Excerpts from Must Read Books & Articles on
Mental Health Topics
Books, Part XXII
Psychiatric Interviewing: The Art of Understanding
Shawn Christopher Shea, M.D.
Chapter 3- Nonverbal Behavior: The Interview as Mime
"And now a dark cloud of seriousness spread over her face. It
was indeed like a magic mirror to me. Of a sudden her face bespoke
seriousness and tragedy and it looked as fathomless as the hollow
eyes of a mask."
Herman Hesse, Steppenwolf
In this chapter we will explore the intricate processes known as
nonverbal behavior. Few studies are more intriguing or more pertinent
for the clinician. Our study will include not only body movements
but also those elements of verbal communication that are concerned
not with the content of spoken word but with how the words are spoken.
Indeed, the noted social scientist Edward T. Hall has commented that
communication is roughly 10% words and 90% a "hidden cultural
grammar." He continues, "In that 90% is an amalgam of feelings,
feedback, local wisdom, cultural rhythms, ways to avoid confrontation,
and unconscious views of how the world works. When we try to communicate
only in words, the results range from the humorous to the destructive."(1)
The practical relevance of Hall's words
can be readily seen in the following clinical vignette. During an
afternoon of supervision, I had the opportunity to watch two interviewers
interact with the same patient in back-to-back interviews. The patient,
a male in his early twenties, sat with a slumped posture, his head
seemingly pulled to his chest by an invisible chain. His legs were
open, and his hands lay resting quietly on his lap. The interviewer
was a young woman, who spoke in a quiet but persistent voice. The
blending between the two was weak at best, provoking an occasional
upward nod from the patient, rewarding the starved interviewer with
a momentary scrap of interest.
When the second interviewer entered
the room, an intriguing process unfolded. Within 5 minutes the patient
sat more alertly in his chair. Eye contact improved significantly
and was accompanied by actual animation, albeit mild, in his voice.
By the end of the interview, the conversation was proceeding naturally,
and a reasonably good therapeutic alliance had been formed. Both interviewers
were relatively young women, both of whom conveyed a caring attitude.
One wonders what factors resulted in the clearly more powerful blending
of the second interview.
Some of the answers may lie in the communication
channels each of these interviewers used in an effort to engage the
patient. The first interviewer spoke in a quiet tone of voice intermixed
with numerous nods of her head. Such head nodding frequently appears
to facilitate interaction. Unfortunately, visual cues lose their impact
if the patient refuses to look at the clinician. In short, her facilitatory
efforts were on the wrong sensory channel. To the contrary, the second
interviewer spoke in a more lively tone of voice, which appeared to
perk the patient's attention. More important, her words were frequently
punctuated with auditory facilitators such as, "uh huh"
and "go on." In contrast, the first interviewer verbalized
few such auditory facilitators. The patient had been stranded in the
room, responding with detachment to the clinician's monotone voice.
Like the first clinician, the second interviewer also utilized head
nodding, but her nods became progressively more effective as the patient
met her eyes more frequently.
This example demonstrates the usefulness
of flexibly employing different communication channels depending on
the receptiveness of the patient. If the patient's head is down, one
can increase the number of facilitatory vocalizations. With a deaf
patient, one can increase head nodding. Perhaps more important this
example emphasizes the overall influence of the interviewer's nonverbal
communication on the patient. It suggests that we may be able to consciously
alter our nonverbal style in an effort to create a specific impact
on the patient.
This fact brings us to one of the most
important challenges of this chapter. In order to flexibly alter their
styles, interviewers must become familiar with the baseline characteristics
defining their own styles. From such a self-understanding, flexibility
Thus a study of nonverbal behavior provides
two distinct avenues of exploration. First, as the opening quotation
from Steppenwolf suggests, one can learn an immense amount
about the patient by studying nonverbal cues. This aspect of nonverbal
behavior is the most commonly acknowledged. Hesse's protagonist quickly
perceives his companion's change of affect as "a dark cloud of
seriousness spread over her face." Second, as our clinical vignette
illustrates, one can discover the impact of one's own nonverbal behavior
on the patient and subsequently alter it as deemed appropriate.
Before proceeding it may be expedient
to examine the definition of nonverbal behavior, for this term can
have different meanings. In their excellent book, Nonverbal Communication:
The State of the Art, Harper, Wiens, and Matarazzo explore some
of the ramifications of defining this term.(2) In the first place,
it is of value to make a distinction between the terms nonverbal communication
and nonverbal sign. Nonverbal communication consists of an actual
attempt to communicate a message using an accepted code between an
encoder and a decoder.(3) A nonverbal sign does not involve an attempt
at communication but represents a nonverbal behavior to which the
observer infers a meaning.
Although developed as a refinement of
research theory, this distinction between nonverbal communications
and nonverbal signs can be adapted to provide a sound background through
which to discuss clinical work. Specifically, in this book nonverbal
behavior is viewed as the general category of all behaviors displayed
by an individual other than the actual content of speech. In this
context, tone of voice and the pacing of speech are also considered
as examples of nonverbal behavior.
This broad category of nonverbal behavior
can then be split into two subcategories, nonverbal communications
and nonverbal activities. In the first category, nonverbal communications,
the patient is using a commonly accepted symbol associated with a
specific meaning. An irate football fan "throwing the finger"
to the quarterback of the visiting team is displaying a piece of rather
vivid nonverbal communication. In the second category, nonverbal activities,
the overt behavior does not have a single commonly agreed upon meaning,
and the sender may not be consciously trying to convey a message.
The act of chain smoking cigarettes would represent a nonverbal activity.
This activity may indeed be usefully interpreted by the observer as
having a meaning, perhaps indicating anxiety; however, this interpretation
is inferred and may be wrong. In short, nonverbal activities may have
As clinicians we are interested in attempting
to understand the significance of both nonverbal communications and
nonverbal activities. It is important to keep in mind that nonverbal
activities are generally multiply determined. It seems unwise to begin
assuming that one "knows" exactly what any given activity
means. In this regard Wiener and associates criticized some psychoanalytically
oriented researchers as immediately positing unwarranted unconscious
meanings to nonverbal activities.
Considering this context one is reminded
of the old psychoanalytic saw in which the astute clinician observes
that the patient is experiencing severe marital discord because the
patient is playing with her wedding band. Such interpretations of
nonverbal activities are invaluable if kept in perspective. The clinician
needs to think about other possible causes of the stated activity.
For instance, this patient may be playing with her wedding band because
she feels intimidated by the interviewer. She releases her anxiety
by playing with objects in her hands. Normally she rolls a pencil
back and forth, but because no pencil is available, she twists her
ring. Other interpretations may be equally correct. To ignore these
other possibilities while assuming the marriage is troubled is to
ignore sound clinical judgment. On the other hand, having considered
the various possibilities, the experienced clinician may gently probe
to sort out which is correct and may indeed uncover marital discord.
From this discussion, the following
general principle emerges. Nonverbal communications are relatively
easily deciphered, whereas nonverbal activities should be cautiously
interpreted, because more than one process may be responsible for
the behavior. This point deserves emphasis because both clinical literature
and popular literature sometimes read as if the authors felt that
they knew the exact meanings of nonverbal activities. They imply that
one can read a person like a book. In a similar vein, the concept
of "body language" suggests that nonverbal activities are
more codified than behavior actually is.
A similar element of caution emerges
as one surveys the research concerning nonverbal behavior. The body
of research appears both vast and promising, but there exist many
limitations. Nonverbal interactions are so complex that it remains
difficult to successfully isolate variables to study. For instance,
suppose research was designed to prove that it was the paralanguage
(how the words were said) of the second interviewer in our clinical
vignette that directly increased blending. An attempt to isolate this
single variable would prove difficult, for a variety of other variables
could have had an impact, such as the interviewer's physical attractiveness,
the distance between seats, and even the fact that there were two
Even when one successfully isolates
the relevant variables, the very act of isolation poses serious problems.
Nonverbal elements seldom function as isolated units.(4) Instead,
the various nonverbal elements exert their influences jointly, making
the findings of research based on single channels such as paralanguage
or eye gaze somewhat artificial. A different approach, the functional
approach, attempts to study the various nonverbal elements as they
function in unison.
These research issues are worth mentioning
because it is important for the clinician to realize that little knowledge
exists on nonverbal activity that can be called "factual."
It is safe to say that this body of exciting research is in its childhood.
In this regard the material of this chapter is best viewed as opinion
concerning an evolving craft or art. The subsequent material is culled
from a variety of sources, including clinical work, supervision, research
literature, personal communications, and even popular literature (5)
if it seems to shed light on clinical issues.
The following chapter is divided into
two sections. In the first section three of the main categories of
nonverbal behavior are briefly surveyed. As with the previous chapter,
we shall develop a practical language through which to study the phenomena
in question. Specifically, the following three areas are addressed:
1- proxemics (the study of the use of space), 2- kinesics (the study
of body movement), and 3- paralanguage (the study of how things are
In the second section we shall adopt
a functional perspective, carefully investigating the interplay of
these three areas as applied to clinical practice. The broad clinical
tasks studied include assessing the nonverbal behaviors of patients,
actively engaging patients, persuading and focusing patients, and
calming hostile patients.
BASIC PRINCIPLES OF NONVERBAL BEHAVIOR-
Edward T. Hall was quoted at the beginning of the chapter. Few people
would be more suitable for introducing the topic of nonverbal behavior,
because Hall literally coined the term "proxemics." It was
in his book The Hidden Dimension that he defined proxemics
as "the inter-related observations and theories of man's use
of space as a specialized elaboration of culture."(6)
Proxemics deals with the manner in which
people are affected by the distances set between themselves and objects
in the environment, including other people. As Hall notes, humans,
like other animals, tend to protect their interpersonal territories.
As humans move progressively closer to one another, new feelings are
generated and new behaviors are anticipated. Hall postulates that
people learn specific "situational personalities" that interact
with the core traits of the individual, depending on the proximity
of other individuals. This set of expected behaviors and feelings
can be used by the clinician to improve blending. By observing the
patient's use of space, the clinician may even uncover certain diagnostic
Hall delineated four interpersonal distances:
1- intimate distance, 2- personal distance, 3- social distance, and
4- public distance. With each of these distances different sensory
channels assume various levels of importance.
At the intimate distance (zero to 18
inches), the primary sensory channels tend to be tactile and olfactory.
People feel at home with the specific scents they associate with lovers
and children. At these close distances, thermal sensations also play
a role, especially when making love or cuddling. Visual cues are of
diminished importance. In fact, at the intimate distance, most objects
become blurred unless specific small areas are focused upon. Voice
is used sparingly. Even whispered words can sometimes create the sensation
of more distance.
As one moves to the personal distance
(1'/z feet to 4 feet), kinesthetic cues continue to be used but olfactory
and thermal sensations diminish in importance. With their decline
the sense of sight begins to assume more importance, especially at
the further ranges of this interpersonal space.
Upon arriving at the social distance (4 to 12 feet), we have reached
the region where most face-to-face social interchange occurs. Touch
is less important, and olfactory sensations are markedly less common.
This region is the playland of the voice and the eyes. Most conversations
and interviews unfold within the range of 4 to 7 feet. At the public
distance (12 feet or more), vision and audition remain the main channels
of communication. Most important, as people move further and further
away, they tend to lose their individuality and are perceived more
as part of their surroundings.
A respect for these spaces is of immediate
value to the initial interviewer. In general, people seem to feel
awkward or resentful when strangers, such as initial interviewers,
encroach upon their intimate or personal space. With this idea in
mind it is probably generally best to begin interviews roughly 4 to
6 feet away from the patient. If an interviewer is by nature extroverted,
by habit the interviewer may sit inappropriately close to the patient,
intruding upon the patient's personal space. Obviously such a practice
can interfere with blending and should be monitored.
It should be kept in mind that patients
do not determine a sense of interpersonal space by slapping yardsticks
down between themselves and clinicians. As observed by Hall, it is
the intensity of input from various sensory channels that creates
the sensation of distance. An interviewer with a loud speaking voice
may be invading a patient's personal space even when seated at 6 feet.
