Nonverbal Communication and Health Care

Nonverbal Communication
and Health Care

Health and illness are complex, socially influenced concepts and un­derstandings that rely heavily on communication. Nonverbal commu­nication-the use of dynamic but non-language messages such as facial expressions, gestures, gaze, touch, and vocal cues-is especially important when emotions, identities, and status roles are significant, as well as in situations where verbal communications are untrustwor­thy, ambiguous, or otherwise difficult to interpret (DePaulo & Fried-man, 1998). The importance of nonverbal cues is thus central in the health arena. Health care providers need accurate information from their patients regarding the type and duration of their symptoms; the frequency and validity of health-relevant behaviors; reactions to ill­ness and treatment; and the probabilities associated with future be­haviors. Patients, however, may be unable to report this information, and they may be motivated to conceal or misinterpret certain symp­toms or behaviors, and to overestimate the likelihood of adherence to their medical regimens.

From the patient's perspective, transactions in a health care setting are often confusing and intimidating. The medical encounter repre­sents a unique social situation, with one person holding most of the power, knowledge, and prestige and the other disclosing personal de-tails about him- or herself, often while scantily dressed and experienc­ing considerable anxiety about the symptoms that precipitated the visit. The information that patients receive from health care providers

may be difficult to understand due to technical language or jargon, as well as the stress of the situation. Further, the health recommenda­tions that are made or prescribed may seem confusing, daunting, or unreasonable.

Patients and providers share the common goal of improving patient health, but often have different communicative styles, bodies of knowl­edge, and philosophical perspectives. In many cases, there are no sim­ple ways to decide if one is healthy or ill, as people vary markedly in their pain perceptions, their genetics, their motivations, and their be­havioral reactions to physiological states. Rather, health and illness are often socially negotiated states. Further, there are very few areas of health care that do not involve extensive face-to-face interactions. As models for understanding health and illness have moved steadily away from traditional mechanical, biomedical approaches and toward the biopsychosocial model (Engel, 1977), increasing emphasis has been placed on treating the person within this complex system, rather than trying to isolate one particular part of the whole. Thus, with the impor­tance of effective communication now recognized, efforts to enhance interactions and negotiations between patients and health care work­ers have increased steadily over the past two decades (Ha11, Harrigan, & Rosenthal, 1995; Roter, 2000).

This chapter focuses on the nonverbal elements of communication within a health care setting. Because nonverbal behaviors are often more subtle and abstruse than verbal behaviors, they tend to be poorly understood. And, the challenges associated with measuring and inter­preting nonverbal cues make research in this area difficult. Despite the challenges, a body of literature on nonverbal communications in health care settings has accumulated. The present chapter will briefly review this literature beginning with nonverbal cues that are transmitted from patients to providers and the ways in which health care providers inter­pret and understand these communications, followed by an overview of nonverbal transmissions of information from health care providers to patients and the ways in which these are utilized. We wi11 then focus more specifically on identifying elements of good nonverbal communi­cation, and ways in which these can be increased to improve both the patient-provider encounter and patient health outcomes. Finally, mea­surement limitations, innovations, and current trends in this important sub-field of Health Psychology wi11 be addressed.

PATIENTS' NONVERBAL COMMUNICATION

Thoughtful attention to the unspoken details of patients' presenting complaints has been a component of diagnosing and treating illness for centuries, especially when the physician had few diagnostic tests available. Hippocrates urged the practitioner to first focus on the pa­tient's face, and the face-to-face clinical intake or diagnostic interview has become the cornerstone of modern diagnosis (Friedman, 1982). In

theory, computerized questionnaires and blood analysis could go a long way toward initial diagnosis but, in practice, the value of complex, difficult-to-specify information gleaned from a face-to-face interview remains central.

An experienced clinician gains many insights from the gestalt (con-figural) view of a patient. Pallor, weakness, tenderness, restricted movement, emotion, breathing changes, voice tones, perspiration lev els, and so on may paint an informative picture. Further, many particu­lar nonverbal diagnostic techniques also have been uncovered or documented. Patients' nonverbal behaviors may be the best means for physicians' detection of pain levels (Craig, Prkachin, & Grunau, 2001). Nonverbal cues can often be a good indicator of psychopathological co-morbidity, an important issue as depression is increasingly recog­nized as relevant to many illnesses. Nonverbal cues are essential to diagnosing syndromes such as the Type A Behavior Pattern (e.g., in­volving explosive speech and glaring facial expressions; Chesney, Ekman, Friesen, Black, & Hecker, 1990; Hall, Friedman, & Harris, 1986) and related unhealthy patterns of hostility.

