hall - harrigan - nonverbal behavior in clinician-patient interaction

7/28/2019 Hall - Harrigan - Nonverbal Behavior in Clinician-patient Interaction

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Applied & Preventive Psychology4:21-37 (1995). Cambridge University Press. Printed in the USA.Copyright 1995 AAAPP 0962-1849/95 $9.00 + .10

Nonverbal behavior in clinician-patient interactionJ U D I T H A . H A L LNortheastern UniversityJ I N N I A . H A R R I G A NCalifornia State University , FullertonR O B E R T R O S E N T H A LHarvard University

Abs t r a c t

Empirical studies on nonverbal communication in clin ician -patie nt interaction are reviewed for both thepsychotherapeutic and med ical settings. Nonverbal behavior is considered both as the consequence of antecedentvariables, such as individual or relationship characteristics, and as a predictor of clinical effectiveness and patientoutcomes. The concept of rapp ort is considered in relation to nonverbal behavior, both theoretically and empirically.Also, the relevance of a p atient 's nonverbal behavior to the diagnostic goals of the clinical visit is demonstrated byresearch on nonverbal cues to psychopathology, Type A/B personality , and pain. Although the topic of nonverbalbehavior and cl inicia n-pati ent interaction has had a prom ising start, much research is stil l needed, especially thatwhich experimentally manipulates either antecedent variables or nonverbal behavior itself to demonstrate cause andeffect relations.Key words: Nonverbal behav ior , Cl in ician-pat ien t interact ion

I do no t l ike thee, Dr . Fel l ;T h e r easo n w h y I can n o t t e l l ;B u t t h i s I k n o w , an d k n o w fu l l w e l l ,I d o n o t l i k e t h ee , D o c to r F e l l !

Mother GooseW h e n t h is b i t o f d o g g e r e l a p p l i e s t o p a t i e n t s ' f e e l i ng s a b o u tth e i r p h y s i c i an s o r p sy ch o th e rap i s t s , m o s t l i k e ly i t w as l e s sw h a t t h e c l i n i c i an s sa id an d m o re h o w th ey sa id i t t h a t l ed toth e u n ex p la i n ed a f f ec t iv e s t a t e . S u ch d i s l i k e , fu r th e rm o re , i sl i k e l y to h a v e c o n s e q u e n c e s f o r th e m e d i c a l a n d / o r p s y c h o -th e rap eu t i c o u tco m e fo r t h e p a t i en t co n ce rn ed , fo r t h e r ep u -t a t io n o f t h e c l i n i c i an , an d fo r t h e o v e ra l l e f f i cacy an d co s t so f t h e h e a l t h c a r e s y s t e m .T h e p u r p o s e o f t h is p a p e r i s t o p r o v i d e a n o v e r v i e w o f t h er o l e o f n o n v e r b a l b e h a v i o r i n t h e c l i n i c i a n - p a t i e n t i n t e r a c-t i on . B y c l i n i c i a n - p a t i e n t i n t e r ac t i o n w e m e a n a n y p r o f e s -s i o n a l c o n t a c t b e t w e e n m e d i c a l p r a c t i t i o n e r s o r p s y c h o -th e rap i s t s an d th e i r p a t i en t s . B y n o n v erb a l b eh av io r (o rc o m m u n i c a t i o n ) w e m e a n f a c i a l e x p r e s s i o n , ga z e , b o d y

Preparation of this paper was supported in part by the Spencer Founda-tion; its content is solely the responsibility of the authors. Send correspon-dence and reprint requests to Judith A . Hall, Department of Psychology,125 NI, Northe astern University, Boston, MA 02115.21

m o v e m e n t a n d g e s t u re , v o i c e q u a l i t y, a n d q u a s i v e r b a l v o c a lb eh av io r s su ch as i n t e r ru p t io n s , f ac i l i t a to r s , h es i t a t i o n s , an ds p e e c h e r r o rs . T h e i m p o r t a n c e o f s t u d y i n g c l i n i c i a n - p a t i e n tn o n v e r b a l c o m m u n i c a t i o n d e r i v e s f r o m : ( a ) t h e r a p i d ly a c -cu m u la t in g r e sea rch in n o n c l in i ca l se t t i n g s sh o w in g th e im -p o r t a n c e o f n o n v e r b a l b e h a v i o r t o t h e o u t c o m e s o f a w i d ev ar i e ty o f i n t e rp e r so n a l i n t e rac t io n s an d (b ) t h e sp ec i a l f ea -t u re s o f t h e c l i n i c i a n - p a t i e n t i n t e r a c ti o n .

