Professional Documents
Culture Documents
COMMUNICATION SKILLS
Liubov Ben-Nun
In order to maintain relationships effectively humans must
communicate with each other. In everyday life, there are many types
of communication including with work colleagues, family, neighbors,
and friends, some efficient and some inefficient.
Non-verbal communication is defined as not involving words of
speech: voluntary or involuntary non-verbal signals, such as smiling
or blushing. The present research deals with non-verbal
communication among humans, evaluating biblical verses associated
with this topic from a viewpoint of contemporary perspective.
Liubov Ben-Nun
Professor Emeritus
th
44 Book.
Published by B. N. Publication House, Israel. 2014.
Distributed Worldwide
1
CONTENTS I
MY VIEW
PREFACE 2
FOREWORD 3
INTRODUCTION 4
THE BIBLICAL VERSES 8
CHARACTERISTICS OF NON-VERBAL COMMUNICATION 9
FACIAL EXPRESSIONS
GESTURES
PARALANGUAGE
PHYSICAL COMMUNICATION
KINESICS
PROXEMICS
EYE GAZE
HAPTICS
APPEARANCE
AESTHETIC COMMUNICATION
SIGNS AND SYMBOLS OF COMMUNICATION
EXPRESSION OF EMOTIONS 21
TACTILE CHANNEL
LISTENING AND COMPREHENSION 25
NOISY ENVIRONMENT
CHANGES IN BREATHING
LISTENING TO PARENTS
PASSIVE-LISTENING AND ACTIVE RESPONSE
RACE BIAS 32
TELEVISED NON-VERBAL BEHAVIOR 35
IDENTIFYING LEADERS 35
ROBOT INTERACTION 37
PHYSICIAN-PATIENT INTERACTION 37
EMPATHIC LISTENING
TRAUMATIC BRAIN INJURY
DEMENTIA
PATIENTS IN NURSING HOMES
TECHNOLOGISTS 56
DIETITIANS 56
MENTAL DISORDERS 58
PSYCHOTHERAPY
SILENCE IN PSYCHODYNAMIC PSYCHOTHERAPY
CLINICAL VIGNETTE
PEDIATRICS 73
DISCLOSING MEDICAL ERRORS 75
NURSES' NON-VERBAL COMMUNICATION 78
TEACHING 84
SUMMARY 93
ABBREVATIONS 99
1
MY VIEW
PREFACE
The purpose of this research is to analyze the medical situations
and conditions referred to in the Bible, as we are dealing with a
contemporary medical record.
FOREWORD
In the health care professions, the results of miscommunication
and misunderstanding can be costly. Stress-related ailments and
burnout occur frequently. Managers therefore should examine
organizational communication strategies and offer ways of dealing
with stress, if necessary. One stress-reduction measure that can be
undertaken at little cost is bridge building. The bridge-building
process involves making a connection or link between people by
careful listening and attention to their interactions with another.
Bridge building may include persons from all organizational levels;
the only limits are participants' willingness to risk and their desire to
improve the work environment. One strategy for bridge building is
the story meeting. Because stories are a representative way of
addressing complex issues, they can provide a framework for
handling sensitive situations. Creating a story about a department or
work team allows persons to deal with inner frustrations in a
nonthreatening way and to consider creative outcomes to their
shared problem (1).
Because communication is something that is often taken for
granted, many people do not consciously think about communication
habits and behaviors. When patients are questioned concerning
important attributes of a doctor, they say they want someone who
respects and listens to them. In a time of increasing malpractice
litigation, physicians need to examine their communication skills. In
an increasingly more diverse world, social and cultural beliefs,
attitudes, and behaviors have a considerable effect on the health of
communities. Patient safety, satisfaction, and successful outcomes
rely on understanding the patient's medical and cultural needs. The
concept of becoming a "cultural anthropologist" is improbable, but
becoming aware of the demographics of the community in which the
physician serves will improve communication and lead to improved
patient and physician satisfaction, better patient compliance, and
improved health outcomes (2).
Effective communication is essential to practice and can result in
improved interpersonal relationships at the workplace. Effective
communication is shaped by basic techniques such as open-ended
questions, listening, empathy, and assertiveness. However, the
relationship between effective communication and successful
4
References
1. Ward JR. Communications bridges raise productivity, reduce stress.
Health Prog. 1987;68(2):71-2.
2. Lewis VO, McLaurin T, Spencer HT, et al. Communication for all your
patients. Instr Course Lect. 2012;61:569-80.
3. Grover SM. Shaping effective communication skills and therapeutic
relationships at work: the foundation of collaboration. AAOHN J. 2005;
53(4):177-82; quiz 186-7.
4. Anderson M. The unspoken exchange between two human beings.
Creat Nurs. 2011;17(4):198-200.
INTRODUCTION
Effective communication is an essential skill in general practice
consultations. The art of communication is the development of
effective skills and finding a style of communication that suits the
clinician and produces benefits for both patient and doctor. The
essential skills are required for effective communication with a
patient and clinicians should consider this communication as an art
that can be developed throughout a medical career. Good
communication can improve outcomes for patients and doctors, and
deserves equal importance as developing clinical knowledge and
procedural skill. A therapeutic patient-doctor relationship uses the
clinician as a therapeutic intervention and is part of the art of
communication. Despite all the technological advances of recent
5
of 38.8 (16.0) years, and 30.8% were male. Intercoder reliability was
good, with mean intercoder correlations of 0.76 and 0.67 for all
categories of provider and patient talk, respectively. Providers
accounted for the majority of the conversation in the tapes (median
= 239 utterances, IQR = 168 to 308) compared to patients (median =
145 utterances, IQR = 80 to 198). Providers' utterances focused most
on patient education and counseling (34%), followed by patient
facilitation and activation (e.g., orienting the patient to the next steps
in the ED or asking if the patient understood; 30%). Approximately
15% of the provider talk was spent on data gathering, with the
majority (86%) focusing on biomedical topics rather than
psychosocial topics (14%). Building a relationship with the patient
(e.g., social talk, jokes/laughter, showing approval, or empathetic
statements) constituted 22% of providers' talk. Patients' conversation
was mainly focused in 2 areas: information giving (47% of patient
utterances: 83% biomedical, 17% psychosocial) and building a
relationship (45% of patient utterances). Only 5% of patients'
utterances were devoted to question asking. Patient-centeredness
scores were low. In conclusion, in this sample, both providers and
patients spent a significant portion of their talk time providing
information to one another, as might be expected in the fast-paced
ED setting. Less expected was the result that a large percentage of
both provider and patient utterances focused on relationship
building, despite the lack of traditional, longitudinal provider-patient
relationships (3).
The purpose of this article is to provide a commentary on non-
verbal communication in the physician-older patient interaction. A
literature review of physician-older patient communication yielded
several published studies on this topic. Non-verbal behaviors were
rarely examined in this body of literature even though the need to
adopt a more "biopsychosocial" model of care was mentioned in
several of the articles. The non-verbal communication literature was
also reviewed to determine whether aging had been a variable of
interest with regard to encoding (sending) and decoding
communication (receiving) skills. There have been very few studies
that have investigated the role of non-verbal communication in the
physician-older patient interaction. Selected encoding and decoding
characteristics for both physicians and patients are discussed with
the context of the aging process. In lieu of direct evidence linking
7
References
1. Warnecke E. The art of communication. Aust Fam Physician. 2014;43
(3):156-8.
2. Shaw JR. Four core communication skills of highly effective
practitioners. Vet Clin North Am Small Anim Pract. 2006;36(2):385-96, vii.