Facial expressions can yield important information about an indi­vidual's true physical or emotional state but are also most subject to distortion. The neural pathways for volitional facial expression are at the cortical level, whereas subcortical areas govern spontaneous ex­pressions (Rinn, 1991). Thus, a patient might consciously exhibit a pleasant expression while reassuring the doctor that 'the pain is better

' but unknowingly contradict this with an involuntary expression of pain seconds later. An astute observer will note this discrepancy and probe for further details (e.g., Quill, 1989). Although the face is thus a common place to look for nonverbal information, people are also likely to take this into account when consciously trying to hide some thing or convey a different emotion than is truly felt. We learn to closely monitor and control our facial expressions (Ekman & Friesen, 1969). Therefore, other nonverbal channels, such as speech patterns, ges­tures, or posture should not be ignored. Because we may be less prac­ticed in controlling non-facial cues, these areas can be valuable sources for detecting nonverbal 'leakage' (DePaulo & Friedman, 1998; Friedman, 1982).

In addition to leaking information about their current states through nonverbal channels, patients may also exhibit behaviors that carry a particular message about their desires or needs within the medical encounter itself. Patients who behave submissively (using pas­sive voice tone, making little eye contact, holding the body with a closed posture) and who talk less are lowering their own likelihood for involvement in the medical care process (Kaplan, et al., 1989; Patterson, 1983). A patient's desire for involvement may be expressed by leaning toward the doctor, making eye contact, smiling, nodding, and otherwise being both facially and vocally expressive (Coker & Burgoon, 1987). When met with resistance from the physician, a pa-

tent might pause in speaking until the doctor appears attentive, inter­rupt, lean further toward the physician, or fail to make eye contact with the doctor as she or he exits, binding the physician to the encounter or signaling nonadherence (Patterson, 1983).

Physicians who are sensitive to the nonverbal cues of their patients may obtain a more accurate view of the patients' needs (physical, so­cial, and emotional). The importance of physician skill in decoding nonverbal cues to patient satisfaction was first demonstrated by the positive relationship of physicians' scores on the Profile of Nonverbal Sensitivity (PONS; Rosenthal, Hall, DiMatteo, Rogers, &Archer, 1979) to their patients' levels of satisfaction with care received (DiMatteo, Friedman, & Taranta, 1979). This study suggested that doctors who are better able to read the nonverbal cues of their patients might be better equipped to meet their patients' needs.

PHYSICIANS' NONVERBAL COMMUNICATION

Patients often seek clues to their own health status or judge the quality of their care by the nonverbal behavior exhibited by their doctors (e.g., DiMatteo & DiNicola, 1982; Friedman, 1982; Roter & Hall, 1992). Most patients report that they want to be involved in their own care and health-decision making, and although the level of desired involvement does vary, many patients say that they would like to receive more infor­mation and be more involved than they are (e.g., Blanchard, Labrecque, Ruckdeschel, & Blanchard, 1988; Faden, Becker, Lewis, Freeman, & Faden, 1981; Strull, Lo, & Charles, 1984). The information that pa­tients glean from nonverbal channels supplements the information that is given to them verbally, and is important because patients often are ill-equipped to judge the technical quality of care received or to understand the complexity of their technical diagnosis. So, they may rely instead on the interpersonal quality of care. In some cases, such as in cases of life-threatening diseases, patients may have reason to disbelieve what their health care providers say to them, or may think that they are receiving less than the full truth regarding their health, and in these cases nonver­bal expressions also become highly salient.

Power and Status

The difference in power and status between physicians and patients may contribute to increased patient attention to physicians' nonverbal cues (Fiske, 1993; Friedman, 1982). In addition to being knowledge-able, expert physicians have inherently higher status than patients and this status differential is reinforced by having patients come to the ter­ritories (offices) of physicians, by control over time (appointments), by dress (physicians in white coats versus patients in gowns), and by voice tones. Physicians further communicate power by touching the bodies of patients (including intimate places). Even though such exam-

inations are for instrumental (task) purposes, they also carry socio­emotional implications as patients react. Indeed, skilled physicians of-ten employ this power differential to encourage the healing process. The 'healing touch' as well as the nonverbal encouragement and posi tive expectations of a high-status physician can help encourage, moti­vate, and reassure a distraught or confused patient.