Once again clinicians must examine their own tendencies in order to
determine how they come across to patients.
To emphasize the point that it is sensory
input, not geographic distance, that determines interpersonal space,
one need only consider the impact of a patient who seldom bathes.
Such patients frequently create a sense of resentment, because, in
essence, olfactory sensations are supposed to occur only at intimate
and personal distances. These patients invade the intimate space of
those around them even when seated at a distance. The same principle
can explain why even pleasant odors such as perfume can also be resented
if they are too strong.
If a clinician intrudes into a patient's
personal space, the clinician can set into motion the same awkward
feelings and defenses commonly encountered in elevators. The artificial
intimacy created by invading the patient's space results in a shutdown
of interactive channels, so as not to further the intimate contact.
Like a person in an elevator the patient will avoid eye contact and
move as little as possible. The patient's uneasiness may even predispose
the patient to decreased conversation. In effect, the clinician might
just as well be conducting the interview on an elevator, hardly the
image of an ideal office. This "elevator effect" can also
occur if the clinician ignores cultural differences.
Hall's distances were determined primarily
for white Americans. These distances may vary from culture to culture.
One piece of research found that Arab students spoke louder, stood
closer, touched more frequently (7) and met the eyes of fellow conversants
more frequently. Sue and Sue relate that Latin-Americans, Africans,
and Indonesians like to converse at closer distances than do most
Anglos.(8) They go on to describe that when interviewing a LatinAmerican,
an interviewer may push away, because the situation may feel crowded.
Unfortunately this need for distance by the clinician could be perceived
as an element of coolness or indifference by the client. In a similar
light, the clinician may make the mistake of immediately feeling that
the client is socially invasive, when in reality the client is merely
interacting at the appropriate distance for Latin-American culture.
Race may also play a role during the
interview. Research suggests that African-Americans may prefer greater
distances than Caucasians.(9) Moreover, Wiens discusses the finding
that the sexes of the participants can affect the preference for interpersonal
distance.(10) One study demonstrated that male-female pairs sat the
closest, followed by female-female pairs. Male-male pairs sat the
Kinesics is the study of the body in movement. It includes "gestures,
movements of the body, limbs, hands, head, feet, and legs, facial
expressions (smiles), eye behavior (blinking, direction and length
of gaze, and pupil dilation) and posture.(11) In short, kinesics is
the study of how people move their body parts through space with an
added attempt to understand why such movements are made. As a field,
it is a natural companion to proxemics. Like proxemics, it had its
own avatar of sorts, Ray T. Birdwhistell, who first elaborated his
work in 1952 with the book Introduction to Kinesics: An Annotation
System for Analysis of Body Motion and Gesture.(12)
Birdwhistell is an anthropologist and
emphasized understanding body movements in the context of their occurrence.
He also pioneered the study of videotapes in an effort to decipher
the subtle nuances of movement. Through his microanalysis he attempted
to define the basic identifiable units of movement. For instance,
he coined the word "kine" to represent the basic kinesic
unit with a discernible meaning.(13)
Albert Scheflen, a student of Birdwhistell's,
expanded these notions to the study of broad patterns of kinesic exchange
between people. In this context Scheflen postulated that kinesic behavior
frequently functions as a method of controlling the actions of others.(14)
By way of example, hand gestures and eye contact may be used to determine
who should be speaking at any given moment in a conversation.
Kinesics plays a role in all interviews.
Specific activities may shut down or facilitate the verbal output
of any given patient. Besides yielding information that may help the
clinician to foster engagement, the study of kinesics can provide
valuable insights into the feelings and thoughts of patients. Freud
phrased it nicely when he stated, "He that has eyes to see and
ears to hear may convince himself that no mortal can keep a secret.
If his lips are silent, he chatters with his fingertips; betrayal
oozes out of him at every pore.(15)
The study of paralanguage focuses on how messages are delivered. It
may include elements such as tone of voice, loudness of voice, pitch
of voice, and fluency of speech.(16) The power of paralanguage is
immense and popularly acknowledged. Phrases such as, "It's not
what you said, but the way you said it that I don't like," are
considered legitimate complaints in our society. One can easily picture
John Wayne snarling out such a phrase to some unruly bandit. Moreover,
actors and comedians are well aware of the power of timing and tone
of voice as it impacts upon the meaning of a statement.
By way of illustration, the phrase "that was a real nice job
in there" appears complimentary at first glance. But one cannot
determine its meaning unless one hears the tone of voice used in its
conveyance. It could be far from pleasant if it was said with a sarcastic
sneer by a displeased supervisor following an interview observed via
a one-way mirror.
Besides the tone of the voice, speech
is characterized by a number of other vocalizations. Although not
words per se, vocalizations can play an important role in communication.
One set of vocalizations consists of "speech disturbances."(17)
Under the heading of flustered or confused speech, these disturbances
include entities such as stutters, slips of the tongue, repetitions,
word omissions, and sentence incompletions, as well as familiar vocalizations
such as "ah" or "uhm." Such disturbances occur
roughly one time for every 16 spoken words. As would be expected,
under stressful conditions these disturbances increase significantly.
Thus they can serve to warn the clinician of patient anxiety as the
There is more to vocalizations than
just their appearance or lack of it. Some vocalizations serve to enhance
blending, as seen with the frequently used facilitatory statements
"uh-huh" and "go on." But once again the way in
which these vocalizations are used can significantly alter their effectiveness,
as shown in the following vignette.
The interviewer in question possessed
a pleasant and upbeat personality. He was a caring clinician, but
he found patients shutting down at times during his interviews. Videotape
analysis revealed an interesting phenomenon. As he listened to patients,
he frequently interspersed his silences with the vocalization "uh-huh."
His "uhhuhs" were said quickly with a mild sharpness to
his voice as if chopping off sausages. He also used vocalizations
such as "yep" and "yea," also stated with a curt
tone of voice.
The net result was the creation of the
feeling that he was in a hurry, wanting just the facts. And that is
exactly what his patients gave him. This habit, combined with a tendency
to overutilize notetaking, fostered a business-like persona, despite
his natural warmness in daily conversation. It was a habit well worth
breaking and once again highlights the power of paralanguage.
Cross-cultural differences also affect
paralanguage. Sue and Sue describe the variations in paralanguage
that can interfere with the blending or assessment process when working
with people outside the clinician's culture. For instance, silences
are frequently interpreted as moments when the patient, for conscious
or unconscious reasons, is holding back. Silence may also signal that
the patient is ready for a new question. At other moments, silence
can create a feeling of uneasiness in both interviewer and interviewee.
But as Sue and Sue clearly state, the
obvious may be too obvious.
Although silence may be viewed
negatively by Americans, other cultures interpret and use silence
much differently. The English and Arabs use silence for privacy, whereas
the Russians, French, and Spanish read it as agreement among parties.
In Asian culture silence is traditionally a sign of respect for elders.
Furthermore, silence by many Chinese and Japanese is not a flooryielding
signal inviting others to pick up the conversation. Rather, it may
indicate a desire to continue speaking after making a particular point.
Oftentimes, silence is a sign of politeness and respect rather than
lack of desire to continue speaking. A counselor uncomfortable with
silence may fill in and prevent the client from elaborating further.
An even greater danger is to impute false motives to the client's
apparent reticence. (18)
Many other cultural subleties exist, but they are beyond the scope of
this text. Clinicians frequently working with other cultures should
make it a point to understand the cultural characteristics of their
CLINICAL APPLICATION OF NONVERBAL BEHAVIOR
Assessment of the Patient
Sir Denis Hill made the following observations during the 47th Maudsley
Lecture in 1972:
Many experienced psychiatrists
of an earlier generation believed that they could predict the likely
mental state of the majority of the patients they met by observations
within the first few minutes of contact before verbal interchange
had begun. They did this from observation of nonverbal behavior-the
appearance, bodily posture, facial expression, spontaneous movements
and the initial bodily responses to forthcoming verbal interaction.(19)
Sir Denis Hill was concerned that the ability to observe nonverbal behavior
astutely represented a skill that had fallen by the wayside. Let us
hope this demise is not the case, because experienced clinicians today
as much as yesterday need to utilize nonverbal clues throughout their
clinical work. The knowledge available today concerning nonverbal behaviors
is significantly more advanced than 40 or 50 years ago. It is to this
knowledge that we now turn our attention.
To begin our discussion we will look at
another statement by Sir Denis Hill: "An important difference between
the disturbed mental states which we term 'neurotic' and those we term
'psychotic' is that in the latter, but not in the former, those aspects
of nonverbal behavior which maintain social interactional processes
tend to be lost."(20)
An awareness of these potential deficits
in the psychotic patient can alert the clinician to carefully probe
for more explicit psychotic material in a patient whose psychotic
process is subtle.
Perhaps an example will be useful at this time. I was observing an
initial assessment between a talented trainee and a woman in her mid-20s.
The patient had been urged to the assessment by her sister and a close
friend. Apparently the patient's mother was currently hospitalized
with major depression.
By the end of the interview, the clinician
seemed aware that the patient was probably also suffering from major
depression or some form of an affective illness. But the severity
of the patient's condition did not seem to have registered. Instead
the clinician was about to recommend outpatient follow-up. The patient's
nonverbal behavior was telling the clinician to take another look.
In the second interview, which I performed, the patient disclosed
a recent weekend brimming with psychotic terror. She had felt that
her long-dead father had returned to the house to murder her. She
was so convinced of this delusion that she had shared her secret with
several young siblings, not a good idea if one is trying to get baby
brother and sister to sleep. Eventually she ran from her house to
escape her father's wrath. Even in the interview she could not clearly
state that her father's return was an impossibility, although she
hesitatingly said she thought it was.
Let us return to the interview in order
to uncover the nonverbal cues that suggested the possibility of an
underlying psychotic process. The patient, whom we shall call Mary,
answered honestly and appeared cooperative. She displayed no loosening
of associations or other overt evidence of thought process disorganization,
but she demonstrated some oddities in her communicational style. With
regard to paralanguage, she demonstrated long pauses (about 4 to 8
seconds) before beginning many of her responses. This gave her a somewhat
distracted appearance as if muddled by her thinking. This effect was
heightened by a mild slowing of her speech and a flattening of the
tone of her speech as well.
As we have seen, silences, especially
of this length, are generally avoided in daily conversation. Everyday
social protocol would ordinarily pressure Mary to answer more quickly.
This breakdown in normal communicational interaction was one suggestion
that all was not well and represents a disruption of the empathy cycle.
Her body also spoke to her internal turmoil.
Although for the most part she had reasonably
good eye contact, there existed protracted periods of time when she
looked slightly away from the interviewer in a distracted fashion, whether
she was talking or listening. This lack of "visual touching"
during conversation is unusual.(21, 22)
Frequently, before beginning to speak, the intended speaker glances
away briefly. As he or she looks back, speech will begin. While talking
the speaker will frequently look away. But as the end of the speaker's
statement is reached, the speaker will look towards the listener.
This glance signals the listener that the speaker's message is over.
The speaker and the listener glance at each other's eye regions in
varying lengths, usually between 1 and 7 seconds, the listener giving
longer contact. This complex eye duet was frequently missing with
Mary. In depression the eyes are frequently cast downward, but it
is the peculiar manner in which Mary tended to stare past the clinician
that hinted at the possible presence of psychotic process. As Sir
Denis Hill had suggested, Mary had lost some of the nonverbal cues
that maintain social interaction.
Other kinesic indicators of speech pattern
have been called "markers of speech. "(23) For instance, hand
gestures are generally made as one initiates words or phrases. As the
speaker finishes commenting, the hands may tend to assume a position
of rest. To keep one's hands upwards, in front of oneself, can indicate
that one is not done speaking or will soon interrupt.
In Mary these markers of speech were generally diminished. She sat
stiffly with her feet flat on the floor. Her head seemed to weigh
her body down as she sat slightly hunched over with her fingers interlocked.