3. McCarthy DM, Buckley BA, Engel KG, et al. Understanding patient-
provider conversations: what are we talking about? Acad Emerg Med. 2013;
20(5):441-8.
4. Irish JT. Deciphering the physician-older patient interaction. Int J
Psychiatry Med. 1997;27(3):251-67.
8
Reference
ND
1. The Penguin English Dictionary. 2 ED. Penguin Books. Robert Allen
Consultant ed. 2003. England.
2. Examples of Non Verbal Communication. Available 15 May 2014 at
yourdictionary.com/examples-of-non-verbal-communication.
9
CHARACTERISTICS OF NON-VERBAL
COMMUNICATION
An estimated 60 to 65 percent of interpersonal communication is
conveyed via non-verbal behaviors (1). Unfortunately, the emphasis
in the clinical setting is disproportionately placed on verbal
interactions. Many non-verbal behaviors are unconscious and may
represent a more accurate depiction of a patient's attitude and
emotional state. They can belie a patient's anxiety regarding a
specific topic discussed in therapy despite verbal assertions that the
subject is inconsequential and not causing distress. It is critically
important to consider a patient's non-verbal behaviors when
assessing risk of harm to self or others. Alternatively, non-verbal
behaviors may shed light on feelings of transference and counter-
transference between patient and physician (2).
All non-verbal behavior must be interpreted within context. Knapp
and Hall specifically address the issue of physicians' limited training in
non-verbal communication. Physicians can use this kind of
knowledge. However, it is important that physicians not only notice
cues but also that they draw appropriate interpretations from them
(3). Non-verbal cues cannot be interpreted in a vacuum. No single
behavior or gesture means the exact same thing in every conceivable
context. For example, consider the hand gesture of extending only
the index and middle fingers, spread apart in a V shape, while closing
the rest of the hand. This might signify a number, 2. In the United
States if the palm is facing the individual using this gesture it signifies
victory and if the palm is facing others it is identified as a symbol
meaning peace. In England, however, making the American V for
victory sign is an insult with sexual connotations. In London,
displaying the American peace sign instead represents victory (3).
Non-verbal communication is one of the key aspects of
communication and especially important in a high-context culture. It
has multiple functions: used to repeat the verbal message e.g. point
in a direction while stating directions; often used to accent a verbal
message e.g. verbal tone indicates the actual meaning of the specific
words, often complement the verbal message but also may
contradict, e.g. a nod reinforces a positive message (among
Americans); a wink may contradict a stated positive message;
10
FACIAL EXPRESSIONS
Non-verbal communication includes facial expressions, gestures,
and eye contact. When someone is talking, changes in facial
expressions are noticed and respond accordingly. These include
raising eyebrows, yawning, sneering, rolling eyes, gaping, and
nodding. The meaning of these movements is pretty much the same
in all cultures (6).
12
GESTURES
Gestures are many times an individuals way of communicating as
most people gesture when talking (4). Deliberate movements and
signals are an important way to communicate meaning without
words. Common gestures include waving, pointing, and using fingers
to indicate numeric amounts. Other gestures are arbitrary and
related to culture (6).
People move their hands as they talk - they gesture. Gesturing is a
robust phenomenon, found across cultures, ages, and tasks. Gesture
is found in individuals blind from birth. However, what purpose, if
any, does gesture serve? Gesture when it stands on its own,
substituting for speech and clearly serving a communicative function
is examined. When called upon to carry the full burden of
communication, gesture assumes a language-like form, with
structure at word and sentence levels. However, when produced
along with speech, gesture assumes a different form - it becomes
15
imagistic and analog. Despite its form, the gesture that accompanies
speech also communicates. Trained coders can glean substantive
information from gesture - information that is not always identical to
that gleaned from speech. Gesture can thus serve as a research tool,
shedding light on speakers' unspoken thoughts. The controversial
question is whether gesture conveys information to listeners not
trained to read them. Do spontaneous gestures communicate to
ordinary listeners? Or might they be produced only for speakers
themselves? These are not mutually exclusive functions - gesture
serves as both a tool for communication for listeners, and a tool for
thinking for speakers (17).
When speakers talk, they gesture. The goal of this review is to
investigate the contribution that these gestures make to how we
communicate and think. Gesture can play a role in communication
and thought at many time spans. In turn, gesture's contribution to
how language is produced and understood in the moment is
explored; its contribution to how we learn language and other
cognitive skills; and its contribution to how language is created over
generations, over childhood, and on the spot. The gestures speakers
produce when they talk are integral to communication and can be
harnessed in a number of ways. 1] Gesture reflects speakers'
thoughts, often their unspoken thoughts, and thus can serve as a
window onto cognition. Encouraging speakers to gesture can thus
provide another route for teachers, clinicians, interviewers, etc., to
better understand their communication partners. 2] Gesture can
change speakers' thoughts. Encouraging gesture thus has the
potential to change how students, patients, witnesses, etc., think
about a problem and, as a result, alter the course of learning,
therapy, or an interchange. 3] Gesture provides building blocks that
can be used to construct a language. By watching how children and
adults who do not already have a language put those blocks together,
we can observe the process of language creation. Our hands are with
us at all times and thus provide researchers and learners with an
ever-present tool for understanding how we talk and think (18).
Gesture has privileged access to information that children know
but do not say. As such, it can serve as an additional window to the
mind of the developing child, one that researchers are only beginning
to acknowledge. Gesture might, however, do more than merely
reflect understanding - it may be involved in the process of cognitive
16
PARALANGUAGE
Paralanguage includes other mental status elements, such as
prosody, rate, rhythm, volume, tone, and pitch of speech (20).
Paralinguistics refers to vocal communication that is separate
from actual language. This includes factors such as tone of voice,
loudness, inflection and pitch, considering the powerful effect that
tone of voice can have on the meaning of a sentence. When said in a
strong tone of voice, listeners might interpret approval and
enthusiasm. The same words said in a hesitant tone of voice might
convey disapproval and a lack of interest (6).
PHYSICAL COMMUNICATION
Physical communication covers the personal kind of
communication, and includes a smile or frown, wink, touch, smell,
salute, gesture, and other bodily movements. Social conversation
uses many of these physical signals along with the spoken words (21).
Physical communication is the most used form of non-verbal
communication. A person that is aware of anothers non-verbal cues
will understand that person better. Even the way one is standing and
his/her position in a group of people can communicate. The amount
of distance between 2 persons will be interpreted in a certain way,
17
and the meaning will change according to the culture. It either can
mean an attraction, or can signal intensity. Standing side-to-side can
show cooperation, where a face-to-face posture may show
competition. A posture can communicate in a non-verbal way,
whether a person is folding his arms, slouching, crossing his legs, or
standing and sitting erect. Finally, any actual touching can convey
attraction or a level of intimacy. Examples of non-verbal
communication of this type include shaking hands, patting the back,
hugging, pushing, or other kinds of touch (6).
KINESICS
Kinesics includes how the body moves. This includes posture,
body movements, gestures, eye behaviors, and facial expressions.
Each refers to elements of the mental status examination in a
different guise (e.g., general appearance and behavior, psychomotor
functioning, eye contact, and affect) (20).
Posture and movement can convey a great deal of information.
Research on body language has grown significantly since the 1970's,
but popular media have focused on the over-interpretation of
defensive postures, arm-crossing, and leg-crossing, especially after
the publication of Julius Fast's book Body Language. While these non-
verbal behaviors can indicate feelings and attitudes, research
suggests that body language is far more subtle and less definitive that
previously believed (6).
