdominal pain. In the scenario, a life-sized VP was projected on the
wall of an examination room in SP teaching and testing centers at
both institutions. VP and SP scripted responses to student questions
were identical. To prompt an empathetic response (i.e.,
acknowledging the patients' feelings), during the interview the VP or
SP stated "I am scared; can you help me?" Clinicians (n=4) rated
student videotapes with respect to nonverbal communication skills
and empathetic behaviors using a Likert-type scale with anchored
descriptors. Clinicians rated students interacting with SPs higher with
respect to the nonverbal communication skills such as head nod (2.78
+/- .79 vs. 1.94 +/- .44, p<0.05), body lean (2.97 +/- .94 vs. 1.93 +/-
.58, p<0.05), level of immersion in the scenario (3.31 +/- .49 vs. 2.26
+/- .52, p<0.05), anxiety (1.16 +/- .31 vs. 1.45 +/- .33, p<0.05),
attitude toward the patient (3.24 +/- .43 vs. 2.89 +/- .36, p<0.05), and
asking clearer questions (3.06 +/- .32 vs. 2.51 +/- .32, p<0.05)
compared with the VP group. The students in the SP group also had a
higher empathy rating (2.75 +/- .86 vs. 2.16 +/- .83, p<0.05) and
better overall rating (4.29 +/- 1.32 vs. 3.24 +/- 1.06, p <0.05) than the
VP group. Empathy was positively correlated with the observed non-
90
verbal communication behaviors. Eye contact was the most strongly

correlated with empathy (p<0.001), followed by head nod (p<0.001),
and body lean (p<0.001). In conclusion, medical students
demonstrate non-verbal communication behaviors and respond
empathetically to a VP, although the quantity and quality of these
behaviors were less than those exhibited in a similar SP scenario.
Student empathy in response to the VP was less genuine and not as
sincere as compared to the SP scenario. While we will never duplicate
a real physician/patient interaction, virtual clinical scenarios could
augment existing SP programs by providing a controllable, secure,
and safe learning environment with the opportunity for repetitive
practice (11).
This study examined the accuracy rate of judging non-verbal skills
used by nursing students in communicating with patients. Self-ratings
of the students were compared with composite instructor ratings to
find areas of disagreement regarding the quality of the non-verbal
skills. Students who rated their non-verbal acuity higher than the
instructors and students who rated their non-verbal acuity lower
than the instructors were parceled out of the total sample of 92
senior nursing students enrolled in a baccalaureate program. Non-
verbal acuity was measured by asking subjects to identify non-verbal
information about emotional states from pictures. A November
Picture Test consisting of 120 pictorial items was utilized as the
dependent variable. Results showed that almost one-half of the
sample disagreed with the instructor rating applied to their non-
verbal skills with patients. The differences between the groups was
significant at the 0.05 level and the students were accurate in
designating the direction of difference (12).
Speech anxiety training may help subjects improve their skills on
keeping audiences interested in the speech and on managing calm or
restless audiences. Attention and lack of attention during speeches
are displayed through several non-verbal cues. Such and other non-
verbal behaviors can also spread throughout a group and engage
whole audiences. The current study is an inquiry into the non-verbal
markers of attention and lack of attention during lectures (e.g. note
taking, eye gaze towards the speaker, and conduct with electronic
devices such as mobile phones or laptops). Additionally, the study
tries to identify non-verbal behaviors that are diffused and their
spatial and time diffusion characteristics. Thirty-seven university
91
students at the Ilmenau University of Technology have been

observed during a 40-minutes lecture. A quantitative content analysis
is conducted to identify patterns of behaviors depicting attention and
inattention. Afterwards a qualitative content analysis is carried out to
identify contagious behaviors and their spreading characteristics.
These findings are used to design virtual audiences whose members
react with each other or display observable audience responses and
will be implemented into training scenarios for training university
students against speech anxiety (13).
An increasing number of medical schools have introduced
undergraduate programs in the social sciences in an attempt to
improve the ability of their graduates to communicate with patients
and to meet their needs. However, teaching programs in the social
sciences have often encountered varying degrees of student
resistance, possibly because of their uncertain relevance for clinical
practice, incongruity with the biomedical model, teachers' attitudes,
and poorly defined educational goals. The objective of this essay is to
analyze the causes of students' resistance to the social sciences and
to identify the features of a teaching program responsive to their
needs (14).
Assessment: communication skills and the psychosocial