She displayed little hand gesturing, leaving the interviewer with
the odd sensation that it was not clear when Mary was going to start
or stop speaking. Most likely, Mary's lack of movement was an associated
aspect of her major depression, but it may also have been a ramification
of her psychotic process.
A more striking nonverbal clue to the
degree of Mary's psychopathology lay in her method of dealing with
unwanted environmental input, in this instance the questions of the
interviewer. Apparently Mary had been concerned for some time that
she might be "just like her mother," who was currently in
the hospital. In addition, her sister had undergone a psychotic depression
approximately 6 months earlier. Mary had been attempting to hide from
herself the evidence of her own psychotic process, while the fear
of an impending breakdown nagged at her daily. During the interview,
as questions directed her back into her paranoid fears, she began
to realize the extent of her problems. At this moment she did something
out of the ordinary.
Mary leaned forward slowly, her elbows
perched upon the tops of her knees with her head cupped between her
hands. In this position her hands literally covered her ears, as if
keeping out unwanted questions or thoughts. All eye contact was disrupted.
Mary remained in this position for a good 5 minutes, answering questions
slowly but cooperatively. She appeared detached from the world around
her. This type of behavior has been studied under the rubric of "cut-offs."(24)
Cut-offs represent nonverbal behaviors made to dampen out environmental
stress. When exaggerated to the degree of appearing socially inappropriate,
as was the case with Mary, they may be indicators of psychotic process.
Indeed, catatonic withdrawal represents a prolonged and drastic cut-off.
One must also attempt to compare nonverbal
activities to the patient's baseline behavior. Mary was normally a
high-functioning secretary and most likely possessed better than average
social skills. In this light, her preoccupied conversational attitude,
and in particular her prolonged cut-off, represents very deviant behavior
for her. A subsequent interview with Mary's friend revealed that Mary
had been observed at work sitting and staring at the phone for hours.
For a moment I would like to elaborate
on the issue of cut-offs. We have been discussing dramatic forms of
cut-off behavior, which may indicate underlying psychotic activity,
but mild forms of cut-off behavior occur routinely in our work with
nonpsychotic individuals. These more subtle forms of cut-off are not
without meaning and warrant some discussion. Morris (25) described four
such visual cutoffs, to which he attaches some descriptively poetic
With the "Evasive Eye," the
patient shuns eye contact by looking distractedly towards the ground,
as if studying some invisible object. It can create the feeling that
the patient is purposely not attending to the conversation and may
frequently accompany the speech of disinterested adolescents. In the
so-called "Shifty Eye," the patient repeatedly glances away
and back again. With the "Stuttering Eye," the patient now
faces the interviewer directly, but the eyelids rapidly waver up and
down as if swatting away the clinician's glance. Finally, in the "Stammering
Eye" the patient once again faces the clinician but shuts the
eyes with an exaggerated blink.
These four eye maneuvers represent nonverbal
activities whose meaning may be multiple. They may indicate that the
patient at some level no longer wants to communicate. Perhaps a specific
topic has been raised that is disturbing to the patient, resulting
in a nonverbal resistance. At such moments a simple question such
as, "I am wondering what is passing through your mind right now,"
may uncover pertinent material. Such cut-offs may also represent objective
signs of decreased blending and movement into a shutdown interview.
Exaggerated examples of these cut-offs can also be part of a histrionic
presentation and in this sense could also be seen in both wandering
and rehearsed interviews.
Investigators have also looked at the
promising possibility that nonverbal activities could provide even more
specific diagnostic clues, but at this point the research results remain
tentative.(26,27) Moreover, the results appear to be in accordance with
what common clinical sense would predict.
Concerning the diagnoses found on Axis I, schizophrenia appears to
be accompanied by some distinctive nonverbal behaviors. Studies show
that schizophrenic presentations are marked by a tendency for gaze
aversion. A flattening of affect with decreased movement of the eyebrows
was noted (which could alternatively be secondary to antipsychotic
medication). Patients' postures were slumped, and they had a tendency
to lean away from the interviewer. Naturally the type of schizophrenia
and the stage of the process could significantly affect the type of
nonverbal behavior present, emphasizing a cautionary note to these
Depression has also been investigated.
Researchers have noted that nonverbal behaviors vary depending on whether
one is observing an agitated depression or a retarded depression. In
the agitated depression, patients demonstrated "a puzzled expression,
grimacing and frowning, gaze aversion, agitated movements, a crouched
posture, and body leaning towards the interviewer. Subgroup 2 (retarded
depressives) showed some increase in gaze, slowed movements, self-touching,
an emotionally blank expression, and a backward lean away from the interviewer.(28)
In many respects, these findings have limited usefulness, because they
simply seem to confirm the obvious.
But at a different level, especially with
depressive patients, these findings emphasize the importance of nonverbal
behaviors as clinical indicators of improvement.(29) The return of routine
hand gesturing may herald an oncoming remission even before the patient
admits to much subjective improvement. As the clinician becomes more
aware of such behaviors as spontaneity of facial expression, smiling
behavior, and eye contact, the informal monitoring of such cues to improvement
can become a routine element of clinical follow-up.
With regard to Axis II, less research
is available. Consequently, we will emphasize principles derived from
clinical observations. Observations made during the first 5 minutes
of the scouting period may provide important diagnostic clues. In
this sense, these cues can help determine which diagnostic regions
to emphasize in the body of the interview, for in the limited time
available, it is generally not feasible to explore all areas of Axis
II pathology. The following three clinical vignettes illustrate the
usefulness of nonverbal activities in suggesting the presence of possible
In the first example, I was observing
an interview performed by a psychiatric resident during morning rounds
on an inpatient unit. The patient was an adolescent girl with a head
of curly lightreddish hair. The interviewer was sitting on a couch
in a group activity room. The patient pertly entered the room and
promptly plunked down beside the clinician. At first she leaned towards
him with her right arm straddling the back of the couch behind his
shoulder, but she quickly withdrew the arm. Her final perch was with
her right knee up on the couch resting a few inches from the clinician's
In a proxemic sense, she had positioned
herself well within the personal distance zone and actually very close
to being within the clinician's intimate zone. Her speech was bright
and snappy, percolating from a face rich with expressions and playful
eyes. All this activity occurred in a matter of a few seconds. The
clinician immediately responded by leaning away from the patient and
crossing his legs by placing his left ankle over his right knee. This
brief territorial excursion by this patient is not a typical initial
interaction, even with adolescents who frequently feel more comfortable
with "chummier" interpersonal distances. Instead, this type
of interpersonal game may be seen in people with underlying histrionic
personality traits or borderline personality traits.
The second patient was a woman in late
middle age, with graying hair pulled back in a bun. Before the interview,
she had had to wait longer than usual before entering the room. Initially,
the clinician gently apologized for the inconvenience with a warm
smile on his face. She made cool eye contact. Her lips did not so
much as consider returning his smile. She fluctuated between a baseline
of mildly cooperative answers, with a reasonably lengthy duration
of utterance (DOU), to brusque shut-down remarks.
A peculiar piece of body movement gradually
evolved as she continued with her acerbic tone of voice. She tended
to lean back in her chair and gradually proceeded to stretch her legs
out in front of her towards the interviewer. The movement was ingeniously
slow but as steady as a barge pulling into a dock. As usually happens,
the dock was gently bumped by her feet, at which point she did not
pull away. Instead, the dock recoiled, with the interviewer quickly
tucking his feet beneath his chair.
Her nonverbal activities may be multiply
determined, but one possibility well worth exploring would be underlying
passive-aggressive traits. Later historical information from the interview
tended to further substantiate this diagnostic hunch.
The third and final patient carefully
orchestrated a relatively unappealing opening gambit. She was a tall
woman in her mid-20s with long black hair hanging limply about her
body. She was dressed in jeans and a black pullover sweater. Her first
noticeably unusual action consisted of reaching over to pull up a
chair, which she promptly used as a footstool. She stretched her body
out, making herself conspicuously at home. This settling in did not
signify the beginning of an easy engagement, because she proceeded
to visually cut the female interviewer off throughout most of the
interview. She would look down at her hands, frequently using the
Evasive Eye movement described earlier.
All of this display was topped with
a convincingly dour facial expression. Concerning paralanguage, she
managed to push through her disinterested facial mask an equally disinterested
and mumbling voice. Her attitude visibly disturbed the interviewer.
She also demonstrated one other nonverbal communication with a set
meaning. Specifically, she held her coat on her lap throughout the
interview, perhaps communicating an eagerness to leave.
Her collection of behaviors, all present
during the first few minutes of the interview, suggested a variety
of personality traits worth exploring later. Her lack of concern for
making the interviewer feel more at ease could suggest a possible
hint of antisocial leanings. Along similar lines her obvious attempt
to display disinterest could be part of the manipulative trappings
of a borderline personality or perhaps of a narcissistic personality.
And as we saw with our previous example, some passive-aggressive tendencies
may be present. Her behaviors in no way prove that she has any of
these disorders, but they do provide suggestions of which disorders
warrant additional consideration, further highlighting the importance
of noting nonverbal behavior.
Let us now move from away from diagnostic
issues, and look at some of the nonverbal clues that may suggest that
patients are feeling uncomfortable or anxious. One of the most well-known
indicators of increased anxiety remains the activation of the sympathetic
nervous system, the system geared to prepare the organism for fight
or flight. During the activation of this system a variety of physiologic
adaptations occur that can serve as hallmarks of anxiety. The heart
will beat faster and blood will be shunted away from the skin and gut
to be preferentially directed towards the muscle tissue that is being
prepared for action. This shunting accounts for the paleness so frequently
seen in acutely anxious people, who look like they have seen a ghost.
Saliva production decreases, and the bowels and bladder are slower to
eliminate. Breathing rate increases, as does the production of sweat.
This last sign, increased sweating,
reminds me of one of the more striking and humorous examples of autonomic
discharge I have encountered. A medical student was doing one of his
first physical examinations on a real patient, which can truly be
an upsetting experience, as the student frequently feels painfully
inept. In this case, the patient was a child about 9 years old, who
could be generally classified under the label "brat." As
the exam labored onward, with the worried mother looking increasingly
fretful, the student began to sweat profusely. As the student leaned
over to listen to the child's heart, a bead of sweat fell from his
forehead directly onto the child's chest. Being a subtle kid, he immediately
looked the student in the eve and in a loud voice said, "What's
a matter with you, you're sweatin' all over me!"
If the poor student was not already
uptight, that little proclamation did it. He sheepishly turned to
the increasingly upset mother and produced a quick-witted white lie,
"Don't worry, I've got a thyroid condition." I know this
story all too well because I was the poor panic-stricken medical student.
It clearly shows the truth that the autonomic system does not lie.
With our patients, subtle signs of anxiety such as sweating, damp
palms, and increased breathing rate can help us detect anxiety. If
the anxiety represents evidence of poor blending, we may be able to
purposely attend to the patient's fears. If it represents the presence
of unsettling thoughts, we may be inclined to probe deeper.
If the sympathetic system is not presented
with a chance to actually get the organism into action soon enough,
the parasympathetic system may try to counterbalance with a discharge
of its own. In these cases, one may find a sudden urge to urinate
or defecate, as people frequently feel before public performances
or job interviews. If a patient begins a session by immediately requesting
the need for a restroom, this may represent a clue to a higher anxiety
level than the patient may verbally admit.
Other good indicators of anxiety are described
by Morris under the rubric of "displacement activities."(30)
These activities are those body movements that release underlying tension.
I recently watched a businessman waiting for a meeting. As he sat in
the lobby, he nervously tugged at his tie and picked at his clothes.