Health care providers nonverbally communicate not only their own internal states, but also their preferences for how the medical encoun ter ought to proceed. Physicians who behave in a hurried manner con vey the expectation that patient involvement is not important, whereas doctors who match their patients' affiliative behaviors demonstrate their expectation that their patients will be involved in the medical care process (Buller & Street, 1992; Lepper, Martin, & DiMatteo, 1995; Svarstad, 1974). Other behavioral clues that patients are not invited to participate in their own care include: longer speaking turns, interrup tions of the patient, more pauses, sitting or standing with a backward lean, looking at (or writing in) the chart during patient speech, and more use of social touch which reinforces the difference in status be tween patient and physician (Fisher, 1983; Patterson, 1983; Street & Buller, 1987, 1988; West, 1984).

Nonverbal communication by the health care provider can be re­lated to patient outcomes. For example, patient anxiety, recall, and per ceptions of severity were shown to increase with the apparent anxiety of the oncologist who communicated their mammogram results (Shapiro, Boggs, Melamed, & Graham-Pole, 1992). Nonverbal behav­iors (such as head nodding, forward lean, uncrossed legs and arms, direct body orientation, arm symmetry, and gaze that is appropriate to the situation and not overly intense) may be significantly associated with patient outcomes such as satisfaction, understanding, and lowered anxiety (Beck, Daughtridge, & Sloan, 2002).

These effects of provider nonverbal communications on patient out comes can be long lasting. A study of the nonverbal behaviors of physi­cal therapists indicated that even over a several-month follow up period, distancing (not smiling, looking away from the client) was strongly associated with decreases in both physical and cognitive func­tioning, whereas facial expressiveness (nodding, smiling, and frown­ing) was linked to improvements in functioning (Ambady, Koo, Rosenthal, & Winograd, 2002).

LEARNING TO COMMUNICATE NONVERBALLY

Certain medical educators now advocate rapport-building and part­nering within the health care encounter (Barnett, 2001; Novack, Volk, Drossman, & Lipkin, 1993; Roter & Hall, 1992; Simpson, Buckman, Stewart, Maguire, Lipkin, Novack, & Till, 1991; Zinn, 1993). As of 2004, mandated by the board overseeing the United States Medical Li­censing Examination, medical students have to pass a clinical skills

examination, essentially a test of successful 'bedside manner.' But, to what degree are the components of high quality rapport or facilitative style teachable? at exactly is bedside manner, and is it reasonable to assume that it can be learned?

Bedside manner refers broadly and informally to the interpersonal behaviors shown by a physician or other health care provider, espe­cially those that foster trust and a sense of well-being in patients. Hip­pocrates (1923 translation) noted that through 'contentment with the goodness of the physician' a patient in perilous condition might nevertheless recover. In addition to some of the nonverbal behaviors outlined above that might facilitate an interpersonal connection be­tween patient and physician, bedside manner also includes the psychosocial elements of empathy (sensitivity and emotional connec­tion to another person; Rogers, 1951) and rapport (synchrony of interactants' behaviors, mutual positive feelings, and mutual atten­tiveness; Tickle-Degnan & Rosenthal, 1990).

Empirical evidence suggests that at least some of these processes occur unconsciously. One recent study demonstrated that facial mim icry, measured by electromyographic activity as participants viewed pictures of happy and angry faces, corresponded more closely to self-reported emotional experience in individuals with high empathy (Sonnby-Borgstrom, 2002). Another study exposed participants to happy or angry facial pictures in very brief flashes, so that participants were not consciously aware of them, and found that both negative and positive emotional reactions could be facially evoked without the par­ticipants' knowledge or recognition of them (Dimberg, Thunberg, & Elmehed, 2002).

Despite such findings of the importance of the individual and the overall context, the empirical evidence also suggests that health pro fessionals can learn to effectively engage their patients in positive inter-changes and health-building partnerships (Fallowfield, Jenkins, Farewell, Saul, Duffy, & Eves, 2002; Langewitz, Eich, Kiss, & Woeessmer, 1998; Seeman & Evans, 1961 a, 1961b; Smith, Lyles, Mettler, Marshall, et al., 1995). These studies show that improving the physician-patient partnership is not simply a matter of teaching doc tors to speak more clearly and avoid jargon. A wide range of competen­cies, including nonverbal competency, can be learned with practice, and these skills are not habits that accrue naturally over time, without intervention (e.g., Fallowfield, et al., 2002). Data also point to the im portance of learning the appropriate behaviors and style, however, be cause what seems intuitively sensible may not be valid. For example, the common advice that patients should be offered alternative courses of treatment as a way of partnering with them may backfire; one study showed that patients who were offered more alternatives did not feel that their physicians facilitated their involvement in care (Martin, Jahng, Golin, & DiMatteo, 2003). This same study showed that some other typically suggested physician behaviors, such as using warm and