PROXEMICS
People often refer to their need for "personal space," which is also
an important type of non-verbal communication. The amount of
distance we need and the amount of space we perceive as belonging
to us is influenced by a number of factors including social norms,
situational factors, personality characteristics and level of familiarity.
For example, the amount of personal space needed when having a
casual conversation with another person usually varies between 18
18
EYE GAZE
Looking, staring and blinking can also be important non-verbal
behaviors. When people encounter people or things that they like,
the rate of blinking increases and pupils dilate. Looking at another
person can indicate a range of emotions, including hostility, interest
and attraction (6).
Eye contact is important in communicating non-verbally. A
persons emotion through their eyes can be read, and many times is
not the same emotion as their words are saying (4).
HAPTICS
Communicating through touch is another important non-verbal
behavior. There has been a substantial amount of research on the
importance of touch in infancy and early childhood. Harry Harlow's
classic monkey study demonstrated how the deprivation of touch
and contact impedes development. Baby monkeys raised by wire
mothers experienced permanent deficits in behavior and social
interaction. Touch can be used to communicate affection, familiarity,
sympathy and other emotions (6).
APPEARANCE
Our choice of color, clothing, hairstyles and other factors affecting
appearance are a means of non-verbal communication. Research on
color psychology has demonstrated that different colors can evoke
different moods. Appearance can also alter physiological reactions,
judgments and interpretations. The first impressions are important,
19
which is why experts suggest that job seekers dress appropriately for
interviews with potential employers (4).
AESTHETIC COMMUNICATION
Aesthetic communication occurs through creative expression.
This includes the arts: music, dance, theatre, crafts, art, painting, and
sculpture. Ballet is a great example of this, as there is dance and
music, but no spoken or sung words. Even in an opera, where there
are words, there are still facial expressions, costumes, posture, and
gestures (21).
References
1. Burgoon JK, Guerrero LK, Floyd K. Nonverbal Communication. Boston,
MA: Allyn and Bacon. 2009.
2. Philippot P, Feldman R, Coats E. The role of nonverbal behavior in
clinical settings. In: Philippot P, Feldman R, Coats E (eds.). Nonverbal
Behavior in Clinical Settings. New York, NY: Oxford University Press. 2003,
pp. 313.
3. Knapp ML, Hall JA. Nonverbal Communication in Human Interaction,
Seventh Edition. Wadsworth, Canada: Cengage Learning. 2010.
4. Non Verbal Communication. Available 15 May 2014 at
andrews.edu/~tidwell/bsad560/NonVerbal.html.
5. Samovar LA, Porter RE, McDaniel ER. Communication Between
Cultures. Cengage Learning. Social Science. 2009.
6. Kendra Cherry. Types of Nonverbal Communication. Available 16 May
2014 at psychology.about.com/.../nonverbalcommunication/.../nonverbal
types.htm.
7. D'Agostino TA, Bylund CL. Nonverbal accommodation in health care
communication. Health Commun. 2014;29(6):563-73.
8. Gretchen N. Foley, Julie P. Gentile. Nonverbal Communication in
Psychotherapy. Psychiatry (Edgmont). 2010;7(6):3844.
9. Yamamoto K, Suzuki N. Effect of an observer's presence on facial
behavior during dyadic communication. Percept Mot Skills. 2012;114(3):949-
63.
10. Ekman P, Friesen WV. Constants across cultures in the face and
emotion. J Personal Soc Psychol. 1971;17(2):124129.
11. Ekman P, Friesen WV. Unmasking the Face. Englewood Cliffs, NJ:
Prentice-Hall Inc. 1975.
12. FACS vs. F.A.C.E. The differences between FACS and F.A.C.E. Available
15 April 2010 at training paulekman.com/products/facs-vs-f-a-c-e/.
13. Berg JH, Clark MS. Differences in Social exchange between intimate
and other relationships. Gradually evolving or quickly apparent? In Derlega
VJ, Winstead BA (eds.). Friendship and Social Interaction. New York Springer-
Verlag. 1986.
14. Yamamoto K, Suzuki N. Facial expressions in the course of
relationship formation. Shinrigaku Kenkyu. 2008;78(6):567-74.
21
EXPRESSION OF EMOTIONS
Relationship-centered care reflects both knowing and feeling: the
knowledge that physician and patient bring from their respective
domains of expertise, and the physicians and patient's experience,
expression, and perception of emotions during the medical
encounter. These processes are conveyed and reciprocated in the
care process through verbal and non-verbal communication. The
emotional context of care is especially related to non-verbal
communication and emotion-related communication skills, including
sending and receiving non-verbal messages and emotional self-
awareness are critical elements of high-quality care. Although non-
verbal behavior has received far less study than other care processes,
the current review argues that it holds significance for the
therapeutic relationship and influences important outcomes
including satisfaction, adherence, and clinical outcomes of care (1).
This study investigated the hypothesis that different emotions are
most effectively conveyed through specific, non-verbal channels of
communication: body, face, and touch. Experiment 1 assessed the
production of emotion displays. Participants generated non-verbal
displays of 11 emotions, with and without channel restrictions. For
both actual production and stated preferences, participants favored
22
the body for embarrassment, guilt, pride, and shame; the face for
anger, disgust, fear, happiness, and sadness; and touch for love and
sympathy. When restricted to a single channel, participants were
most confident about their communication when production was
limited to the emotion's preferred channel. Experiment 2 examined
the reception or identification of emotion displays. Participants
viewed videos of emotions communicated in unrestricted and
restricted conditions and identified the communicated emotions.
Emotion identification in restricted conditions was most accurate
when participants viewed emotions displayed via the emotion's
preferred channel. This study provides converging evidence that
some emotions are communicated predominantly through different
non-verbal channels. Further analysis of these channel-emotion
correspondences suggests that the social function of an emotion
predicts its primary channel: The body channel promotes social-
status emotions, the face channel supports survival emotions, and
touch supports intimate emotions (2).
Just as there are facial expressions that appear to be universally
understood, vocally expressed emotions are also readily identifiable
by members of different cultures (3). In fact, an individual often can
differentiate the appropriate emotional state of a speaker when the
words spoken have no contextual relationship to the emotion being
expressed, even if words are spoken in a foreign language (4). In
Pell's study (4), native Argentinean Spanish-speaking (and
monolingual) listeners accurately identified the emotion of joy 89
percent of the time and the feeling of anger 81 percent of the time
when spoken in pseudo-utterances, which are nonsense words
modeled after Spanish linguistic properties that removed any content
or contextual clues with which to identify the emotion. The same
listeners were fairly successful identifying emotions of speakers
talking in other languages. In fact, 77 percent of the listeners
correctly identified the feeling of anger when the words were spoken
in German, 74 percent accurately identified sadness spoken in
English, and 77 percent rightly identified sadness when spoken in
Arabic (4).
23
References
1. Roter DL, Frankel RM, Hall JA, Sluyter D. The expression of emotion
through nonverbal behavior in medical visits. Mechanisms and outcomes. J
Gen Intern Med. 2006;21 Suppl 1:S28-34.
2. App B, McIntosh DN, Reed CL, Hertenstein MJ. Nonverbal channel use
in communication of emotion: how may depend on why. Emotion. 2011;
11(3):603-17.
3. Scherer KR, Banse R, Walkbott H. Emotional interferences from vocal
expression correlate across languages and cultures. J Cross-Cultur Psychol.
2001;32:7692.
4. Pell MD, Monetta L, Paulmann S, Kotz S. Recognizing emotions in a
foreign language. J Nonverb Behav. 2009;33:107120.