He then hoisted his briefcase onto his lap and meticulously unloaded
it piece by piece, after which he gingerly repacked the case, carefully
feeling each object as he delicately reassembled his "peripheral
These behaviors were accomplishing very
little in the way of needed physical functions, but they offered a
calming effect of some sort for the businessman. Other typical displacement
include smoking, twirling one's hair, picking at one's fingers, nailbiting,
playing with rings, twitching one's feet, tugging at the ear lobe, self-grooming
activities, tearing at paper cups, and twirling and biting pens. The
list could certainly be extended. For instance, Morris points out that
serving drinks and holding them in one's hands at cocktail parties probably
serve to decrease people's anxiety, as they "have something to
Clinically speaking, displacement activities
are worth noting during both the initial interview and subsequent
psychotherapy. Each patient seems to display a unique set of displacement
activities. Once decoded by the clinician, these activities can be
usually reliable indicators of patient anxiety. When suddenly increased,
they may represent a more reliable indicator than the patient's facial
expression or verbal response that an interpretation was on the mark.
It is also of interest that anxiety
will sometimes display itself not through the appearance of displacement
activities but in their conspicuous absence. When engaged in an active
conversation, most people will display a normal amount of periodic
displacement activities. If these suddenly stop or are not present
from the beginning, then the person may be experiencing anxiety. In
a sense the person may be trying to avoid mistakes by doing nothing.
This "still-life response"
frequently appears when people are videotaped or interviewed in public.
It seems to afflict interviewers even more than patients. Supervisors
need to be aware that this response may be more of an artifact than
a stylistic marker.
Another area of interest revolves around
facial clues that the patient is visibly shaken or on the verge of
tears. I am sure the reader is well aware of the faint quiverings
of the chin and glazed quality of the eyes that frequently indicate
that a patient is close to tears. But a fact not as well publicized
is the tendency for people to demonstrate extremely fine muscle twitches
across their faces when stressed. These frequently occur beside the
nostrils and on the cheek. In people who demonstrate this tendency,
these fine twitches can be extremely accurate indicators of tension.
By way of example, I was working with a young businesswoman during
an initial interview. She had been referred to me for psychotherapy.
She was attractively dressed with a bright disposition and her speech
was accompanied by a collection of animated gestures. When asked to
talk about her history, she launched into a detailed review of her
life since age 16. Of note was her striking avoidance of any events
prior to age 16.
When asked why she had done this, she
responded that she did not know and had not noticed it. I asked her
if any aspects of her life seemed different before the age of 16.
She commented, "Not really, although I spent more time with my
father back then." At that point a few muscle twitches appeared
by her left nostril. I commented that I had a feeling she was feeling
upset, and she burst into tears. Subsequent therapy revealed a complex
and ambivalent relationship with her father and other male figures.
Throughout therapy, these faint twitches were a sure sign of tension.
This issue of tension leads directly to
another important aspect of nonverbal behavior, the detection of deception.
In one piece of research a group of nursing students were asked to participate
in a study in which they would be asked to deceive a person.(32) They
were told that gentle deceptions were sometimes needed in clinical work,
as when comforting frightened patients. Thus the nurses felt a need
to perform well in the testing situation.
In the research itself the nurses were
exposed to two different types of films. Some films were pleasant
in nature, such as an ocean scene, and other films depicted unpleasant
scenes such as a burn victim and a limb amputation. After seeing the
pleasant film segments, the nurses were asked to describe their feelings
to the listener. This task was obviously not problematic. But after
viewing the unsettling film, in one experimental design, the nurse
had to convince the listener that the gory film was pleasant and enjoyable
to watch. This task was not so easy. Indeed, it so reproduced the
sensation of lying that some nurses dropped out of the study.
All of these interactions were videotaped.
Segments of these videotapes were then shown to subjects, who were
supposed to determine from the visual images who was indeed lying.
It was an ingenious experiment and represents the foundation work
upon which further research on deception proceeded.
The original researchers, Ekman and
Friesen, predicted that subjects would state that while lying they
would focus on making their faces "look natural." This prediction
proved to be true. The deceivers did attend to their faces more, which
suggested that nonverbal activities from the neck down may provide
a better lead concerning deception. Interestingly, trained observers
could pick up clues of deception from videotaped facial expressions.
These microexpressions represent accurate clues but are too difficult
to pick up routinely.
On the other hand, the body of the deceiver
had a tendency to betray its own head, so to speak, and further research
has substantiated many of these initial findings as described in Ekman's
fascinating book Telling Lies.(33) Apparently, changes in below-the-neck
movements may be of the most practical significance for accurately detecting
deception. Direct communications or emblems, as Ekman refers to them,
can sometimes be useful indicators of deceit. Emblems represent nonverbal
behaviors that carry a distinct meaning, such as a yes or no head nod
or pointing to an object. Just as slips of the tongue may betray hidden
feelings, slips of the body can occur. With the nursing students in
the above study, many felt a helpless sensation that they were not hiding
their feelings well. This feeling of helplessness was sometimes inadvertently
conveyed by a shrugging movement.
When representing indicators of nonverbal
leakage, emblems usually appear in part. Thus only one shoulder may
partially rise or one palm may turn up during a shrug. Another good
indicator that an emblem represents a deceitful mannerism is the display
of the emblem in an unusual placement. An angry fist will not be raised
towards an antagonist but will quietly appear by the side of the patient.
Hand gestures, which people make while
speaking, have been called illustrators by Ekman, and they tend to decrease
when deceit is under way. This decrease is particularly true if the
patient has not had time to rehearse the lie and must carefully attend
to what is being said. The clinician can monitor behaviors such as those
described above while exploring regions in which resistance and deceit
may be high. For example, when eliciting a drug and alcohol history
from a typically active interviewee, a sudden decrease in associated
hand movements may suggest that deception is occurring. Several other
studies have also found supportive evidence for the idea that below-the-neck
clues are best for detecting deceit on a practical level.(34, 35)
Besides kinesic indicators of deception,
the clinician can look for paralanguage clues that deceit is occurring.(36)
For instance, a higher pitch to the voice has been associated with deception
as well as emotions such as fear. In a complementary sense, lower pitches
have been associated with judgments by observers that the subject is
more relaxed and sociable. Another possible clue to deception involves
the response time latency (RTL). Deceptive subjects were found to demonstrate
a longer RTL and to give longer answers when in the act of deceiving.
It should be kept in mind that most of
the kinesic and paralanguage clues to deception mentioned so far represent
nonverbal activities, not nonverbal communications. Thus these behaviors
may be multiply determined and do not in any way ensure that the patient
is being deceitful. In many cases, they may simply indicate that the
patient is feeling more anxious. Each activity must be interpreted in
the interpersonal matrix in which it was born. By way of example, one
researcher found that an increased latency of response could be interpreted
in different fashions. If it was followed by a self-promoting comment,
then it was often interpreted as being an indication of deception. On
the other hand, if the pause was followed by a self-deprecating comment,
it was often registered in the opposite direction as evidence of a truthful
It is probably best to conclude the
discussion of cues of deception at this point. Clearly the research
is somewhat tentative, but it suggests that some changes in the baseline
behavior of the patient may provide useful hints that deception may
be at hand. Two practical points warrant mentioning. First, as the
interview proceeds, it is generally a good idea to ascertain the baseline
body movements that are typical of the patient. Second, during sensitive
inquiries, it is best to avoid notetaking. Notetaking can completely
eliminate the ability of the interviewer to observe the subtle nonverbal
clues that may be the only warnings of deception.
In the same sense that nonverbal activities
may indicate that the patient may be deceiving the clinician, a variety
of important mixed nonverbal messages may be sent to an interviewer.
These mixed messages are not necessarily deceptions. Instead, they
may represent hallmarks of patient ambivalence and confusion.
In order to explore this fascinating area,
the work of Grinder and Bandler (38) offers a wellspring of practical
and sound clinical observation. Although controversy has arisen over
their later work, their first two books provide some pioneering insights
into engagement techniques.
Their work follows naturally from the
principles we have been discussing thus far. Put simplistically, they
state that as a person communicates a message, the message is transferred
through a variety of communicational channels simultaneously. The
patient's message may be conveyed through the content of the spoken
words, the tone of voice, the rate of speech, the amount and type
of hand gesturing, the posture, and the facial expression. These messages
are termed paramessages. When all paramessages have the same meaning,
the paramessages are said to be congruent. But if some of the channels
convey discordant information, then the paramessages are said to be
The underlying theory is simple; perhaps
that is why it proves to be so powerful therapeutically. People who
consistently communicate with an incongruent style can frequently
create a confusing impression. Their incongruence may make the people
around them feel ill at ease and uncomfortable. If the clinician can
detect this selfdefeating interpersonal style, he or she may be able
to help the patient modify it. In a more immediate sense, incongruent
paramessages may indicate underlying mixed feelings of which the patient
is unaware. Once again, the therapist may be able to cue off this
incongruence, leading the patient into an exploration of the uncovered
More germane to the topic of the initial diagnostic interview, episodes
of incongruent communication may alert the clinician to areas worthy
of more immediate investigation or perhaps regions pertinent to explore
in later sessions.
I am reminded of a woman in her early
30s who I was evaluating for possible psychotherapy or medication.
Ms. Davis, as we shall call her, was coping with a variety of stresses,
not the least of which was the loss of her mother several months earlier.
For years she had been her mother's caretaker and verbal whipping
post. Ms. Davis was mildly overweight with stocky legs, offset by
a face embraced by a full head of black hair. As she spoke, her conversation
turned to her bitter relationship with her boyfriend, who apparently
enjoyed her sexually but found marital ceremonies not to his liking.
She commented, "I hate him, I'll never go back to him. He's not
Harsh words, but one should be wary
of taking them too seriously, for Ms. Davis' body spoke differently.
The words were spoken with a tone of pained resignation, not biting
anger. They had the quality of the child-like pout, "Daddy's
not bringing home a present from his vacation." Not only did
her voice lack selfindignation, but her hands played a martyr's role.
Rather than the more typical pointing and jerking movements of an
angry accusation, they were held low towards her lap with the palms
upwards. This type of hand positioning is frequently associated with
a tone of supplication and need.
Put more precisely, Ms. Davis was communicating
with an incongruent set of paramessages. As Grinder and Bandler point
out, all of these messages may have elements of truth to them. In
Ms. Davis' case, she certainly did have angry feelings towards her
boyfriend, as suggested by the content of her words. But she also
had extremely powerful needs to be accepted by him; indeed, these
needs bordered on a masochistic willingness to be verbally beaten
by him. Her tone of voice and hand gestures suggested her strong need
for acceptance. Even her breathing rate did not increase or become
more spurt-like, as is frequently seen as someone becomes increasingly
angered. This set of incongruent messages was one of the first clues
to her deeply rooted problems concerning hostile dependence, which
became central working issues in the remaining therapy. Indeed, her
relationship with her mother was in reality no different from her
relationship with her boyfriend.
In any given initial interview, periods
of incongruent communication may occur. If noted, they can serve as
road signs that effectively guide the interviewer towards a deeper
understanding of the patient.
In a similar fashion the work of Scheflen,
whom I mentioned earlier, deserves more detailed examination, because
it too focuses on the nonverbal interactions that serve as communication
scripts for people.(39) Scheflen discusses the idea that humans, like
other animals, engage in certain shared behaviors that tend to escalate
into specific actions. Such actions include fighting behavior, mating
behavior, and parenting behavior. Frequently, these mutually arousing
actions serve to eliminate the actual need to engage in the final activity.
In such a manner animals will frequently avoid actual combat by undergoing
a territorial display of sorts. Scheflen calls such escalating patterns
of behavior "kinesic reciprocals."
Kinesic reciprocals can frequently be
seen in clinical interactions. If the patient begins the reciprocal,
the clinician may inadvertently continue the process. I have certainly
seen this process occur within the realm of the courting or mating
reciprocal. I remember watching a videotape of a session of psychotherapy.
The patient was a young woman interacting with her therapist, who
was a relatively young man with about 7 years of clinical experience.
The patient sat pertly forward, cigarette hanging aesthetically from
her fingers. The therapist, who was dressed casually in a sport shirt,
sat rakishly back, also with a cigarette in hand. Their voices possessed
a spritely coyness.