T h ese f ea tu res i n c lu d e th e f ac t t h a t t h e o u tco m e o fc l i n i c i a n - p a t i e n t i n t e r ac t i o n s a r e o f t e n a m a t t e r o f l i f e o rd ea th , r eco v ery o r i l l n ess , h ap p in ess o r m i se ry . T h ese o u t -co m es a re o f g rea t an d im m e d ia t e co n c e rn to u s a s p a t i en t s ,a s c l i n i c i an s , an d as t h o se c lo se to p a t i en t s o r c l i n i c i an s .G i v e n t h e e n o r m o u s c o s t s o f h ea l t h c a r e a n d t h e i m p a c t o ft h e s e c o s t s o n t h e n a t i o n ' s e c o n o m y , h e a l t h c a r e o u t c o m e sh a v e b e c o m e e v e r y o n e ' s c o n c e r n .

I t h a s l o n g b e e n a c k n o w l e d g e d t h a t t h e c o m m u n i c a t i o nb e tw een p sy ch o th e rap i s t s an d p a t i en t s i s c ru c i a l t o p a t i en to u t c o m e s ; i n d e e d , c o m m u n i c a t i o n i s o f t e n a s s u m e d t o b eth e v e ry co re o r e s sen ce o f p sy ch o th e rap y . T h i s u n d er s t an d -in g o f t h e cen t r a l i t y o f co m m u n ica t io n , w i th t h e co ro l l a ryr e c o g n i t i o n o f t he i m p o r t a n c e o f e m p i r i c a l r e s e a r c h o n c o m -m u n i c a t i o n p r o c e s s e s , h a s c o m e m u c h m o r e s l o w l y t o m e d i -c i n e . F o r m a n y y e a r s , a n o b s e s s i o n w i t h e x p e r t k n o w l e d g e


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22 Hall , Harrigan, and Rosenthal

a n d t e c h n o l o g y s e e m e d t o r e l e g a t e m e r e h u m a n i n t e r a c ti o n sto t h e s id e li n es . I n t e rp e r so n a l i n t e r ac t i o n w as e i t h e r an i r r e l -ev an t d i s t r ac t i o n o r w as so easy t o u n d e r s t an d th a t sp ec i a lt r a in in g an d sc i en t i f i c s t u d y w ere n o t n eed ed .

T h e s i tu a t io n i n m e d i c i n e h a s c h a n g e d d r a m a t i c a l l y w i thth e ad o p t io n o f th e b io p sy c h o so c i a l m o d e l (E n g e l , 1 9 7 7 ),t h e a c c u m u l a t i n g e m p i r i c a l e v i d e n c e t h a t c o m m u n i c a t i o np r o c e s s e s c a n n o t b e s e p a r a t e d f r o m t h e o v e r a l l q u a l i t y o fca re (R o te r & H a l l , 1 9 9 2 ; S t r ee t & W iem an n , 1 9 8 4 ) , an d aw id esp read b e l i e f i n b o th l ay an d p ro fes s io n a l c i r c l e s t h a tt h e m ed ic a l p ro fes s io n h as a l o w r eg a rd fo r t h e p e r so n a l s i d eo f h ea l t h an d h ea l th ca re . N o w , m e d ica l ed u ca to r s a r e t ry in gto t each y o u n g p h y s i c i an s t h a t " t h e r em ark ab le sc i en t i f i ca d v a n c e s i n m e d i c i n e h a v e n o t c h a n g e d t h e f a c t t h a t p h y s i-c i an s ' co re c l i n i ca l sk i l l s a r e i n t e rp e r so n a l " (N o v ack , V o lk ,D ro ssm an , & L ip k in , 1 9 9 3 , p . 2 1 0 1 ) .

I n b o t h p s y c h o t h e r a p y a n d m e d i c i n e , e a r l y r e s e a r c h e r sau d io reco rd ed c l i n i ca l i n t e r ac t i o n s an d th en s tu d i ed t h et r an sc r ip t s p ro d u ced f ro m th ese r eco rd in g s . T h i s "d ry r e -co rd " l ed t o a s tu d y o f th e w o rd s w i th o u t m u s i c . I n m ed i -c in e , i t i s s t i l l m u ch m o re co m m o n to s tu d y v e rb a l co n t en tth an n o n v erb a l b eh av io r (B u l l e r & S t r ee t , 1 99 2 ; R o te r , H a l l ,& K a t z , 1 98 8) . A s k n o w l e d g e o f n o n v e r b a l a s p e c ts o f c o m -m u n ica t i o n i n n o n c l in i ca l s e t t i n g s d ev e lo p ed , i t b ecam ec l e a r t h a t m a n y o f t h e s a m e p r o c e s s e s m a y b e a t w o r k i nc l i n i ca l s e t ti n g s . V ar i ab l e s o f l i k e ly r e l ev an ce i n c lu d e a r ch i -t ec tu re an d in t e r io r d es ig n ; p h y s i ca l a t t r ac t i v en ess , c lo th in g ,an d o th e r a sp ec t s o f t he i n t e r ac t an t s ' ap p ea ran c e ; an d in t e r -p e r so n a l d i s t an ce , p o s tu re , g aze , f ac i a l ex p res s io n , b o d ym o v e m e n t , g e s tu r e , t o uc h , a n d t o n e o f v o i c e ( f o r a n o v e r -v i e w o f r e s e a r c h o n n o n v e r b a l c o m m u n i c a t i o n , s e e K n a p p& H a l l , 1 99 2 ). N o n v erb a l co m m u n ica t i o n is ch a rac t e r i zedb y g rea t su b t l e ty , a f ac t t h a t b r in g s i n t e r e s t in g m e th o d o lo g i -ca l ch a l l en g es , b o th b ecau se t h e p h en o m en a a r e d i f f i cu l t t od esc r ib e an d b ecau se i n t e r ac t an t s a r e o f t en u n aw are o f t h e i ro w n a n d o t h e r s ' n o n v e r b a l b e h a v i o r . N o n v e r b a l b e h a v i o rp ro v id es a g rea t d ea l o f i n fo rm a t io n v e ry q u i ck ly , w i th o b -v i o u s i m p l i c a t io n s f o r i ts i m p a c t i n h u m a n r e l a ti o n s ( A m -b ad y & R o sen th a l , 1 9 9 3 ) .