TACTILE CHANNEL
Participants in the current study were allowed to touch an
unacquainted partner on the whole body to communicate distinct
emotions. Of interest was how accurately the person being touched
decoded the intended emotions without seeing the tactile
stimulation. The data indicated that anger, fear, disgust, love,
gratitude, and sympathy were decoded at greater than chance levels,
as well as happiness and sadness, 2 emotions that have not been
shown to be communicated by touch to date. Moreover, fine-grained
coding documented specific touch behaviors associated with
different emotions (1).
Good communication skills are integral to successful doctor-
patient relationships. Communication is verbal or non-verbal, and
touch is a significant component, which has received little attention
in the primary care literature. Touch may be procedural (part of a
clinical task) or expressive (contact unrelated to a
24
References
1. Hertenstein MJ, Holmes R, McCullough M, Keltner D. The
communication of emotion via touch. Emotion. 2009;9(4):566-73.
2. Cocksedge S, George B, Renwick S, Chew-Graham CA. Touch in
primary care consultations: qualitative investigation of doctors' and
patients' perceptions. Br J Gen Pract. 2013;63(609):e283-90.
25
References
1. Kacperek L. Non-verbal communication: the importance of listening.
Br J Nurs. 1997;6(5):275-9.
2. Shipley SD. Listening: a concept analysis. Nurs Forum. 2010;45(2):125-
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3. Parrott LJ. Listening and understanding. Behav Anal. 1984;7(1):29-39.
4. Skinner B. F. Verbal behavior. Cambridge, MA: Prentice Hall. 1957.
5. Schlinger HD. Listening is behaving verbally. Behav Anal. 2008;31(2):
145-61.
6. Shen J, Itti L. Top-down influences on visual attention during listening
are modulated by observer sex. Vision Res. 2012;65:62-76.
7. Srqvist P, Hurtig A, Ljung R, Rnnberg J. High second-language
proficiency protects against the effects of reverberation on listening
comprehension. Scand J Psychol. 2014;55(2):91-6.
29
NOISY ENVIRONMENT
Multi-talker conversations challenge the perceptual and cognitive
capabilities of older adults and those listening in their L2. In older
adults, these difficulties could reflect declines in the auditory,
cognitive, or linguistic processes supporting speech comprehension.
The tendency of L2 listeners to invoke some of the semantic and
syntactic processes from their L1 may interfere with speech
comprehension in L2. These challenges might also force them to
reorganize the ways in which they perceive and process speech,
thereby altering the balance between the contributions of bottom-up
vs. top-down processes to speech comprehension. Younger and older
L1s as well as young L2s listened to conversations played against a
babble background, with or without spatial separation between the
talkers and masker, when the spatial positions of the stimuli were
specified either by loudspeaker placements (real location), or
through use of the precedence effect (virtual location). After listening
to a conversation, the participants were asked to answer questions
regarding its content. Individual hearing differences were
compensated for by creating the same degree of difficulty in
identifying individual words in babble. Once compensation was
applied, the number of questions correctly answered increased when
a real or virtual spatial separation was introduced between babble
and talkers. There was no evidence that performance differed
between real and virtual locations. The contribution of vocabulary
knowledge to dialog comprehension was larger in the virtual
conditions than in the real whereas the contribution of reading
comprehension skill did not depend on the listening environment but
rather differed as a function of age and language proficiency. The
acoustic scene and the cognitive and linguistic competencies of
listeners modulate how and when top-down resources are engaged
in aid of speech comprehension (1).
Reference
1. Avivi-Reich M, Daneman M, Schneider BA. How age and linguistic
competence alter the interplay of perceptual and cognitive factors when
listening to conversations in a noisy environment. Front Syst Neurosci. 2014
Feb 25;8:21.
30
CHANGES IN BREATHING
Reference
1. Paccalin C, Jeannerod M. Changes in breathing during observation of
effortful actions. Brain Res. 2000;862:194200.
2. Rochet-Capellan A, Fuchs S. Changes in breathing while listening to
read speech: the effect of reader and speech mode. Front Psychol. 2013 Dec
9;4:906.
31
LISTENING TO PARENTS
The purpose of this study was to increase understanding of the
experience of parenting kindergarten-aged children who were
anxious. Twenty-three in-depth interviews were conducted with
parents of kindergarten-aged children who expressed interest in a
parent-focused early intervention program for child anxiety offered
in a local elementary school. Key concerns of the parents included
their children's separation anxiety, social anxiety, and oppositional
behavior. The child's anxiety was identified as a stressor on the child,
the parent, and the family. Parents utilized a range of parenting
responses although they tended to be reactive and did not have a
consistent strategy for managing the anxiety. A salient parenting
struggle was whether or not to push the child to face challenging
situations although there were few descriptions of overprotection or
overcontrol. The findings suggest greater attention be given to the
strengths of parents of children who are anxious and the ways in
which parents may be a positive factor in mitigating the effects of
child anxiety. Implications for intervention are discussed (1).
Reference
1. Hiebert-Murphy D, Williams EA, Mills RS, et al. Listening to parents:
the challenges of parenting kindergarten-aged children who are anxious.
Clin Child Psychol Psychiatry. 2012;17(3):384-99.
Reference
1. Wang Y, Holland SK. Comparison of functional network connectivity
for passive-listening and active-response narrative comprehension in
adolescents. Brain Connect. 2014;4(4):273-85.
RACE BIAS
A voluminous literature has examined how primates respond to
non-verbal expressions of status, such as taking the high ground,
expanding one's posture, and tilting one's head. This research was
extended to human intergroup processes in general and interracial
processes in particular. Perceivers may be sensitive to whether racial
group status is reflected in group members' non-verbal expressions
of status. Whether people who support the status hierarchy would
prefer racial groups whose members exhibit status-appropriate non-
verbal behavior to racial groups whose members do not exhibit such
behavior was evaluated. People who reject the status quo should
exhibit the opposite pattern. These hypotheses were supported in 3
studies using self-report (Study 1) and reaction time (Studies 2 and 3)
measures of racial bias and 2 different status cues (vertical position
and head tilt). For perceivers who supported the status quo, high-
33
References
1. Weisbuch M, Slepian ML, Eccleston CP, Ambady N. Nonverbal
expressions of status and system legitimacy: an interactive influence on race
bias. Psychol Sci. 2013;24(11):2315-21.
2. Weisbuch M, Pauker K, Ambady N. The subtle transmission of race
bias via televised nonverbal behavior. Science. 2009;326(5960):1711-4.
3. Olson MA, Fazio RH. Discordant evaluations of Blacks affect nonverbal
behavior. Pers Soc Psychol Bull. 2007;33(9):1214-24.
4. Stepanikova I, Zhang Q, Wieland D, et al. Non-verbal communication
between primary care physicians and older patients: how does race matter?
J Gen Intern Med. 2012;27(5):576-81
35
Reference
1. Weisbuch M, Ambady N. Unspoken cultural influence: exposure to
and influence of nonverbal bias. J Pers Soc Psychol. 2009; 96(6):1104-19.
IDENTIFYING LEADERS
Research investigating the influence and character of non-verbal
leader displays has been carried out in a systematic fashion since the
early 1980s, yielding growing insight into how viewers respond to the
televised facial display behavior of politicians. The major streams of
research in this area considers the key ethological frameworks for
understanding dominance relationships between leaders and
followers and the role non-verbal communication plays in politics and
social organization. The analysis focuses on key categories of facial
display behavior by examining an extended selection of published
experimental studies considering the influence of non-verbal leader
behavior on observers, the nature of stimuli shown to research
participants, range of measures employed, and make-up of
participant pools (1).