It was unclear whether I was watching the beginning moments of a therapy
session or the opening sequences of a grade B movie. In any case,
the therapist and his patient were engaging in the courting reciprocal,
otherwise known as flirting. Inadvertent participation in such reciprocals
can create a variety of problems. Obviously it can stimulate an erotic
transference. Moreover, if initiated unconsciously by the therapist
and then reciprocated by the patient, it can lead the therapist towards
the inappropriate perception that the patient is histrionic.
I am reminded of one clinician who tended
to be pleasantly flirtatious and buoyant with staff. She was surprised
when male patients, following initial evaluations, would ask her out.
On videotape the answer was obvious in that some of her flirtatious
qualities appeared in her clinical work, albeit in a much toned down
Scheflen provides a good description of
kinesic behaviors utilized by both sexes in the courting reciprocal:
The full-blown picture of the female courting posture is
well known to us, for models and actresses simulate it continually
in being seductive or attractive. The head is held high and cocked.
The "mark" is looked at from the corners of the eyes. The
chest is brought out so that the breasts protrude. And the legs appear
"sexy" as the foot is extended and the calf musculature
is tightened.... An actively courting woman may present her palm,
a highly affiliative act, in many ways; e.g., when she pushes back
her hair, when she smokes, or when she covers her mouth while coughing.
The man's state of high tonus is evident most clearly in the thoracic-
abdominal behavior. He moves from a slump, with abdominal protrusion
to thoracic display by sucking in his belly and squaring his shoulders.
A man may use some of the same behavior in courting that he uses in
dominance. He may draw up to full height, protrude his jaw, stand
in close, and display what is generally regarded as a masculine stance.(40)
Other reciprocal behaviors besides the courting reciprocal can occur
in an initial interview. A striking example was provided by a videotape
made of an initial interview for use in supervision.
The interviewer was a young woman. Across
from her the patient sat with eyes occasionally cast downwards. As the
interview unfolded, the patient produced a folded piece of paper, and
asked the clinician to read the paper before proceeding. Her voice seemed
to step meekly away from her lips. In the meantime the patient began
fumbling with the microphone. She had correctly wrapped it around her
neck but had problems attaching it to her blouse. Noticing her problems
the clinician looked over and asked if she needed help. The patient
did not look up for a moment as she continued to fumble. Then with her
head cocked downwards, she innocently glanced upwards shaking her head
"yes." She gazed with the helpless eyes of a little girl and
said not a word. The clinician promptly leaned over and fixed the microphone.
The parenting reciprocal had emerged as
naturally as if enacted between a true mother and her child. In this
brief vignette, the power of the first few minutes of the scouting period
to provide clues for further diagnostic probing is once again amply
demonstrated. This patient's manipulative style and dependent behavior
suggested the possibility of some form of character pathology. Indeed,
further interviewing revealed a mixed personality disorder with histrionic,
passive-aggressive, and dependent characteristics. Apparently this patient
had perfected the art of eliciting parental responses as a method of
This patient also displayed another type
of nonverbal activity, auto-contact behavior. Auto-contact behavior
consists of movements involving self-touching.(41)Such behaviors may
consist of grooming behaviors, defensive-covering behaviors, and self-intimacies.
Self-intimacies are defined as, "movements
that provide comfort because they are unconsciously mimed acts of being
touched by someone else."(42) These self-intimacies appear frequently
during interviews. Patients may hold their own hands or sit with their
knees pulled up to their faces, arms literally hugging their own legs.
In regressed patients, one can see even more extreme forms of selfhugging
as patients lay in tightly curled fetal positions.
With regard to frequency, the most common
self-intimacies in order of most to least frequent are as follows: 1-
the jaw support, 2- the chin support, 3- the hair clasp, 4- the cheek
support, 5- the mouth touch, and 6- the temple support. With hair touching
there is a 3:1 bias in favor of women. Temple touching demonstrates
the opposite bias with a preference in men of 2:1. Sometimes these kinesthetic
comforters can be tied into other sensory modalities as well. I remember
one patient who would pull her hair across her cheek. She would simultaneously
gently sniff at her hair, which she related as being very comforting.
Such activity was a sure sign of her underlying anxiety, much like a
In this manner these behaviors may serve
to alert the interviewer that the patient is feeling pained or anxious.
It can cue the interviewer that the patient may need some verbal comforting,
perhaps prompting an empathic statement. It can also alert the clinician
that powerful affective material is being approached, possibly suggesting
the need for further exploration.
In summary, in the above material the
focus has been on the power of the patient's body to convey information
to the perceptive clinician. It is now time to explore the reverse situation,
those moments when the clinician uses his or her body to affect the
Utilization of Nonverbal Behavior to Engage the Patient
SEATING ARRANGEMENT AND PROXEMICS
One of the exercises undertaken in our interviewing class concerns
the use of seating arrangement. Two of the trainees sit in the middle
of the room on easily rolled chairs. They are given a simple task,
to situate themselves so that they feel the most comfortable with
regard to conversing with one another. In about 90% of the cases,
the participants choose a similar position.
They sit roughly 4 to 5 feet apart.
They are turned towards each other but do not quite directly face
one another. Instead, they are turned about a 5 to 10-degree angle
off the line directly between them, both in the same direction, as
shown in Figure 3A. Only about 10% choose to face each other directly.
If the participants are asked to turn
directly towards each other, they complain of feeling significantly
less comfortable. Some will even push their chairs back a bit. The
discomfort is related as feeling "too close." More specifically,
many of the trainees complain that the head-on position forces eye
contact, making it difficult to break eye contact without undertaking
a significant head movement. This head-on position fosters a sensation
On the other hand, the preferred position
readily allows for good eye contact but also makes it easy to break
contact in an unawkward fashion. In my own practice, I have certainly
found this position to be the most comfortable and the most flexible
interviewing position for me. This last statement is important, because
it emphasizes that the most comfortable position may be different
for each interviewer and indeed for each interviewing dyad. Each clinician
needs to discover a comfortable position, keeping in mind that the
clinician must also be willing to alter this position depending on
the needs of the patient.
In addition to the nonconfrontational
feeling provided by the position described above, another phenomenon
may be enhancing its comfortableness. As discussed before, one of
the key processes that enhances blending is the ability of the clinician
to convey a sense of seeing the world through a shared perspective.
If one looks at the actual fields of
vision available to each participant in the interview, an important
relationship readily becomes apparent. When two people are directly
facing each other, the fields of vision exhibit little overlap. What
overlap exists lies directly between the two participants. This situation
tends to foster the sensation that "You are over there, and I
am here." It seems to work against the sensation of "We
are here together." On the other hand, when the two participants
are turned slightly away from each other, so that they are subtly
facing the same direction, then the feeling that "We are here,
and the rest of the world is out there" naturally emerges.
Thus, in a phenomenological sense,
the feeling of confrontation is decreased, while the sense of blending
is given a gentle boost, as illustrated in Figure 3B. It should be
noted that the directly oppositional position may be preferred by
some people. Indeed, some clinicians recommend it,(43) but I myself
do not, for the reasons provided above.
The concept of seating raises the more
general issue of furniture arrangement. Some clinicians prefer setting,
away from their desk, two large comfortable chairs. Another alternative
is to utilize the desk creatively. In general, I believe a desk should
not sit between the clinician and the patient, because this creates
an authoritarian distance appropriate for chief executive officers,
On the other hand, the desk can be placed as shown in Figure 3C with
only a corner protruding between the clinician and the patient. If
the clinician's chair rides on wheels, the clinician can move the
chair and alter the resultant interpersonal distance either by increasing
or decreasing the amount of desk between the participants. A paranoid
patient may require more distance from the clinician, which can easily
be accomplished by moving only a short way, because the desk quickly
provides a protective barrier. On the other hand, the clinician can
easily move to a point where essentially no desk intervenes.
The overall concept of the clinical
setting warrants attention. When designing a private office, an effort
should be made to provide a comfortable and professional atmosphere.
The office represents an extension of the clinician's persona, and
the patient's first impression in the scouting period may be significantly
affected by the decor of the clinician's waiting area or office. Calming
prints or photographs, accompanied by several diplomas and shelves
of books, provide a reassuring and pleasant environment.
Trainees are faced with limited financial
resources. But three or four unframed art posters and a few plants
can be bought very reasonably, producing a sometimes startling change
in the atmosphere of the room. There is no need for a trainee's room
to look like a prison cell. On the contrary, part of the training
experience is learning to consider the principles behind creating
an appropriate private office.
Outside the office, situations can be
a bit more difficult, because the clinician faces crowded hospital
rooms and disorganized emergency rooms. It remains important in these
situations to consider the comfort of both the patient and the clinician.
While performing a consultation in a crowded hospital room, there
is nothing wrong with saying, "Before we start, would you mind
if I slide your bed over, so both of us can have more room to talk."
This discussion of seating arrangements
leads to the issue of determining an optimum distance between the
clinician and the patient, which will vary for each interviewing dyad.
There does seem to exist a small region in which the clinician's presence
respects the patient's sense of personal space while still allowing
the movements of the clinician to have an immediate impact on the
patient. This zone of effective interpersonal space may be referred
to as the "responsive zone" (RZ). If the clinician moves
out of the RZ towards the patient, then the interviewer risks frightening
the patient or creating a sense of discomfort. On the other hand,
if the interviewer leaves the RZ by moving too far away from the patient,
then the movements of the clinician may have little impact on the
patient. For instance, the act of gently leaning forward towards a
patient, which can enhance communication during particularly sensitive
moments of an interview, may have no effect if done outside the RZ.
Two examples may help clarify the importance
of establishing an RZ that seems most comfortable for each patient.
First, if one intuits that a patient may be feeling paranoid, it is
useful to remember that such patients may require a larger space around
them in order to feel more comfortable. In these cases the RZ is larger
and it may be wise to begin such interviews sitting further from the
patient than one normally would sit or perhaps using a desk or table
to help provide a safety barrier as mentioned earlier. As the interchange
proceeds the clinician may find that the distance can be gradually
decreased; hence the RZ frequently may change as the blending waxes
In the second example, one looks at
the problem of accurately eliciting a formal cognitive examination
in elderly patients who are seriously depressed and withdrawn. To
attract and maintain their attention, the interviewer might need to
sit considerably closer than normal. This more intimate RZ may help
decrease the likelihood of obtaining poor cognitive results secondary
to the patient's lack of attention or interest. If a patient is not
interested in answering, then the risk of getting artificially low
scores becomes very real indeed. In such cases the tendency to suspect
a real dementia when only a pseudodementia is present can become a
Another way of obtaining the withdrawn
patient's attention during the cognitive examination is to speak more
loudly, effectively moving closer but not moving one's chair. At times
it is also important to ensure attention by literally asking the patient
to look at the clinician as the questions are asked. For instance,
the interviewer can gently but firmly make statements such as, "It
may help you to do well on these questions if you watch me as I actually
say the digits to you." In the last analysis, if a withdrawn
patient is looking down at the floor as the clinician performs the
cognitive mental status, the validity of the results are certainly
The concept of increasing the validity
of the cognitive examination also raises the issue of touching patients.
Some clinicians seem to have a block against the idea of touching
a patient. Although it is not frequent for me to touch a patient during
an initial interview (except for handshakes), I sometimes find touching
useful and poignant. With regard to the cognitive examination, some
depressed and withdrawn patients may ignore the clinician's attempts
to make eye contact and attend to the task at hand. In such instances,
one can touch the arm of the patient, offering comments such as, "I
know it is difficult for you to concentrate right now, but it really
is important." At such points, the patient may glance up at the
interviewer and more effective contact will have begun.
Of course, touching, a method of entering
the patient's intimate space, as described by Hall, may also be used
at points at which the patient may benefit from some simple comforting.
I am reminded of a sad, middle-aged man who I interviewed as he was
entering the hospital. For all of his life he had been a kind and
hard-working mill worker. Unbeknownst to himself he was being exposed
to an extremely toxic industrial poison. Over the years he experienced
gradual changes in his behavior, including irritability and occasional
violent outbursts, which frightened him and produced extreme guilt.
Simultaneously he underwent marked changes in his intellectual functioning,
to the point that he had problems dealing with everyday activities.