dimensions of patient care are currently considered core
competencies in medical schools. Non-verbal communication is an
essential part of a physician's interpersonal skills, and it has attracted
attention in medical education. An increasing number of medical
schools have introduced undergraduate programs in the social
sciences in an attempt to improve the ability of their graduates to
communicate with patients and to meet their needs.
References
1. Courteille O, Josephson A, Larsson LO. Interpersonal behaviors and
socioemotional interaction of medical students in a virtual clinical
encounter. BMC Med Educ. 2014 1;14(1):64.
2. Sherer M, Rogers RW. Effects of therapists nonverbal communication
on rated skill and effectiveness. J Clin Psychol. 1980;36(3):696-700.
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Caribbean medical school: "Touch is a touchy issue". Teach Learn Med.
2013;25(1):39-46.
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4. Poeschl S, Doering N. Designing virtual audiences for fear of public

speaking training - an observation study on realistic nonverbal behavior.
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communication skills be taught? Med Teach. 2010;32(10):860-3.
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during improvisations. Simul Healthc. 2013;8(4):207-14.
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nursing students. J Nurs Educ. 1977;16(3):5-11.
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and listen? Stud Health Technol Inform. 2013;191:120-4.
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students. Isr J Med Sci. 1996;32(3-4):217-21.
93
SUMMARY
Non-verbal communication is an important human characteristic.
In order to maintain relationships effectively humans must
communicate with each other. In everyday life, there are many types
of communication including with work colleagues, family, neighbors,
and friends, some efficient and some inefficient.
This research deals with biblical verses: "He who guards his
mouth and his tongue keeps his soul from troubles" (Proverbs 21:23),
and "I will keep a curb on my mouth, while the wicked man is before
me" (Psalms 39:2).
Communication is defined as the exchange information, or the use
of common system of symbols, signs, behavior for this; a verbal or
written message; a system of routes; techniques for the effective
transmission of information, ideas, etc. Communication also transfers
information from one person to another. Non-verbal communication
is defined as not involving words of speech: voluntary or involuntary
non-verbal signals, such as smiling or blushing.
Verses described above show that non-verbal communication is
an essential part of human existence. These verses have a wide
range of implications for our everyday. Since the author of this
research is a medical doctor, studying Medicine in the Bible, it is
natural that this study concentrates mainly on non-verbal
communication in a variety of medical situations. How can we deal
with these verses in our everyday life?
Non-verbal communication includes: physical communication:
smell, salute, posture and other bodily movements, pause (silence);
facial expressions: raising eyebrows, yawning, sneering, rolling eyes,
gaping, a smile, wink, frown and nodding; gestures: waving, pointing,
and using fingers to indicate numeric amounts; paralinguistics such
as vocal communication, separate from actual language, including
tone of voice, loudness, inflection and pitch; proxemics: the need for
"personal space"; eye gaze: looking, contact, staring and blinking;
haptics: communication through touch; appearance: choice of color,
clothing, hairstyles and other factors affecting appearance; aesthetic
communication: creative expression: music, dance, theatre, crafts,
art, painting, and sculpture; signs: signal flags or lights, a 21-gun
salute, a display of airplanes in formation, horns, and sirens; symbols:
jewelry, cars, and clothing.
94
Non-verbal behavior holds significance for the therapeutic