36
Reference
1. Stewart PA, Salter FK, Mehu M. Taking leaders at face value: ethology
and the analysis of televised leader displays. Politics Life Sci. 2009;28(1):48-
74.
2. Stein RT. Identifying emergent leaders from verbal and nonverbal
communications. J Pers Soc Psychol. 1975;32(1):125-35.
3. Gitter AG, Black H, Goldman A. Role of nonverbal communication in
the perception of leadership. Percept Mot Skills. 1975;40(2):463-6.
37
ROBOT INTERACTION
How do humans coordinate their intentions, goals and motor
behaviors when performing joint action tasks? Recent experimental
evidence suggests that resonance processes in the observer's motor
system are crucially involved in our ability to understand actions of
others to infer their goals and even to comprehend their action-
related language. In this paper, a control architecture for human-
robot collaboration that exploits this close perception-action linkage
as a means to achieve more natural and efficient communication
grounded in sensorimotor experiences is presented. The architecture
is formalized by a coupled system of dynamic neural fields
representing a distributed network of neural populations that encode
in their activation patterns goals, actions and shared task knowledge.
The verbal and non-verbal communication skills of the robot in a joint
assembly task in which the human-robot team has to construct toy
objects from their components were validated. The experiments
focus on the robot's capacity to anticipate the user's needs and to
detect and communicate unexpected events that may occur during
joint task execution (1).
Reference
1. Bicho E, Louro L, Erlhagen W. Integrating verbal and nonverbal
communication in a dynamic neural field architecture for human-robot
interaction. Front Neurorobot. 2010 May 21;4. pii: 5.
PHYSICIAN-PATIENT INTERACTION
The physician-patient interview is the key component of all health
care, particularly of primary medical care. This review sought to
evaluate existing primary-care-based research studies to determine
which verbal and non-verbal behaviors on the part of the physician
during the medical encounter have been linked in empirical studies
with favorable patient outcomes. The literature was reviewed from
1975 to 2000 for studies of office interactions between primary care
physicians and patients that evaluated these interactions empirically
38
eye contact, smiling, tone of voice, nod, and facial expressivity) in the
3 encounters. Multiple regression approaches were used to
investigate the association of physician non-verbal behavior with
patient satisfaction in the context of the "quality" of the interview (SP
checklist performance, and measures of verbal communication skills),
controlling for physician characteristics (gender, and postgraduate
year). Non-verbal communication skills were an independent
predictor of standardized patient satisfaction for all 3 patient
stations. The effect sizes were substantial, with non-verbal
communication predicting 32% of the variance in patient satisfaction
for the chest pain station, 23% of the variance for the depression-
sexual abuse station, and 19% of the variance for the HIV counseling
station. In conclusion, better non-verbal communication skills are
associated with greater patient satisfaction in a variety of different
types of clinical encounters with SPs. Formal instruction in non-verbal
communication is important addition to residency (4).
There are several measurement tools to assess verbal dimensions
in clinical encounters; by contrast, there is no established tool to
evaluate physical non-verbal dimensions in geriatric encounters. The
present paper describes the development of a tool to assess the
physical context of examination rooms in doctor-older patient visits.
Salient features of the tool were derived from the medical literature
and systematic observations of videotapes and refined during current
research. The tool consists of 2 main dimensions of examination
rooms: 1] physical dimensions comprising static and dynamic
attributes that become operational through the spatial configuration
and can influence the manifestation of 2] kinesic attributes. In
conclusion, details of the coding form and inter-rater reliability are
presented. The usefulness of the tool is demonstrated through an
analysis of 50 National Institute of Aging videotapes. Physicians in
examination rooms with no desk in the interaction, no height
difference and optimal interaction distance were observed to have
greater eye contact and touch than physicians' in examination rooms
with a desk, similar height difference and interaction distance. The
tool can enable physicians to assess the spatial configuration of
examination rooms (through Parts A and B) and thus facilitate the
structuring of kinesic attributes (Part C) (5).
41
cues. The most frequent features were tone of voice, eye contact,
and facial expressions. Less frequent were examination room
characteristics, touch, interpersonal distance, GP clothing, gestures,
and posture. In conclusion, non-verbal communication is an
important factor by which patients spontaneously describe and
evaluate their interactions with a GP. Family GPs should be trained to
better understand and monitor their own non-verbal behaviors
towards patient (7).
A field study of 28 residents in family practice was conducted.
Physicians' self-reports of empathy, self-monitoring ability, and
affective communication skill as well as their objectively measured
non-verbal communication skills were examined as predictors of
patient satisfaction, appointment noncompliance, and physician
workload (schedule density). Physicians completed the Hogan
Empathy Scale, Snyder Self-Monitoring Scale, Affective
Communication Test, short form of the Profile of Non-verbal
Sensitivity, and a non-verbal encoding task. Patient satisfaction with
communication, affective care, and technical care was assessed using
a 25-item, visit-specific satisfaction scale. Appointment records were
used to determine the number of patients seen by each physician
and the compliance of patients with scheduled appointments. Results
indicated that the 3 self-report measures were unrelated to the
measures of patient noncompliance and patient satisfaction, but self-
reported affective communication ability was significantly correlated
with physician workload. Objectively measured physician sensitivity
to audio communication predicted patient compliance: more
sensitive physicians experienced fewer un-rescheduled appointment
cancellations (8).
Recent empirical findings document the role of non-verbal
communication in cross-cultural interactions. As ethnic minority
health disparities in the US continue to persist, physician competence
in this area is important. Physicians' abilities to decode non-verbal
emotions across cultures were examined, the hypothesis being that
there is a relationship between physicians' skill in this area and their
patients' satisfaction and outcomes. First part tested Caucasian and
South Asian physicians' cross-cultural emotional recognition ability.
Physicians completed a balanced forced multiple-choice test of
decoding accuracy judging emotions based on facial expressions and
vocal tones. In the second part, patients reported on satisfaction and
43
References
1. Beck RS, Daughtridge R, Sloane PD. Physician-patient communication
in the primary care office: a systematic review. J Am Board Fam Pract. 2002;
15(1):25-38.
2. Mast MS. On the importance of nonverbal communication in the
physician-patient interaction. Patient Educ Couns. 2007;67(3):315-8.
3. DiMatteo MR, Taranta A, Friedman HS, Prince LM. Predicting patient
satisfaction from physicians' nonverbal communication skills. Med Care.
1980;18(4):376-87.
4. Griffith CH 3rd, Wilson JF, Langer S, Haist SA. House staff nonverbal
communication skills and standardized patient satisfaction. J Gen Intern
Med. 2003;18(3):170-4.
5. Gorawara-Bhat R, Cook MA, Sachs GA. Nonverbal communication in
doctor-elderly patient transactions (NDEPT): development of a tool. Patient
Educ Couns. 2007;66(2):223-34.
44
6. Mast MS, Hall JA, Kckner C, Choi E. Physician gender affects how
physician nonverbal behavior is related to patient satisfaction. Med Care.
2008;46(12):1212-8.
7. Marcinowicz L, Konstantynowicz J, Godlewski C. Patients' perceptions
of GP non-verbal communication: a qualitative study. Br J Gen Pract. 2010;
60(571):83-7.
8. DiMatteo MR, Hays RD, Prince LM. Relationship of physicians'
nonverbal communication skill to patient satisfaction, appointment
noncompliance, and physician workload. Health Psychol. 1986;5(6):581-94.
9. Coelho KR, Galan C. Physician cross-cultural nonverbal
communication skills, patient satisfaction and health outcomes in the
physician-patient relationship. Int J Family Med. 2012;2012:376907.
