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 emerges.
     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 numerous meanings.
     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 interviews.
     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 said).
     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-
Proxemics
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 clues.
     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 furthest apart.

Kinesics
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)

Paralanguage
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 interview proceeds.
     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 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)

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)

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 of confrontation.
     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, not therapists.
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 or wanes.
     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 true dilemma.
     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 questionable.
     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 damage.
     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 process.
     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."
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

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 intimate.
     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 violent.

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 phenomenon, and
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 notes."
     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 paranoid patients.

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 critical test.
     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 immediate violence.
     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 of violence.
     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 fists.
     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.

CONCLUSION
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 interviewing.

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