friendly tones and speaking to the patient as an adult, were related in the expected ways to patients' perceptions of being invited to partici­pate in their own care. A review of nonverbal behavior in patient-pro­vider interactions indicated that not talking too much, and instead listening closely, is generally viewed as helpful in building rapport (Hall, Harrigan, & Rosenthal, 1995). But, although this maybe true on average, it is also clear that the effectiveness of this rapport-building tool can vary across situations. For example, in interactions where the doctor and/or patient is male, interruptions by either party are nega tively associated with patient satisfaction, perhaps because they foster or indicate dominance or competition. But, in female-female dyads, interruptions tend to relate to greater patient satisfaction, maybe be-cause they indicate enthusiasm or collaboration (Hall, Irish, Roter, Ehrlich, & Miller, 1994). Other nonverbal cues, such as touch and eye contact, are also highly context dependent (Larsen & Smith, 1981; Davidhizar, 1992). Thus, training systems and strategies that aim to increase partnership-skills must pay careful attention to the types of situations in which these skills will be used, and would do well to teach a flexible system of responses, rather than striving for increases or decreases in absolute numbers of particular nonverbal behaviors (Lee, Back, Block, & Stewart, 2002).

MEASUREMENT OF NONVERBAL BEHAVIOR IN PATIENT-PRACTITIONER INTERACTIONS

A great deal of the literature on physician-patient communication has focused primarily on verbal aspects of the interchange (Buller & Street, 1992), often using such measures as the Roter Interaction Analysis System (RIAS; Roter, 1991) or the Verona Medical Interview Classification System (Verona-MICS; Del Piccolo, Saltini, Cellerino, & Zimmermann, 1998). These systems, despite their emphasis on pro­viding a standard, reliable, and valid documentation of the encounter are often also able to provide good information regarding the affective (emotional and motivational) elements of interactions. The RIAS, in particular, has demonstrated sensitivity to emotional facets of physi cian-patient communication and is flexible enough to be useful across a wide range of age, gender, and cultural groups (Hall, Horgan, Stein, & Roter, 2002; Roter, 2000; Roter & Larson, 2002).

Despite mounting evidence regarding the broad utility of some of the most popular medical interaction coding systems, researchers who are interested in nonverbal aspects of communication often rely more on global assessments of the encounter, as assessed by raters, because these potentially allow for even greater integration of subtle nuances that are difficult to otherwise operationally define. Many of the global ratings are judged from audio-recorded encounters, and while certain elements of nonverbal communication can be assessed from audio-tape (e.g., voice tone, inflection, rate, volume, and number of interrup-

tions), how well these really reflect the overall nonverbal character of the encounter is unclear.

A comprehensive study (Riddle, Albrecht, Coovert, Penner, Ruckdeschel, Blanchard, Quinn, & Urbizu, 2002) addressed this is-sue by assessing whether ratings were different when coders viewed videotaped information vs. heard only the audio portion of the video-tape. The Moffitt Accrual Analysis System (MARS; Albrecht, Blanchard, Ruckdeschel, Coovert, & Strongbow, 1999), designed for use with video, and the RIAS (Roter, 1991), designed for use with au­dio, were used for ratings. Results indicated that the measures were al-most identically reliable, but the ratings themselves were not equivalent-relational communication information was coded differ­ently according to the type of data (audio vs. video) used, with different factor structures emerging from exploratory factor analyses of both the RIAS and the S. In each instance, the video-based factor analy­ses accounted for a greater proportion of variance, and were more con­sistent with theoretical predictions than were the audio-based factor analyses. These researchers argue that, despite the cost and intrusive­ness of videotaping, serious consideration should be given to the types of information that can be obtained from video vs. audio-tapes, and se­lections should be made with the understanding that these two forms of recording will not subsequently be coded in the same way.

Does this mean that techniques, such as the MARS, which were de-signed for use with videotaped data should become the gold standard for analysis of interpersonal interactions? The findings by Riddle and colleagues (2002) do not establish that the video-based scoring system is a better tool, nor have problems arisen in previous studies that have used the RIAS with videotaped data (e.g., Roter & Larson, 2000; Roter & Larson, 2002). Instead, these results suggest that the goals of each study must be clearly defined and that, having weighed the merits and shortcomings of each methodological approach, the most appropriate form of data collection for addressing those particular questions or goals should be selected. Many tools exist for assessing nonverbal de-coding skills (e.g., the PONS), encoding skills (e.g., the Affective Com­munication Test, ACT; Friedman, Prince, Riggio, & DiMatteo, 1980) and elements of the interaction itself (e.g., RIAS, MARS, Verona-MICS). Together, these instruments provide the means for assessing much of the complexity inherent in the physician-patient interchange.