EMPATHIC LISTENING
As part of the epistemological transition from positivistic to
relativistic science that had begun earlier in the twentieth century,
Kohut attempted to update psychoanalytic thinking in formulating
the empathic mode of observation (1-4). The purpose of this paper is
to reassess, through a conceptual and historical lens, the
considerable controversy generated by the empathic perspective.
The author specifically addresses constructivist philosophical
underpinnings, the use and impact of the analyst's subjectivity, the
inclusion of unconscious processes, the need for additional listening
perspectives, and the influence of theoretical models in the
organization of empathically acquired data (5).
Empathy, the ability to communicate an understanding of a
client's world, is a crucial component of all helping relationships. It is
important to focus on the failure of measures of empathy to reflect
clients' views about the ability to offer empathy. It is argued that, if
clients are able to perceive the amount of empathy in helping
relationships, they are able to advise professionals about how to
offer empathy. There are the inconclusive research evidence that
existing courses have enabled professionals to offer empathy, and
the disagreement about how empathy is best taught (6).
Empathy is crucial to all forms of helping relationships. While
most studies cited are more than a decade old, the relationship
45
References
1. Kohut H. Introspection, empathy and psychoanalysis. J Americ
Psychoanalysis Assn. 1959;7:459-83.
2. Kohut H. The restoration of the self. New York International Press.
1977.
3. Kohut H. Introspection, empathy and the semicircle of mental health.
Intern J Psycho-Anal. 1982;63:359-407.
4. Kohut H. How does analysis cure? Goldberg A, Stepansky P (eds.).
Chicago: The University of Chicago Press. 1984.
5. Fosshage JL. The use and impact of the analyst's subjectivity with
empathic and other listening/experiencing perspectives. Psychoanal Q.
2011;80(1):139-60.
6. Reynolds WJ, Scott B, Jessiman WC. Empathy has not been measured
in clients' terms or effectively taught: a review of the literature. J Adv Nurs.
1999;30(5):1177-85.
7. Reynolds WJ, Scott B. Empathy: a crucial component of the helping
relationship. J Psychiatr Ment Health Nurs. 1999;6(5):363-70.
8. Reynolds B. The influence of clients' perceptions of the helping
relationship in the development of an empathy scale. J Psychiatr Ment
Health Nurs. 1994;1(1):23-30.
9. Gliacomi MK, Cook DJ. Are the results of the study valid? Users' guide
to the medical literature. XXIII. Qualitative research in the health care.
JAMA. 2000a; 284:357-362.
10. Gliacomi MK, Cook DJ. What are the results and how they do help
me care for my patients? Users' guide to the medical literature. XXIII.
Qualitative research in the health care. JAMA. 2000b; 284:478-482.
11. Derksen F, Bensing J, Lagro-Janssen A. Effectiveness of empathy in
general practice: a systematic review. Br J Gen Pract. 2013;63(606): e76-84.
12. Handford C, Lemon J, Grimm MC, Vollmer-Conna U. Empathy as a
function of clinical exposure - reading emotion in the eyes. PLoS One. 2013;
8(6):e65159.
13. Mercer SW, Neumann M, Wirtz M, et al. General practitioner
empathy, patient enablement, and patient-reported outcomes in primary
50
References
1. Croker V, McDonald S. Recognition of emotion from facial expression
following traumatic brain injury. Brain Inj. 2005;19(10):787-99.
2. Hopkins MJ, Dywan J, Segalowitz SJ. Altered electrodermal response
to facial expression after closed head injury. Brain Inj. 2002;16(3):245-57.
3. Bird J, Parente R. Recognition of nonverbal communication of
emotion after traumatic brain injury. NeuroRehabilitation. 2014;34(1):39-43.
4. Prutting CA, Kirchner DM. A clinical appraisal of the pragmatic aspects
of language. J Speech Hear Disord. 1987;52(2):105-19.
5. Aubert S, Barat M, Campan M, et al. Non verbal communication
abilities in severe traumatic brain injury. Ann Readapt Med Phys. 2004;
47(4):135-41.
6. Sainson C. Non-verbal communication and executive function
impairment after traumatic brain injury: a case report. Ann Readapt Med
Phys. 2007;50(4):231-9.
DEMENTIA
This review underlines the importance of non-verbal
communication in Alzheimer's disease. A social psychological
perspective of communication is privileged. Non-verbal behaviors
such as looks, head nods, hand gestures, body posture or facial
expression provide a lot of information about interpersonal attitudes,
behavioral intentions, and emotional experiences. Therefore, they
play an important role in the regulation of interaction between
individuals. Non-verbal communication is effective in Alzheimer's
disease even in the late stages. Patients still produce non-verbal
signals and are responsive to others. Nevertheless, few studies have
been devoted to the social factors influencing the non-verbal
53
References
1. Schiaratura LT. Non-verbal communication in Alzheimer's disease.
Psychol Neuropsychiatr Vieil. 2008;6(3):183-8.
2. Hydn LC. Non-verbal vocalizations, dementia and social interaction.
Commun Med. 2011;8(2):135-44.
54
References
1. Zaletel M, Kovacev AN, Sustersic O, Kragelj LZ. Non-verbal
communication of the residents living in homes for the older people in
Slovenia. Coll Antropol. 2010;34(3):829-40.
2. Zaletel M, Kovacev AN, Mikus RP, Kragelj LZ. Nonverbal
communication of caregivers in Slovenian nursing homes. Arch Gerontol
Geriatr. 2012; 54(1):94-101.
56
TECHNOLOGISTS
Although the amount of time a technologist spends with a patient
may be brief, the attitude and approach he uses with that patient is
of utmost importance. By being sensitive to the often unspoken
thoughts and feelings of the patient, the technologist can respond
with the words, touch, or facial expression that will let the patient
know he is recognized as a human being and his needs are
understood and are being responded to with empathetic concern (1).
Reference
1. Ireland SJ, Hansen EU. Brief encounter: origin of patient
communication. Radiol Technol. 1978;50(1):33-6.
DIETITIANS
Little is known about how dietitians conduct their communication
with individual patients in the process of nutrition education. To
study this issue, both practitioners' and patients' perceptions of
dietitians' skills were examined in the first phase of a 2-phase study.
The resulting narratives were used to develop a questionnaire to
survey Australian dietitians involved in clinical practice. A purposive
sample of dietitians in 1 state (n=46; 12%), working in hospital,
community or private practice, and a quota of their adult patients
(n=34), were interviewed. In the second stage, Australian dietitians
(n=258; 16%) responded to a national survey in 2006, which asked
about educational strategies, communication skills, and professional
attributes. Descriptive statistics were used to compare response
distributions, and nonparametric statistics were used to examine
between-group relationships. Criterion for item acceptance was
established as 70% agreement. Triangulation of results revealed
strong agreement between data sources. Four main communication
competencies were established: interpersonal communication skill,
non-verbal communication, professional values, and counseling skill.
There was insignificant difference in practice by work category or
experience. The communication competencies, together with 26
57
References
1. Cant RP, Aroni RA. Exploring dietitians' verbal and nonverbal
communication skills for effective dietitian-patient communication. J Hum
Nutr Diet. 2008;21(5):502-11.
2. Cant RP. Communication competence within dietetics: dietitians' and
clients' views about the unspoken dialogue - the impact of personal
presentation. J Hum Nutr Diet. 2009;22(6):504-10.
MENTAL DISORDERS
Ethology is relevant to clinical psychiatry for 2 different reasons.