relationship and influences important outcomes including
satisfaction, adherence, and clinical outcomes of care.
Some emotions are communicated predominantly through
different non-verbal channels. The body channel promotes social-
touch supports intimate emotions. Anger, fear, disgust, love,
gratitude, and sympathy are decoded at greater than chance levels,
as well as happiness and sadness, 2 emotions that have not been
communicated by touch to date. In addition, expressive touch
improves interactions between GPs and patients.
The skilled use of non-verbal communication through silence,
facial expression, touch and closer physical proximity facilitates active
listening and helps to develop empathy, and intuition between the
nurse and patient.
Listening is conceptualized as a functional relation between the
responding of an organism and the stimulating of an object.
Understanding is conceptualized as seeing, hearing, or otherwise
reacting to actual things in the presence of their "names" alone.
Listening involves subvocal verbal behavior. Some of the forms and
functions of the listener's verbal behavior include echoic and
intraverbal behavior. There may be no functional distinction between
speaking and listening.
High second-language proficiency protects against the effects of
reverberation on listening comprehension.
Race plays a role in non-verbal communication. Any discomfort
that appears in non-verbal behavior stems not from negative
attitudes per se but from discordance between automatically
activated attitudes toward Blacks and the specific evaluations.
Discordance between general racial attitudes and evaluations of
specific targets is manifested in discomfort-related non-verbal
behavior.
The value of verbal and non-verbal communications to identifying
leaders varied with the type of leadership hierarchy. Non-verbal
communication and modality of presentation had a significant effect
on perception of leadership. Non-verbal cues should be seen as
essential in impression-formation.
95
Non-verbal behaviors such as head nodding, forward lean, direct

body orientation, uncrossed legs and arms, arm symmetry, eye gaze
and proximity are associated with higher patient satisfaction.
Patients are most satisfied with female physicians who behave in
line with the female gender role (e.g., more gazing, more forward
lean, and softer voice) while still stressing their professionalism
(laboratory coat, and medically-looking examination room). For male
physicians, satisfaction is high for a broader range of behaviors,
partly related to their gender role such as louder voice, and more
distance to patient.
Non-verbal communication is an important factor by which
patients spontaneously describe and evaluate their interactions with
a GP. Empathy, the ability to communicate an understanding of a
client's world, is a crucial component of all relationships. The
empathy of practitioners, as perceived by patients, has a direct
impact on patient enablement and health outcome. The patients'
perceptions of the doctors' empathy is of key importance in patient
enablement in general practice consultations in both high and low
deprivation settings.
TBI patients have particular difficulty recognizing non-verbal
communication resulting from vocal intonations. These patients have
difficulty processing tonality, therefore, clinicians, friends, and family
members should emphasize the explicit verbal content of spoken
language when speaking to a person with TBI.
Verbal and non-verbal communication should be equally assessed
in patients with communication difficulties; highlighting distortions in
the people.
In Alzheimer's disease, non-verbal behaviors such as looks, head
nods, hand gestures, body posture or facial expression provide a lot
of information about interpersonal attitudes, behavioral intentions,
and emotional experiences. They play an important role in the
regulation of interaction between individuals. Non-verbal
communication is effective in Alzheimer's disease even in the late
stages. Patients still produce non-verbal signals and are responsive to
others. If non-verbal vocalization such as utterances and responses
in interaction are treated as if they are meaningful, they will become
meaningful.
96
In Slovenia, older people in old people's homes communicate less

frequently with hand gestures and trunk movements than with face
expressions and head movements or different modes of speaking and
paralinguistic signs. Positive attitude, non-verbal communication
among caregivers in nursing homes needs to become one of the most
important contents of their life-long learning and training.
A technologist can respond with the words, touch, or facial
expression that will let the patient know that he is a human being
and his needs are understood and are being responded to with
empathetic concern.
An understanding of communication practice might help enhance
dietitian-patient relations. Dietitian dress style is implicated in non-
verbal communication dialogues between the dietitian and client.
Ethology may contribute significantly to the development of more
accurate and valid methods for measuring the behavior of persons
with mental disorders. Ethology, as the evolutionary study of
behavior, may provide psychiatry with a theoretical framework for
integrating a functional perspective into the definition and clinical
assessment of mental disorders.
Listening, sharing understanding and facilitating consumer, family
and community empowerment through a priority driven partnership
in Far North Queensland becomes possible when there is a concerted
effort to strengthen grassroots community organizations.
Psychiatrist and depressed patient communicate by a biomedical-
centered cluster that emphasizes biomedical questions and
education or counseling and a patient-centered cluster that focuses
on psychosocial, lifestyle questions, and information giving. The
patient-centered cluster is associated with patients' expression of
distress, anger, or other negative effects.
In communications coming from the unconscious of the patient is
the hardest task that must be mastered to become truly empathic
and sensitive in dyadic relationships, a unique expertise that marks
the psychiatrist as a genuine specialist in medical practice.
In psychotherapy, use is made of both verbal and non-verbal
variants of communications between the psychotherapist and the
patient. Non-verbal communication can successfully be used not only
in psychotherapy but also in psychodiagnosis and psychotherapy.
Non-verbal behavior plays a significant role in establishing the
therapeutic alliance in any patient-physician interaction. In
97
psychotherapy settings, it is critically important to the formation of