Only recently had he learned that his problems were secondary to brain
As we neared the end of the interview,
he told me that he was afraid of the hospitalization because "people
say mean things to me, they think I'm stupid. Please let me come in,
I promise I won't hurt anybody, I promise, and I'm not that stupid."
At which point he began to weep. It seemed only natural to reach over
and grasp his arm while reassuring him that I believed what he said
and that we would help him make the transition to the hospital.
Outside of the types of situations described
above, touching patients is not common during initial interviews,
because touch is a powerful communication, that may carry numerous
connotations, not all of which are appropriate. Patients may misinterpret
touch as an erotic gesture or at a minimum as a sign of implied intimacy.
Although the clinician may intend the gesture as a sign of caring,
a psychotic patient or a patient with a histrionic personality may
distort the message considerably. Indeed, if a clinician finds a routine
need to touch patients during initial interviews, it would be wise
for the clinician to determine why such a need is arising. Usually
it is not from clinical considerations. Such clinicians frequently
have a desire to be perceived as "comforting angels." Ironically,
this drive to be perceived as "comforting" may get in the
way of effective caregiving. Such self-exploration may also reveal
flirtatious traits or histrionic qualities in the therapist.
At this point we can turn our attention
to another aspect of nonverbal behavior, which frequently emerges
if the clinician has effectively determined the appropriate RZ for
the patient. At such times the appearance of certain nonverbal behaviors
can suggest that the blending process is proceeding well. As mentioned
in Chapter 1, several verbal signs, such as an increased DOU, may
indicate the presence of improved engagement. In a similar fashion
nonverbal activities may also be used routinely to monitor the blending
For instance, as blending increases,
the patient may begin to make progressively better eye contact, while
spontaneous arm gestures and "talking with one's hands"
may increase. Along similar lines, if a patient in a shut-down interview
begins to talk more with his or her hands, this may be a hint to pursue
the present topic more fully in order to further strengthen the engagement
process. The clinician can also frequently see the patient turn more
towards him or her as blending increases. Relaxation is also shown
by an asymmetry in posture, while tense posture is frequently seen
with a person who feels threatened.(44)
We have been discussing the nonverbal
activities that may suggest powerful levels of blending. It is important
to return to a topic approached earlier, namely, the differences seen
cross-culturally. With regard to the African-American culture, eye
contact is not considered as important in conveying attention to a
listener.(45) Just being in the room or close to the speaker may be
considered enough to convey that attention is being given.
Direct eye contact may be considered
disrespectful in certain cultures, such as with Mexican-Americans
and with the Japanese. In this context, a clinician could be making
a serious error in judgment by interpreting poor eye contact with
members of these ethnic groups as an indication of rudeness, boredom,
lack of assertiveness, or poor blending.
Another process that may emerge more
frequently when one has successfully found the RZ is the surprising
phenomenon of postural echoing.(46) In postural echoing one finds
that two people who are communicating effectively tend to adopt similar
postures and hand gestures. At a cafe, two lovers may sit across from
each other, both heads perched in their hands, as they animatedly
stare into each other's eyes.
A frequent phenomenon seen in interviewing
occurs when one member suddenly shifts positions and relaxes. Simultaneously
the other person will also shift and relax. Moreover microanalysis
of videotapes has suggested that as blending increases, the minute
movements of the interviewer and the interviewee tend to parallel
each other as if a miniature minuet were being performed. During moments
of discordant interchange this reciprocity decreased.
At one level these findings suggest
that the appearance of postural echoing may serve as a clue to the
clinician that the blending process is on the right track. In a slightly
different vein, the clinician can subtly match some of the patient's
postures in an effort to actively increase blending. For example,
if a male clinician is interviewing a steel worker who is crossing
his legs with his ankle over one knee, the therapist may cross his
leg in the same manner, as opposed to crossing his leg at the knees.
The latter method could be misconstrued by the interviewee as "feminine."
By adopting a style similar to that of the patient, the metacommunication
is passed that "we do certain things similarly and we may not
be as different as one might first suppose." This discussion
of the use of postural echoing, in an effort to actively engage the
patient, leads to a consideration of other methods of nonverbally
increasing the blending process.
BASIC FACILITATIVE TECHNIQUES
One collection of nonverbal behaviors potentially useful in the art
of engagement consists of the so-called affiliative behaviors. Such
behaviors include eye contact, smiles, and gesticulations. It has
been shown that counselors who demonstrate these behaviors are viewed
as significantly more persuasive than counselors who do not.(47) Another
commonly encountered affiliative behavior consists of a body lean
of about 20 degrees towards the patient.(48)
One of the most well-recognized affiliative
gestures is the simple head nod. Morris makes the interesting observation
that the vertical head nod indicates a "yes" or "positive"
response in all cultures and groups in which it has been observed,
including Caucasians, African-Americans, Balinese, Japanese, and Eskimos.
It has been observed in deaf and blind individuals as well as in microcephalic
people incapable of speech. He relates that the head nod may convey
different types of "yes" messages, such as the following:
The Acknowledgment Nod: "Yes, I am still listening."
Interviewers should make an attempt to learn the frequency with which
they typically head nod. This frequency can vary significantly among
interviews. From my own observations it appears that interviewers who
are particularly adept at engaging patients tend to head nod numerous
times during any several minutes of an interview. As obvious as the
utility of the head nod may appear, I have found that approximately
20% of professionals I supervise tend to underuse it. A few barely head
nod at all.
The Encouraging Nod: "Yes, how fascinating."
The Understanding Nod: "Yes, I see what you mean."
The Agreement Nod: "Yes, I will."
The Factual Nod: "Yes, that is correct."49
The power of the head nod became apparent
to me in an unexpected fashion during a session of psychotherapy. I
had been working with a middle-aged male patient for several months.
I decided to try a brief exercise in which I would purposely stop my
typical head nodding for several minutes, in order to see what this
practice would feel like to me. To my surprise I found it difficult
to do, because it had become habitual. But more to my surprise, the
patient broke off his spontaneous conversation after about 2 minutes
and asked, "What's wrong? Somehow I feel that you don't like what
I'm saying." This vignette emphasizes the power of nonverbal cues
during clinical interaction.
ENGAGING GUARDED OR PARANOID PATIENTS
In Chapter 1 we discovered that with guarded or paranoid patients,
certain changes in approach could enhance engagement. In particular,
certain verbal approaches that were effective with most patients could
be potentially disengaging with guarded patients. For instance, guarded
patients frequently respond better to basic empathic statements rather
than to complex empathic statements. In a similar fashion, with certain
patients, the clinician's nonverbal behavior may be too empathic or
As mentioned earlier when discussing
proxemics, guarded and paranoid patients may appreciate being provided
with more space than most other patients. Along these lines, some
of the affiliative gestures, when done too frequently, may prove disruptive
to the guarded patient. I have heard paranoid patients comment that
they have disliked frequent eye contact, perhaps twisting the attentive
gaze of the "good listener" into the stark gaze of a potential
persecutor. In this context, one may purposely break eye contact more
frequently with paranoid patients, providing them with visual space.
Even head nodding and arm gestures can
be unsettling when done too frequently with guarded or paranoid patients.
I vividly remember one patient whom I interviewed in an emergency
room. He was an intoxicated male about 30 years old, who wore a frequent
sneer. He challenged me frequently with not-so-subtle sniper's remarks
such as, "I bet you think you're a good listener Doc." And
at one point he suddenly began mocking my head nodding by aping it,
with his jaw jutting outwards while grunting out loud "Uhhuhs."
This was not one of my more rewarding interviews. He was the patient
who later, while waiting for his disposition, spontaneously attacked
one of our safety guards.
This patient also illustrates the point
that if the clinician finds a patient giving negative responses to
typically engaging nonverbal behavior, then the interviewer should
consider the idea that the patient may be guarded, hostile, or potentially
CLINICIAN'S SELF-AWARENESS OF PARALANGUAGE
Each clinician has a unique personality. In particular, clinicians
will vary on parameters such as tone of voice, rate of speech, and
loudness of voice. It is important for clinicians to discover their
own typical way of coming across. This knowledge is of value, because
certain patients may respond better to different approaches. An understanding
one's own natural style offers the clinician the chance to modify
it, if necessary, to enhance the blending process.
With this idea in mind, it is useful
for clinicians to practice exercises such as speaking more gently
and slowing down their rate of speech. If an interviewer tends to
speak loudly and quickly, a toning down of these parameters may prove
more effective with a frightened or guarded patient. By way of example,
my own personality is somewhat upbeat, with a mild pressure to my
speech and a slightly louder voice than many people. When beginning
interviews, I purposely adjust to a calmer middle ground until I understand
the specific needs of the patient. Adjustments can then be made as
deemed necessary. In instances when I have not made this adjustment,
I have certainly come on too strongly for certain patients.
There exists another area in which tone
of voice can frequently disengage a patient. Specifically, when talking
with geriatric patients, clinicians often unconsciously adopt a rather
distinctive tone of voice. They talk as if they were speaking to a
helpless child. This tone of voice, which is often mildly slowed,
can easily be perceived as condescending. It is an extremely frequent
clinicians must guard against it carefully. It is sometimes even done
with psychotic patients and adolescents. In both cases the clinician
is flirting with trouble.
NONVERBAL CUES OF THE CLINICIAN
We are generally well trained to observe the behavior of others, but
the value of self-observation is frequently underplayed. As we have
seen, the interview represents a dyadic process in which an understanding
of one component depends on an understanding of the impact of the
other component. The clinician's nonverbal activity always has the
potential to significantly alter the behavior of the patient, as we
have seen in our discussion of reciprocal behaviors.
With regard to gestures, as with paralanguage,
clinicians need to develop a sound sense of their natural nonverbal
style. One exercise that helps clinicians in developing self-awareness
consists of repeatedly picturing a mirror descending during the interview
itself. This mirror is to drop into place between the clinician and
the patient. Such a visualization exercise rather rudely awakens clinicians
to the fact that their every move is potentially an object of scrutiny
to an inquisitive patient. As a complement to this visualization exercise,
videotaping provides invaluable objective self-observation.
In any case the clinician should foster an awareness of those nonverbal
activities that may inadvertently decrease blending. I am reminded
of an interview, which I supervised, of an adolescent boy. The patient
sat in a pool of brooding preoccupation. He wore a worrisome expression
more suited to a 60-year-old man coping with an agitated depression
than to a boy beginning adolescence. Curiously he had referred himself
to the evaluation center and did not want his mother to be contacted.
During the interview he moved about
anxiously in his chair and had considerable difficulty looking at
the interviewer. He had a rounded face framed by a bowl of sandy hair,
which was neatly clipped around his ears. It was about one of these
ears that his discussion soon focused. Apparently he had the misfortune
of watching a television documentary on cancer several days earlier.
Since then he had become fixated on a small bump on his right ear,
to which he gingerly pointed. He was convinced that he had developed
a malignant tumor. This gnawing obsession, which may very well have
reached delusional proportions, was nestled amidst a variety of depressive
symptoms and difficult life circumstances.
As the interview proceeded the boy became
progressively more ill at ease. At several points he stopped talking,
asking the interviewer, "You don't understand, do you?"
To which the interviewer responded in a reassuring fashion that he
was trying to understand and wanted to hear more. This type of response
generally might have decreased the tension, but in this case it seemed
of no avail.
What the interviewer did not realize was the message conveyed by his
own face. Each time the boy discussed his "tumor" the clinician
furrowed his brow in a not-so-subtle fashion, forming two small vertical
lines between his eyebrows. Apparently the patient interpreted this
facial gesture as a look of disbelief or condemnation. The clinician
had no conscious awareness of this particular expression, which frequently
cropped up as a habit during his interviews. It is just this type
of habit that can lead to recurrent problems with poor blending.
These habits are difficult to recognize
unless the clinician is directly supervised or videotaped. They are
also sometimes hard to accept. The clinician above seemed unimpressed
with my explanation for the poor engagement until several weeks later.
He then approached me sheepishly and said, "You'll never believe
what a patient just did. In the middle of the interview he cut me
off and asked me why I was frowning. My God, I must actually do it!"