Ethology may contribute significantly to the development of more
accurate and valid methods for measuring the behavior of persons
with mental disorders. Ethology, as the evolutionary study of
behavior, may provide psychiatry with a theoretical framework for
integrating a functional perspective into the definition and clinical
assessment of mental disorders. This article describes an ethological
method for studying the non-verbal behavior of persons with mental
disorders during clinical interviews and reviews the results derived
from the application of this method in studies of patients who had a
diagnosis of schizophrenia or depression. The findings emerging from
current ethological research in psychiatry indicate that the
ethological approach is not limited simply to a mere translation into
quantitative and objective data of what clinicians already know on
the basis of their judgment or the use of rating scales. Rather, it
produces new insights on controversial aspects of psychiatric
disorders. Although the impact of ethology on clinical psychiatry is
still limited, recent developments in the fields of ethological and
Darwinian psychiatry can revitalize the interest of clinical
psychiatrists for ethology (1).
This paper provides an example of a mental health research
partnership underpinned by empowerment principles that seeks to
foster strength among community organizations to support better
outcomes for consumers, families and communities. It aims to raise
awareness among researchers and service providers that
empowerment approaches to assist communities to address mental
health problems are not too difficult to be practical but require long-
59
References
1. Troisi A. Ethological research in clinical psychiatry: the study of
nonverbal behavior during interviews. Neurosci Biobehav Rev. 1999;23(7):
905-13.
2. Haswell-Elkins M, Reilly L, Fagan R, et al. Listening, sharing
understanding and facilitating consumer, family and community
empowerment through a priority driven partnership in Far North
Queensland. Australas Psychiatry. 2009;17 Suppl 1:S54-8.
3. Cruz M, Roter D, Cruz RF, et al. Psychiatrist-patient verbal and
nonverbal communications during split-treatment appointments. Psychiatr
Serv. 2011;62(11):1361-8.
4. Chessick RD. Psychoanalytic listening II. Am J Psychother.
1985;39(1):30-48.
5. Gretchen N. Foley, Julie P. Gentile. Nonverbal Communication in
Psychotherapy. Psychiatry (Edgmont). 2010;7(6):3844.
PSYCHOTHERAPY
Communication is the essence of the process of psychotherapy.
Understanding the parameters of communication can form the
foundations for the development of psychotherapeutic skills in the
student therapist. Using learning objectives within the context of
teaching psychotherapy, the process of communication in individual
psychotherapy is explored. With the aim of offering a practical
framework to assist in the analysis of the communication process
63
References
1. Watters WW, Bellissimo A, Rubenstein JS. Teaching individual
psychotherapy: learning objectives in communication. Can J Psychiatry.
1982;27(4):263-9.
2. Trubitsyna LV. Nonverbal communication in psychotherapy. Zh
Nevropatol Psikhiatr Im S S Korsakova. 1990;90(12):59-62.
3. Tickle-Degnen L, Gavett E. Changes in nonverbal behavior during the
development of therapeutic relationships. In: Philippot P, Feldman R, Coats
E (eds.). Nonverbal Behavior in Clinical Settings. New York, NY: Oxford
University Press. 2003, pp. 75110.
4. Holmesland AL, Seikkula J, Hopfenbeck M. Inter-agency work in Open
Dialogue: the significance of listening and authenticity. J Interprof Care.
2014;28(5):433-9
5. Gretchen N. Foley, Julie P. Gentile. Nonverbal Communication in
Psychotherapy. Psychiatry (Edgmont). 2010;7(6):3844.
6. American Psychiatric Association. Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American
Psychiatric Press Inc. 2000.
7. Philippot P, Feldman R, Coats E. The role of nonverbal behavior in
clinical settings. In: Philippot P, Feldman R, Coats E, editors. Nonverbal
Behavior in Clinical Settings. New York, NY: Oxford University Press. 2003.
pp. 313.
68
References
1. Hill CE, Thompson BJ, Ladany N. Therapist use of silence in therapy: a
survey. J Clin Psychol. 2003;59(4):513-24.
2. Lane RC, Koetting MG, Bishop J. Silence as communication in
psychodynamic psychotherapy. Clin Psychol Rev. 2002;22(7):1091-104.
69
had greatly enjoyed her job until the last several months. When
describing her work, she appeared happy and excited until she stated
that a new male physician had recently joined the staff. At this point,
Mrs. Jones's facial expression transformed and she appeared
subdued. The psychiatrist also noted she reverted to her anxious
mannerisms seen at initial presentation, so the psychiatrist invited
Mrs. Jones to discuss whatever she was comfortable sharing.
Mrs. Jones indicated the new physician had been flirting with her
and it was making her uncomfortable. In one case, the physician gave
her an unsolicited neck massage. She reported feeling frozen and
trapped at the time. Mrs. Jones did not reciprocate this physician's
feelings but felt unsure how to deal with the unwanted attention
without causing a problem in the office. Once, she told the physician
she was not interested, but he joked about it and did not appear to
take her concerns seriously. When sharing this information with the
psychiatrist, Mrs. Jones's voice became soft and meek. Mrs. Jones put
her hand to her eyebrow, covering one side of her face, looked at the
floor and became uncharacteristically silent. The psychiatrist inquired
if she somehow felt ashamed about the interactions with this
physician. Mrs. Jones immediately started to cry and admitted she
had never disclosed the flirtation to anyone else. She felt very guilty
for not telling her husband about the interactions at work. In
addition, Mrs. Jones felt she must have done something to lead him
on as the physician was continuing this behavior despite her
noninterest. She reported that the issues at her job reminded her of
an incident in her adolescence where she had been sexually
assaulted by a boyfriend after attempting to break off the
relationship. It was my fault then, and it's my fault now.
Mrs. Jones displayed a significant and rapid shift in facial
expression from happy to sad when the topic of the new male
physician in her office arose. The psychiatrist picked up on this as
well as the return of her fidgeting and gently encouraged Mrs. Jones
to share what was on her mind. Mrs. Jones then appeared ashamed
and embarrassed, indicated by her downcast eyes and by covering
her face, yet she was unable to freely talk about this emotional state
as evidenced by her silence. Again, the psychiatrist recognized the
change in her non-verbal behavior and made an interpretation
regarding the patient's visible affect. This facilitated Mrs. Jones's
sharing more details about the situation at work as well as a
72
Reference
1. Gretchen N. Foley, Julie P. Gentile. Nonverbal Communication in
Psychotherapy. Psychiatry (Edgmont). 2010;7(6):3844.
PEDIATRICS
The objective of this study was to test the independent
association of adult language input, television viewing, and adult-
child conversations on language acquisition among infants and
toddlers. Two hundred seventy-five families of children aged 2 to 48
months who were representative of the US census were enrolled in a
cross-sectional study of the home language environment and child
language development (phase 1). Of these, a representative sample
of 71 families continued for a longitudinal assessment over 18
months (phase 2). In the cross-sectional sample, language
development scores were regressed on adult word count, television
viewing, and adult-child conversations, controlling for socioeconomic
attributes. In the longitudinal sample, phase 2 language development
scores were regressed on phase 1 language development, as well as
phase 1 adult word count, television viewing, and adult-child
74
References
1. Zimmerman FJ, Gilkerson J, Richards JA, et al. Teaching by listening:
the importance of adult-child conversations to language development.
Pediatrics. 2009;124(1):342-9.
2. Dohmen A, Chiat S, Roy P. Nonverbal imitation skills in children with
specific language delay. Res Dev Disabil. 2013;34(10):3288-300.