rapport between the patient and psychiatrist.
Changes in a patient's baseline general appearance and behavior,
affect, eye contact, and psychomotor functioning from session to
session allow the psychiatrist to gather important information about
the patient. Much emphasis is placed on listening to what patients
communicate verbally and observing their interactions with the
environment and the psychiatrist. In a complimentary fashion,
psychiatrists must be aware of their own non-verbal behaviors and
communication, as these can serve to either facilitate or hinder the
patient-physician interaction.
There are non-verbal behaviors that produce information about
the patient. One should take notice of where the patient chooses to
sit, posture during the interview, whether eye contact is maintained,
and how the patient reacts to interpretations beyond simple verbal
acknowledgment.
For the specific event, therapists can use silence to facilitate
reflection, encourage responsibility, facilitate expression of feelings,
not interrupt session flow, and convey empathy. During silence,
therapists observe the client, think about the therapy, and convey
interest. The therapist can use silence to communicate safety,
understanding and containment.
The effects of adult word count are significant when included
alone but are partially mediated by adult-child conversations.
Television viewing alone is significant and negative fully mediated by
the inclusion of adult-child conversations.
The poorer imitative performance of the specific language delay in
children is not explained by motor or non-verbal cognitive skills. The
nature of the task affects children's imitation performance. There is
utility of verbal-nonverbal correspondence-training techniques in
outpatient pediatric settings.
Non-verbal communication has a significant effect on error
disclosure outcomes and thus should be considered. Non-verbal
involvement during medical error disclosures facilitates more
accurate patient understanding and assessment of the medical error
and its consequences on their health and QOL. Non-verbal
involvement increases the likelihood that physicians will be able to
continue caring for their patient.
98
Nurses' verbal listening activities, such as reflection, their non-

verbal involvement activities, and their simultaneous coordination of
non-verbal involvement activities with those of the patient predict
relational information dimensions of trust/receptivity,
depth/similarity/affection, composure, and non-formality.
Nurses use mainly eye gaze, head nodding and smiling to establish
a good relation with their patients. The use of affective touch is
mainly attributable to nurses' personal style. Compared to nurses in
the community, nurses in the home for the elderly more often
display non-verbal behaviors such as patient-directed gaze and
affective touch.
Most nurses are aware of the importance of non-verbal
communication to their interactions with palliative care patients, but
a substantial proportion think that they need to be better educated
in theoretical and practical aspects of communication.
communication challenges in health care delivery. The IEN' non-
verbal behaviors in areas such as hugging, lowering body position to
patient's level, leaning forward, shaking hands, and therapeutic touch
have place for improvement. Targeted interventions focusing on
norms and expectations of non-verbal behaviors in the US health
care setting are called for to improve quality of care.
This research indicates that non-verbal communication relates to
many issues. The wisdom of verses "He who guards his mouth and
his tongue keeps his soul from troubles" (Proverbs 21:23), and "I will
keep a curb on my mouth, while the wicked man is before me"
(Psalms 39:2) should accompany humans and especially HCPs in their
everyday life.
99
ABBREVIATIONS
ADHD Attention deficit hyperactivity disorder
CARE Consultation and Relational Empathy
ED Emergency department
GHQ General Health Questionnaire
GP General practitioner
HCP Health care professional/provider
HIV Human immunodeficiency virus
IEN Internationally educated nurses
IQR Interquartile range
L1 First language
L2 Second language
MRI Magnetic resonance imaging
MYMOP Measure Yourself Medical Outcome Profile
NAAS Non-verbal Accommodation Analysis System
OSCE Objective structured clinical examination
PEI Patient enablement instrument
QOL Quality of life
RCS-O Relational communication scale for
observational measurement
RIAS Roter Interaction Analysis System
RNID Registered Nurses Intellectual Disability
SD Standard deviation
SP Standardized patient
TBI Traumatic brain injury
VCE Virtual clinical encounter
VP Virtual patient
WMC Working memory capacity
The author has requested enhancement of the downloaded file. All in-text references underlined in blue are linked to publications on ResearchGate.