One of my own habits illustrates another
category of clinician movement that can become problematic. As I become
anxious, I begin to twist my hair behind my ears. This nonverbal activity
represents what we have discussed earlier as a displacement activity.
These displacement activities can be used to monitor patient anxiety,
but on the flip side, they can be a useful self-monitor, indicating
anxiety in the clinician.
The clinician may not even have been
aware of the presence of stress, but the appearance of numerous displacement
activities warns that anxiety is present. At such points of self-awareness
in the interview the clinician can explore the origins of the tension.
Sometimes the interviewer is concerned about personal matters not
related to the interview, including countertransference tensions.
At other times the clinician may be intuitively registering patient
hostility or even well-hidden psychotic process. In any case, the
recognition of clinician displacement activities can provide yet another
avenue for understanding.
Another good reason for studying displacement
activities concerns the eradication of potentially disengaging gestures.
For the most part, displacement activities are natural and help to
create a feeling of spontaneous communication. As such there is no
need to eliminate them; indeed, they may actually foster good blending.
But there exist certain displacement gestures that are probably best
eliminated. We can return to my own habit of twisting my hair. This
displacement activity has the potential to be disengaging. To some
patients it may appear effeminate, because as mentioned earlier women
touch their hair three times more frequently than do men. To others
it may simply be distracting. In either case it serves no purpose
and is probably best discarded.
Similarly, certain categories of patients
may not respond well to demonstrations of increased anxiety in the
clinician. The immediate category that comes to mind includes patients
escalating towards violence. These patients are frequently frightened
that they are about to lose control. If they see the clinician becoming
progressively more tense as well, they may become even more agitated.
The same holds true for paranoid patients, who may appear almost ludicrously
hyperattentive to their environments. I remember an older man with
marked paranoid process who once asked me why I had just scratched
my head. When I said I had an itch, he did not seem particularly reassured.
Two other clinician displacement activities
warrant discussion. The first activity is smoking. I personally do
not believe that clinicians should smoke cigarettes or even the proverbial
"Freudian pipe" while interviewing patients. My bias evolves
from the feeling that smoking, at the very least, represents a possible
distraction to the patient. More likely, it may sometimes actually
function as an irritant. Even if one asks permission from the patient,
many patients who do not like smoking may find it difficult to convey
such concerns. Pipe smoking is so stereotypic of "a shrink"
that it may bias transference or simply turn some patients off.
The second displacement activity is
much more of a mixed blessing, because it clearly serves some useful
purposes. I had never even viewed it as a displacement activity until
I had asked one student what his most common displacement activities
were, and he replied, "That's easy, I'm constantly scribbling
There exist many good reasons for taking
detailed notes, such as making process notes to be shared with a psychotherapy
supervisor. On the other hand, in initial interviews I have become
more and more convinced that much of notetaking represents a displacement
activity that frequently distracts both the clinician and the patient.
No matter how one views it, a clinician looking down at his or her
clipboard while actively composing sentences cannot possibly be attending
to the fine nuances of patient behavior available to the clinician
with undivided attention.
Once again I am sharing a bias that
some clinicians would disagree with, but I feel that notetaking should
be minimized in the initial interview. It should be utilized to jot
down hard-to-remember details such as dates, medication dosages, and
family trees. Instead of meticulously making a transcription of the
patient's words, the clinician can carefully attend to the patient
directly. In particular, during the early scouting period, I believe
it is much better to do little, if any, notetaking. At this early
stage the emphasis should be on actively engaging the patient. To
this end, I find that patients are more responsive to clinicians who
seem more interested in them than in the clinician's clipboard.
I frequently do not even pick up a clipboard
until well into the interview. When I do begin to write, as a sign
of respect, I often say to the patient, "I'm going to jot down
a few notes to make sure I'm remembering everything correctly. Is
that all right with you?" Patients seem to respond very nicely
to this simple sign of courtesy. This statement of purpose also tends
to decrease the paranoia that patients sometimes project onto notetaking,
as they wonder if the clinician is madly analyzing their every thought
and action. Along these lines, notetaking should be avoided with actively
NONVERBAL ASPECTS OF CALMING POTENTIALLY VIOLENT PATIENTS
Interacting with a patient who is escalating towards violence presents
the clinician with one of the most difficult of clinical situations.
Although it would be nice to think that violent interactions are rare,
the facts speak otherwise. Tardiff reports that approximately 17%
of patients reporting to an emergency room are violent. He further
reports that roughly 40% of psychiatrists have reported being assaulted
at least once in their careers.(50)
Obviously, it is to the clinician's
benefit to review the various approaches that may de-escalate an angry
patient. In particular, the nonverbal characteristics of potentially
violent dyads are of considerable importance, because issues concerning
proxemics, kinesics, and paralanguage can all be of value in handling
these situations. The interaction with the potentially violent patient
provides an excellent topic with which to close this chapter, for
the craft of utilizing nonverbal behavior is seldom put to a more
I would also like to emphasize that
violence is frequently a dyadic process. The clinician and the patient
represent a two-person system, and it is this system that becomes
violent. Clinicians may inadvertently, with their nonverbal behavior,
further escalate an already agitated patient. Fortunately this cycle,
representing a violence reciprocal, can frequently be broken.
To begin with I am reminded of a curious
story related by an anthropology professor during my undergraduate
education. He described an interspecies encounter in which violence
was averted by the quick thinking of a field anthropologist. This
anthropologist had been extensively studying the behaviors of a baboon
troop. One day he accidentally startled a mother baboon and her baby.
Within seconds the squawkings of the alarmed mother attracted a swarming
bevy of guard males. One can assume their intent was not of a social
variety. Indeed, baboons are both intelligent and ferocious when provoked.
The appearance of an ugly white ape with a mustache and safari hat
was more than ample stimulus to prompt a display of their virility.
Indeed, the baboons could have quickly disposed of the anthropologist.
Having observed baboons demonstrating
submissive behavior within the troop, he purposely replicated their
submissive gestures, which apparently involved lowering oneself and
making certain jaw movements. To his relief, the baboons grunted and
snarled but waved off their attack.
Besides representing a delightful tale for college professors to relate
to wide-eyed undergraduates, the above story has a valuable message.
A group of animals were about to interact violently. The violence
was prevented by the use of specific nonverbal behaviors, which functioned
as actual nonverbal communications. Similar to these baboons the human
animal possesses a repertoire of nonverbal activities and communications
that signal the intent to attack and the intent to submit.
For the clinician, the signals of impending
attack, when recognized in a patient, can quickly alert the clinician
that something needs to be altered in the interpersonal dyad before
a violence reciprocal ensues. Through a knowledge of the signals of
submission, the clinician may alter behavior in a fashion that appears
less threatening to the paranoid or intoxicated patient. In many instances
these alterations can break the dyadic cycle of violence, as effectively
as the anthropologist supplicating the baboon warriors. It should
be kept in mind that in some instances no matter what preventive actions
are undertaken, violence will erupt. The goal is not to eliminate
violence but to decrease its likelihood.
Towards this endeavor the clinician
should consider whether the clinical environment suggests that violence
may be a possibility. In the first place, diagnosis can alert the
clinician to an increased likelihood of aggression. Most psychotic
patients are not violent, but psychotic process as manifested in schizophrenia,
bipolar disorder, paranoid disorder, and other atypical psychoses
may predispose the patient towards aggression, especially when paranoid
delusions are simmering beneath the patient's social facade. If frightened,
these paranoid patients may go to great extremes to protect themselves,
as we would if we shared their vision of the world. It is always important
to remember that such patients may believe that they are literally
fighting for their lives.
Other types of psychosis or poor impulse
control may presentproblems. For instance, patients suffering from
organic brain disease,as seen in frontal lobe syndromes, deliriums,
and various dementias,may be predisposed towards aggression. A particular
red flagshould arise in the clinician's mind when interacting with
peopleunder the influence of various drugs, including speed, Quaaludes,and
PCP. Alcohol intoxication remains a major area in which violence erupts,
especially in settings such as emergency rooms. Because we frequently
deal with alcohol intoxication in social settingsin our culture, it
is easy to be lulled into underestimating thepotential for violence
when dealing with an intoxicated patient.Such patients can quickly
move from jovial jesting into a fit of rage. Diagnoses do not tell
the clinician that any specific patient isabout to be violent. Most
people suffering from schizophrenia arenot violent, but the diagnosis
does alert the clinician to the possibil
ity of aggression. This consideration may represent the first step
in preventing violence. In addition, the clinician may note that a
patient has a history of assaultive behavior. In such instances, the
clinician is well advised to take appropriate precautions, such as
having safety officers unobtrusively nearby and aware of the situation.
Besides diagnostic and historical factors,
the clinician may be part of a situation in which violence is more
likely. If the clinician has been asked to participate in the evaluation
of a patient who is being committed involuntarily, then caution is
always advised. There are probably few life situations more frightening
than to have one's freedom taken away. In this situation patients
should always be considered as potentially violent.
I remember one instance in our emergency
room late at night. The patient, an agitated woman of about 30 years
of age, was being committed. Safety officers had been called down
and were appropriately nearby. The patient appeared to have calmed
and was quietly sitting with family members by her side. Everything
seemed in control. The clinician began to move away from the patient
and turned her back as she headed for the staff room. In a matter
of seconds the patient was ferociously choking the clinician, for
no apparent reason. I mention this vignette because it highlights
the need to think cautiously while evaluating committed patients.
It also reminds one of the old adage that one should never turn one's
back on a patient, an adage as true today as when it was first coined.
One other clinical situation to keep
in mind arises when patients are agitated and accompanied by family
members. In such situations the clinician should attempt to determine
quickly whether the family member is calming or upsetting the patient.
In emergency rooms a common mistake is to not separate feuding family
members until it is too late. It is often best to separate the antagonistic
family members quickly, while allowing different staff members to
attempt to calm and understand the perspectives of both parties.
I have strayed from the topic of nonverbal
behavior. However in a practical sense, the first step in utilizing
nonverbal behavior with violent patients consists of recognizing the
violent situation in its infancy, not its adolescence. If the clinician
is aware of the potential for violence, then the following nonverbal
techniques can be brought into play.
We will first look at various nonverbal
activities that may alert the clinician that violence may be incubating.
Subsequently we will look at ways in which to change our own behaviors
in an effort to avoid confrontation. The signs of impending aggression
can be loosely grouped into two categories--early warning signs and
late warning signs. Although it is extremely difficult to predict
whether a patient will engage in violence in the future, it is not
particularly difficult to tell when a patient may be headed towards
The early warning signs consist of behaviors
that suggest emerging agitation. In the simplest examples, one may
notice the patient beginning to speak more quickly with a subtly angry
tone of voice. These paralanguage clues may be augmented by a display
of sarcastic statements or challenges, such as, "You think you're
a big shot, don't you!"
These types of early warning signs may
appear obvious, which is the exact reason why they warrant mentioning.
As clinicians we may inadvertently ignore these signs, in the process
unintentionally escalating the patient. This seems to occur during
periods of intense time pressure or when the clinical situation has
become increasingly hectic, as in a busy emergency room. Such obstinacy
can unfortunately return as an unwanted gremlin. When these early
warning signs are present, it is very important to crystallize in
one's mind what the patient's needs may be. If the clinician can move
with the patient's needs, hostility will frequently decrease.
Kinesic early-warning signs consist
of actual evidence of agitation, such as pacing and refusing to sit
down. If patients refuse to sit, it is frequently useful to gently
request them to return to their seat. One can use phrases such as,
"It might help you to relax some if you sit over here,"
or "Let's sit down and see if we can sort some things out."
If comments such as these fail to elicit compliance, one can more
firmly state, "I'd like you to sit over here so we can talk."
Some clinicians might quietly add, "It's difficult to have to
keep staring up. I think we'll both be more comfortable if we sit."
If these maneuvers fail, then it is probably best to let the patient
walk around freely, while recognizing that this patient may be seriously
impaired with regard to impulse control. In short, the patient may
be on the way towards violence, and appropriate steps should be taken.