3. Paniagua FA. Utility of verbal-nonverbal correspondence-training
techniques in outpatient pediatric settings. Psychol Rep. 2004;94(1):317-26.
References
1. Hannawa AF. "Explicitly implicit": examining the importance of
physician nonverbal involvement during error disclosures. Swiss Med Wkly.
2012 May 9;142:w13576.
2. Hannawa AF. Disclosing medical errors to patients: effects of
nonverbal involvement. Patient Educ Couns. 2014;94(3):310-3.
3. Hannawa AF. Shedding light on the dark side of doctor-patient
interactions: verbal and nonverbal messages physicians communicate during
error disclosures. Patient Educ Couns. 2011;84(3):344-51.
78
References
1. Gilbert DA. Coordination in nurses' listening activities and
communication about patient-nurse relationships. Res Nurs Health. 2004;
27(6):447-57.
2. Kim HS, Kim MS. Patients' preferences for nurses' nonverbal
expressions of warmth during nursing rounds and administration of oral
medication. Kanho Hakhoe Chi. 1990;20(3):381-98.
3. Xu Y, Staples S, Shen JJ. Nonverbal communication behaviors of
internationally educated nurses and patient care. Res Theory Nurs Pract.
2012;26(4):290-308.
4. Chambers S. Use of non-verbal communication skills to improve
nursing care. Br J Nurs. 2003;12(14):874-8.
5. Caris-Verhallen WM, Kerkstra A, Bensing JM. Non-verbal behaviour in
nurse-elderly patient communication. J Adv Nurs. 1999;29(4):808-18.
6. Martin AM, O'Connor-Fenelon M, Lyons R. Non-verbal communication
between nurses and people with an intellectual disability: a review of the
literature. Part I. J Intellect Disabil. 2010;14(4):303-14.
7. Martin AM, Connor-Fenelon MO, Lyons R. Non-verbal communication
between Registered Nurses Intellectual Disability and people with an
intellectual disability: an exploratory study of the nurse's experiences. Part
2. J Intellect Disabil. 2012;16(1):61-75.
8. Kozowska L, Doboszynska A. Nurses' nonverbal methods of
communicating with patients in the terminal phase. Int J Palliat Nurs. 2012;
18(1):40-6.
84
TEACHING
The VCE may function as an important support for medical
students in or prior to clinical practice to train and ease
communication and socioemotional interactions with patients. This
study was designed to investigate the dynamics and congruence of
interpersonal behaviors and socioemotional interaction exhibited
during the learning experience in a VCE, and to evaluate which
interaction design characteristics contribute most to the behavioral
and affective engagement in medical students. Thirty medical
students (sixth semester) participated voluntarily in an exploratory
observational study with a highly interactive VP case based on a
trustworthy VP encounter with a natural and realistic dialogue
interface. Students worked collaboratively in pairs. They were
videotaped for further behavioral analysis and self-reported (in both
a survey and an interview) personal opinions, perceptions and
attitudes about the VCE. A mixed methods approach was applied. All
participants demonstrated an adequate, respectful and relevant
clinical case management and to obtain psychosocial history. The
collaborative workspace played its role and led to dynamic and
engaged discussions fostering thus shared understanding. The results
suggest that the VCE studied was perceived as a meaningful,
intrinsically motivational and activating learning environment, and
was found to socially and emotionally engage learners. VCEs have the
potential to support the development of relevant and congruent
interpersonal communication skills in trainees. In conclusion, by
taking advantage of socioemotional interaction, VCEs promote not
only critical reflection skills or strategy-selection skills, but also
develop listening and non-verbal skills, induce self-awareness and
target coping behaviors. If applied in early medical education, this
learning approach may facilitate clinical encounters at an early stage
and contribute to responsible clinical decision-making (1).
A therapist's non-verbal behavior may communicate emotion and
feelings toward a client. Thus, skilled utilization of appropriate non-
verbal cues should facilitate many non-behavioral therapies. A 2 X 2 X
2 factorial experiment investigated the therapy-facilitating effects of
3 theoretical dimensions of non-verbal communication: Immediacy,
potency or status, and responsivity. A reenacted client-centered
therapy session was videotaped. Verbal content was held constant,
85
References
1. Courteille O, Josephson A, Larsson LO. Interpersonal behaviors and
socioemotional interaction of medical students in a virtual clinical
encounter. BMC Med Educ. 2014 1;14(1):64.
2. Sherer M, Rogers RW. Effects of therapists nonverbal communication
on rated skill and effectiveness. J Clin Psychol. 1980;36(3):696-700.
3. Williams S, Harricharan M, Sa B. Nonverbal communication in a
Caribbean medical school: "Touch is a touchy issue". Teach Learn Med.
2013;25(1):39-46.
92
SUMMARY
Non-verbal communication is an important human characteristic.
In order to maintain relationships effectively humans must
communicate with each other. In everyday life, there are many types
of communication including with work colleagues, family, neighbors,
and friends, some efficient and some inefficient.
This research deals with biblical verses: "He who guards his
mouth and his tongue keeps his soul from troubles" (Proverbs 21:23),
and "I will keep a curb on my mouth, while the wicked man is before
me" (Psalms 39:2).
Communication is defined as the exchange information, or the use
of common system of symbols, signs, behavior for this; a verbal or
written message; a system of routes; techniques for the effective
transmission of information, ideas, etc. Communication also transfers
information from one person to another. Non-verbal communication
is defined as not involving words of speech: voluntary or involuntary
non-verbal signals, such as smiling or blushing.
Verses described above show that non-verbal communication is
an essential part of human existence. These verses have a wide
range of implications for our everyday. Since the author of this
research is a medical doctor, studying Medicine in the Bible, it is
natural that this study concentrates mainly on non-verbal
communication in a variety of medical situations. How can we deal
with these verses in our everyday life?
Non-verbal communication includes: physical communication:
smell, salute, posture and other bodily movements, pause (silence);
facial expressions: raising eyebrows, yawning, sneering, rolling eyes,
gaping, a smile, wink, frown and nodding; gestures: waving, pointing,
and using fingers to indicate numeric amounts; paralinguistics such
as vocal communication, separate from actual language, including
tone of voice, loudness, inflection and pitch; proxemics: the need for
"personal space"; eye gaze: looking, contact, staring and blinking;
haptics: communication through touch; appearance: choice of color,
clothing, hairstyles and other factors affecting appearance; aesthetic
communication: creative expression: music, dance, theatre, crafts,
art, painting, and sculpture; signs: signal flags or lights, a 21-gun
salute, a display of airplanes in formation, horns, and sirens; symbols:
jewelry, cars, and clothing.
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ABBREVIATIONS
ADHD Attention deficit hyperactivity disorder
CARE Consultation and Relational Empathy
ED Emergency department
GHQ General Health Questionnaire
GP General practitioner
HCP Health care professional/provider
HIV Human immunodeficiency virus
IEN Internationally educated nurses
IQR Interquartile range
L1 First language
L2 Second language
MRI Magnetic resonance imaging
MYMOP Measure Yourself Medical Outcome Profile
NAAS Non-verbal Accommodation Analysis System
OSCE Objective structured clinical examination
PEI Patient enablement instrument
QOL Quality of life
RCS-O Relational communication scale for
observational measurement
RIAS Roter Interaction Analysis System
RNID Registered Nurses Intellectual Disability
SD Standard deviation
SP Standardized patient
TBI Traumatic brain injury
VCE Virtual clinical encounter
VP Virtual patient
WMC Working memory capacity
The author has requested enhancement of the downloaded file. All in-text references underlined in blue are linked to publications on ResearchGate.