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NON-VERBAL

Medical Research in Biblical Times

About the Author

NOT FOR SALE

Ben-Gurion University of the Negev,

Fax: +(972) 8 6883376 Mobile 050 5971592

Technical Assistance: Carmela Ben-Nun-Moshe.

All rights reserved

NOT FOR SALE `

L. Ben-Nun Non-verbal communication skills

MEDICINE IN THE BIBLE

L. Ben-Nun Non-verbal communication skills

These are scientific medical studies incorporating verses from the

Fundamentally, this Research is constructed purely from an

The research is part of a long series of published studies on the

This is not a laboratory research. The Research is built entirely on

L. Ben-Nun Non-verbal communication skills

L. Ben-Nun Non-verbal communication skills

interpersonal relationships are affected by intervening variables. The

L. Ben-Nun Non-verbal communication skills

decades, caring, compassionate, and healing doctors remain the best

L. Ben-Nun Non-verbal communication skills

L. Ben-Nun Non-verbal communication skills

non-verbal behavior and physician-older patient communication,

L. Ben-Nun Non-verbal communication skills

5. Ben-Nun L. Verbal communication as described in the Bible. Research

THE BIBLICAL VERSES

L. Ben-Nun Non-verbal communication skills

L. Ben-Nun Non-verbal communication skills

regulate interactions (non-verbal cues covey when the other person

L. Ben-Nun Non-verbal communication skills

oncology consultations. Cases were then placed in 1 of 7 categories

L. Ben-Nun Non-verbal communication skills

Facial expressions are responsible for a huge proportion of non-

L. Ben-Nun Non-verbal communication skills

someone attempts to conceal by voluntarily displaying another

L. Ben-Nun Non-verbal communication skills

examined. Whether non-verbal social cues are uniquely suited to

L. Ben-Nun Non-verbal communication skills

L. Ben-Nun Non-verbal communication skills

change itself. This question will guide research on gesture as we

L. Ben-Nun Non-verbal communication skills

L. Ben-Nun Non-verbal communication skills

inches to 4 feet. On the other hand, the personal distance needed

L. Ben-Nun Non-verbal communication skills

SIGNS AND SYMBOLS OF COMMUNICATION

Assessment: an estimated 60 to 65 percent of interpersonal

L. Ben-Nun Non-verbal communication skills

blinking; haptics: communication through touch; appearance: choice

L. Ben-Nun Non-verbal communication skills

15. Yamamoto K, Suzuki N. The effects of personal relationships on facial

L. Ben-Nun Non-verbal communication skills

L. Ben-Nun Non-verbal communication skills

Assessment: non-verbal behavior is significant for the therapeutic

L. Ben-Nun Non-verbal communication skills

procedure/examination). The aim of this study was to explore GPs'

Assessment: anger, fear, disgust, love, gratitude, and sympathy

L. Ben-Nun Non-verbal communication skills

LISTENING AND COMPREHENSION

L. Ben-Nun Non-verbal communication skills

The activities involved in mediating reinforcement for a speaker's

L. Ben-Nun Non-verbal communication skills

In conversation, women have a small advantage in decoding non-

L. Ben-Nun Non-verbal communication skills