THE NEXT STEPS FOR NONVERBAL RESEARCH
AND PRACTICE IN HEALTH CARE

Over the past 25 years, there has been a swell of interest in nonverbal communication within the medical encounter on the part of both re-searchers and clinicians. Much of the research literature is still non-experimental, however, and this limits the conclusions that can be drawn about causal relationships between nonverbal behaviors and

outcome variables. The field is now at the point of beginning to aggre gate data from disparate studies in order to discern patterns of physi­cian and patient nonverbal behaviors that 'work' within the encounter, as well as those that seem problematic. Systematic reviews and meta-analyses of physician-patient interactions are providing a clearer picture of which communicative elements tend to be most pow erful, how they are typically perceived, and how they are related to pa tient outcomes although the numbers of nonverbal studies included in such integrative reviews is typically small (e.g., Beck, Daughtridge, & Sloane, 2002; Hall, Harrigan, & Rosenthal, 1995; Ong, de Haes, Hoos, & Lammes, 1995; Stewart, 1995; Stewart, Brown, Boon, Galajda, Meredith, & Sangster, 1999). For example, Beck and colleagues (2002), in their review of studies on primary care physician-patient communication from 1975-2000 found only eight studies of nonverbal communication that met their inclusion criteria. Nonverbal behaviors associated with positive outcomes included physician head-nodding; forward lean; direct body orientation; arm symmetry; uncrossed legs and arms; and less mutual gaze. Negative outcomes were associated with indirect body orientation; backward lean; more patient gaze to-ward the physician; crossed arms; and more frequent touch (Beck et al., 2002). Such findings are in line with what is known more generally about successful nonverbal communication in social interaction. Thus, with better understanding of nonverbal expressions and com­munications within their particular contexts, it is very possible to de­velop useful programs for training health care interactants (professionals and patients) to promote positive outcomes. Of course, ongoing experimental testing will help insure that conclusions regard­ing efficacy wi11 be optimally valid.

In addition, future research should continue to validate the associa­tions of nonverbal expression to health and illness using innovative strategies such as comparing various bodily and facial movements with states of health; and studying nonverbal behaviors as they relate to brain and other physiological activation (with PET scans, fMRIs, pu pil dilation, heart rate, blood pressure, and galvanic skin responses). Such psychophysiological and social neuroscience research will yield additional clues to what has been termed the 'self-healing personality' (Friedman, 1991, 1998). The term self-healing personality refers to a healing emotional style involving a match between the individual and environment, which allows for physiological and psychosocial homeo­stasis, through which good mental health promotes good physical health. Self-healing individuals share certain personality characteris tics, find themselves in environments that match their individual style, experience healthy social interactions and life paths, and often reflect a certain nonverbal style as well. Self-healing people tend to smile natu rally-movements of the eyes, eyebrows, and mouth are synchronized and unforced. Their gestures are smooth and tend to expand out from the body; they are not likely to make aggressive gestures, and tend not

to fidget. These individuals not only walk smoothly, they also talk smoothly, showing fewer speech disturbances and more modulated tones. Their voices are also less likely to change in tone under stress. And, there are exceptions to these rules. A single nonverbal cue cannot tell us much by itself. Still, substantial valid information about a per-son's emotional style can be obtained from just a short episode of so­cial interaction, as has been powerfully demonstrated by the work on 'thin slices' of expressive behavior (e.g., Ambady & Rosenthal, 1992; 1993). These studies have shown that even very short (6 to 30 second) episodes of expressive behavior are strongly related to important out-comes and are highly accurate. This is why a careful intake interview can be so valuable to the health care professional who knows what to look for, and why that first encounter is so important to the subse­quent health of the relationship.

Nonverbal emotional styles are not easily or directly changed. As ex­pressive products, however, they reflect elements of perception, cop­ing, and person-environment match that can be altered with time and effort. Changing emotional responses to make them health promoting involves changing the habits and social environments from which they derive (Friedman, 1991). As small changes in habits are made and as individuals engage in social interactions that encourage the personal qualities they hope to achieve, movement toward self-healing will be evident in their nonverbal expressions. A biopsychosocial model sug­gests that health care providers can gain better understanding of their patients from interpreting nonverbal emotional expressions, and can also foster self-healing by encouraging small but consistent changes in social environments and behaviors (Friedman, 1993).

In medical interactions, as with all social encounters, participants function together to determine outcomes. As such, each individual shares responsibility for these outcomes and plays a role in defining the reality of the encounter. Individual components of communication can be uninformative or even misleading when viewed in isolation, but when placed in a larger context, embedded within the elements that precede and follow them, meaningful patterns emerge and subtle nuances yield rich insights.

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