If no one is aware that the clinician is alone with such a patient,
it is generally best to let someone know what is going on. It is relatively
easy for a clinician to make an excuse for leaving the room at such
points. It may not be so easy 10 minutes later. Along these lines,
if the clinician is at all suspicious of possible violence, the clinician
should carry a "safety button" or know where the safety
button is located in the interview room, so that other staff can be
alerted if problems arise.
Other kinesic early warning clues include
rapid and jerky gesturing. Of particular note is the action of vigorously
pointing one's finger at the clinician to "make a point."
Such a gesture may be a harbinger of impending hostility. Increased
and intense staring may also suggest anger. Finally, the appearance
of suspiciousness or other increases in psychotic process, such as
an increasing disorganization, should alert the clinician to the possibility
As a person comes closer to overt violence,
specific behaviors may serve as reliable indicators that aggression
is imminent. Just like the charging guard baboons with their bared
teeth, humans have evolved symbolic signs of threat. Morris has described
behaviors known as intention movements.(51) These intention movements
consist of those small gestures that suggest impending movement. For
instance, as persons intend to rise from a chair, they frequently
lean forward grasping the arms of the chair. This is a clear signal
that they want to rise, signaling that the conversation is about to
end. The intention movements suggesting possible violence include
activities such as clenching of the fists, whitening of the knuckles
as one tightly grasps an inanimate object, and even a snarling as
the lips are pulled back from the teeth. People may not be as different
from baboons as we would like to think.
Perhaps the most common intention movement
of attack is the raising of a closed fist over the head. Overhand
blows delivered from this position are the most frequent blows seen
in street brawls and riots despite the unlikelihood of hurting one's
opponent in this manner. This behavior may be instinctual in nature,
because it is frequently seen in children who are fighting.
Morris also describes vacuum gestures,
which represent completed actions but are not actually carried out
on the enemy. Frequent vacuum gestures include shaking the fist, assuming
a boxing stance, gesturing as if strangling the opponent, and the
pounding of the fist into the opposite palm. All of these intention
movements and vacuum gestures serve as late warning signals that violence
is near at hand.
It should also be noted that verbal
threats or statements that one is about to strike out often accompany
the nonverbal behaviors described above. When the above late warning
signs are present, violence is a distinct possibility. At this point
an application of nonverbal skills may help to prevent aggression.
Earlier, reciprocal behaviors were discussed,
such as the mating reciprocal, in which two organisms engage in an
orderly sequence of events leading to a final outcome. Scheflen describes
dominance and submission reciprocals.(52) In our story of the baboons,
the anthropologist refused to participate in the dominance reciprocal.
If he had, he might very well have been killed. Instead he chose to
begin the submission reciprocal, which his would-be attackers fortunately
agreed to follow. In a similar fashion, humans can engage in either
of these reciprocals.
When faced with a hostile patient, the
trick is to avoid engaging in the dominance reciprocal while utilizing
some submissive behavior. One avoids the dominance reciprocal by not
demonstrating any of the early or late warning signs of aggression.
Although this appears to make an obvious point, it is striking to
watch the maladapative behavior of clinicians when faced with an agitated
patient. The fear generated by the patient's hostility frequently
results in unconscious behaviors that may threaten the patient. The
clinician's voice may be raised. At times, the actual movements of
the clinician speed up as the waiting area is hurriedly cleared of
furniture and other patients. Even frankly antagonistic remarks may
emerge. In this respect, it is not an exaggeration to say that clinicians
can actually precipitate violence.
There exist no absolute rules for interacting
with a patient on the verge of violence, but some principles seem
relevant. In the first place, the clinician should appear calm. The
speaking voice should appear normal and unharried. It is particularly
important to avoid speaking loudly or in an authoritarian manner.
With regard to kinesics, the clinician wants to avoid an excessive
display of displacement activities, which may be misinterpreted as
aggressive displays. Moreover, exaggerated displacement activities
may create an increasing atmosphere of fear, stoking the patient's
own fears of an impending loss of control.
Eye contact should probably be decreased,
and the hands should not be raised in any gesture that may signify
an intent to attack or defend oneself. Curiously, some clinicians
will place their hands behind their backs, a situation that may raise
fears in the patient that a weapon is being hidden. With regard to
posture, one can purposely stoop one's shoulders slightly in an effort
to appear smaller, because humans, when about to attack, frequently
raise their shoulders and chests, a bit of gorilla-like display. It
is probably also wise to remain in front of the patient, because an
approach from behind or from the side may startle the agitated patient.
One of the most important points concerns
an issue mentioned earlier when discussing proxemics. At least one
study has suggested that potentially violent patients may have significantly
altered buffer zones.(53) Specifically, they will feel that their
intimate body space is being invaded at distances much further away
than for most people. These patients may feel that the interviewer
is "in my face" while standing a full 6 feet away. In general,
the agitated patient needs more room and interpersonal space. This
can be a tough principle to remember, because some good-hearted clinicians
feel a desire to calm the angry patient by touching them. This desire
usually goes away after a few unfortunate encounters with feet or
If these principles are followed, accompanied
by an intelligent use of safety officers and medication as needed,
many violent encounters can be avoided. With regard to avoiding dangerous
situations, another point warrants mentioning. When sitting in a room
with a patient who one does not know, it is probably wise to arrange
the chairs so that the clinician is closer to the doorway, while not
obstructing the patient's pathway to the doorway. With this arrangement
one can always get away if the patient becomes threatening or produces
a weapon. It is naive to think that these situations do not arise,
especially in emergency rooms. To pretend that they do not probably
represents a defensive denial that prevents the clinician from fully
thinking about these situations in a manner that could help prevent
them in the first place.
In conclusion, nonverbal processes are
core elements of human communication during violent interactions.
A sound knowledge of these processes can help the clinician to calm
the angry or frightened patient. Helping patients to regain a sense
of internal control remains one of the fine points of the art of interviewing.
It also increases the chances that the clinician will be around to
practice his or her art.
In this chapter we have reviewed the basic principles of proxemics,
kinesics, and paralanguage. It can readily be seen that these processes
are at the very root of communication. As such integral parts of human
interaction, they remain pivotal in bringing the initial interview
to a successful conclusion.
In these first three chapters, we have reviewed many of the basic
principles of both verbal and nonverbal behaviors as they apply to
the initial interview. Before proceeding much further, the important
topic of gathering and organizing information for treatment planning
warrants a thorough discussion. Such a discussion will quickly move
us into some of the most complex and fascinating aspects of assessment
1. Hall, E. T.: Excerpts from an interview conducted by Carol Travis.
2. Harper, R. G., Wiens, A. N., and Matarazzo, J. D.: Nonverbal
Communication: The State of the Art. New York, John Wiley, 1978.
3. Wiener, M., Devoe, S., Rubinow, S., and Geller, J.: Nonverbal behavior
and nonverbal communication. Psychological Review 79:185-214,1972.
4. Edinger, J. A., and Patterson, M. L.: Nonverbal involvement and
social control. Psychology Bulletin 93(l):30-56,1983.
5. Morris, D.: Manwatching: A Field Guide to Human Behavior.
New York, Harry N. Abrams, 1977.
6. Hall, E. T.: The Hidden Dimension. New York, Doubleday,
7. Watson, O. M., and Graves, T. D.: Quantitative research in proxemic
behavior. American Anthropologist 68:971-985, 1966.
8. Sue, D. W., and Sue, D.: Barrier to effective cross-cultural counseling.
Journal of Counseling Psychology 24(5):420-429, 1977.
9. Baxter, J. C.: Interpersonal spacing in natural settings. Sociometry
10. Wiens, A. N.: The assessment interview. In Clinical Methods
in Psychology, edited by Irving Weiner. New York, John Wiley,
11. Knapp, M. L.: Nonverbal Communication in Human Interaction.
New York, Holt, Rinehart, and Winston, 1972.
12. Birdwhistell, M. L.: Introduction to Kinesis: An Annotation
System for Analysis of Body Motion and Gesture. Louisville, KY,
University of Louisville Press, 1952. 13. Harper, R. G., 1978, p.
14. Scheflen, A. E.: Body Language and Social Order. Englewood
Cliffs, NJ, PrenticeHall, 1972.
15. Freud, S.: Fragment of an analysis of a case of hysteria. In Collected
Papers, Vol. 3. New York, Barri Books, 1959 (originally published
16. Carmier, W. H., and Carmier, L. A.: Interviewing Strategies
for Helpers: A Guide to Assessment, Treatment and Evaluation.
California, Brooks/Cole Publishing Company, 1979.
17. Wiens, A. N., 1976, p. 27.
18. Sue, D. W., 1977, p. 427.
19. Hill, Sir Denis: Non-verbal behavior in mental illness. British
Journal of Psychiatry 24:221-230, 1974.
20. Hill, Sir Denis, 1974, p. 227.
21. Wiens, A. N., 1976, p. 33.
22. Morris, D., 1977, p. 75.
23. Scheflen, A. E., 1972, p. 46.
24. Morris, D., 1977, p. 164.
25. Morris, D., 1977, p. 165.
26. Pansa-Hendersen, M., De L'Horne, D. J., and Jones, I. H.: Nonverbal
behavior as a supplement to psychiatric diagnosis in schizophrenia,
depression, and anxiety neurosis. Journal of Psychiatric Treatment
and Evaluation 43:489-496, 1982.
27. Jones, I. H., and Pansa, M.: Some nonverbal aspects of depression
and schizophrenia during the interview. Journal of Nervous and
Mental Disease 167(7):402409, 1979.
28. Pansa-Henderson, 1982, p. 495.
29. Jones, I. H., 1979, pp. 402-409.
30. Morris, D., 1977, p. 181.
31. Morris, D., 1977, p. 109.
32. Ekman, P., and Friesen, W. V.: Detecting deception from the body
or face. Journal of Personality and Social Psychology 29(3):288-298,
33. Ekman, P.: Telling Lies: Clues to Deceit in the Marketplace,
Politics, and Marriage. New York, W. W. Norton, 1985.
34. Littlepage, G. E., and Pineault, M. A.: Detection of deceptive
factual statements from the body and face. Personality and Social
Psychology Bulletin 53(5):325-328, 1979.
35. McClintock, C. C., and Hung, R. G.: Nonverbal indicators of affect
and deception in an interview setting. Journal of Applied Social
Psychology 5:54-67, 1975. 36. Edinger, J. A., 1983, pp. 42-43.
37. Kraut, R. E.: Verbal and nonverbal cues in the perception of lying.
Journal of Personality and Social Psychology 36:380-391, 1978.
38. Grinder, J., and Bandler, R.: The Structure of Magic II.
Palo Alto, California, Science and Behavior Books, 1976.
39. Scheflen, A. E.: Body Language and Social Order. Englewood
Cliffs, NJ, Prentice Hall, 1972.
40. Scheflen, A. E., 1972, p. 16.
41. Morris, D., 1977, p. 102.
42. Morris, D., 1977, p. 102.
43. Egan, G.: The Skilled Helper: A Model for Systematic Helping
and Interpersonal Relating. California, Brooks/Cole Publishing
Company. 44. Wiens, A. N., 1976, p. 35.
45. Sue, D. W., 1977, pp. 420-429.
46. Morris, D., 1977, p. 83.
47. La Crosse, M. B.: Nonverbal behavior and perceived counselor attractiveness
and persuasiveness. Journal of Counseling Psychology 19:417-424,
48. Hasse, R. F., and Tepper, D.: Nonverbal component of empathetic
communication. Journal of Counseling Psychology 19:417-424,
1972. 49. Morris, D., 1977, p. 68.
50. Tardiff, K.: The violent patient. In Manual of Psychiatric
Consultation and Emergency Care, edited by F. Guggenheim and M.
Weiner. New York, Jason Aronson, 1984.
51. Morris, D., 1977, p. 173.
52. Scheflen, A. E., 1977, p. 173.
53. Wiens, A. N., 1976, p. 28.