I n 1 97 9, H o w a r d F r i e d m a n p r e s e n t e d a n a n a l y si s o f w h yn o n v e r b a l c o m m u n i c a t i o n i s i m p o r t a n t in p h y s i c i a n - p a t i e n tin teract ion . Now, 15 years la ter , we f ind h is analysis s t i l l tob e t i m e l y a n d t o b e r e l e v a n t w i t h f e w a d a p t a ti o n s t o p s y c h o -th e rap y in t e r ac t i o n s a s w e l l . F r i ed m an (1 9 7 9 ) d esc r ib ed t h ero l e o f s en s i t i v i t y an d ex p re s s iv en e ss i n b o th t h e p a t i en t an dth e c l i n i c i an . P a t i en t s a r e e sp ec i a l l y a l e r t t o t h e c l i n i c i an ' sn o n v erb a l cu es b ecau se p a t i en t s a r e an x io u s an d u n ce r t a in- - t h e y n e e d c l a r i f i c a t i o n a n d i n s i g h t r e g a r d i n g t r o u b l i n gp h y s i ca l o r em o t io n a l ex p e r i en ces . P a t i en t s a l so l o o k fo rc u e s b e y o n d t h e m a n i f e s t c o n t e n t o f s p o k e n w o r d s i n h o p e so f d i sce rn in g t h e c l i n i c i an ' s " r ea l " f ee l i n g s ab o u t t h em o rev id en c e o f f ac tu a l i n fo rm a t io n b e in g w i th h e ld . P a t i en t sm ay a l so b e e sp ec i a l l y a t t en t i v e t o t h e c l i n i c i an ' s cu es b e -c a u s e o f t h e i r r e l a ti v e l a c k o f p o w e r a n d c o n t r ol ( s e e F i s k e ,1 9 9 3 ) . P a t i en t s ' n o n v erb a l ex p res s io n s an d b eh av io r s a r e

i m p o r t a n t b e c a u s e t h e s e r e v e a l t h e e m o t i o n a l i m p a c t o f d i s -ru p t ed h ea l th an d b ecau se t h ey a r e d i ag n o s t i ca l l y u se fu l t oth e c li n i c i an. C l in i c i a n s ' n o n v e rb a l b eh av io r i s im p o r t a n tb eca u se i t co n t r i b u t e s g rea t l y t o r ap p o r t an d t ru s t , a s w e l l a st o t h e l i k e l y m e d i a t i o n o f e x p e c t a n c y a n d p l a c e b o e f f e c ts .

T h e s t u d y o f n o n v e r b a l c o m m u n i c a t i o n i s s t i ll g r e a t l yu n d erd ev e lo p ed . In t h e p resen t a r t i c l e w e t ry t o i n d i ca t eg ap s an d fu tu re d i r ec t i o n s a lo n g w i th o u r su m m ary o f f i n d -in g s . W e d i s t i n g u i sh n o n v erb a l b eh av io r a s : ( a ) p r ed i c t ab l ef ro m a n t eced en t v a r i a b l e s ( i .e . , a d ep en d en t v a r i ab l e ) v e r su s(b ) p red i c t i v e o f co n seq u en t v a r i ab l e s ( i .e . , an in d ep en d e n tv a r i ab l e ) . W e d o th i s s ep a ra t e ly fo r b o th t h e p sy ch o th e ra -p eu t i c an d th e m ed ica l co n t ex t . W e th en d i scu ss t h e cen t r a lco n s t ru c t o f rap p o r t . R ap p o r t d ep en d s o n b o th t h e v e rb a la n d n o n v e r b a l b e h a v i o r s t r e a m o c c u r r i n g i n t h e c l i n i c i a n -p a t i en t d y ad (H a l l , in p re s s ) . W e a l so p ro v id e i l l u s tr a t i o n s o ft h e r e l e v a n c e o f p a t i e n t s ' n o n v e r b a l b e h a v i o r t o t h e d i a g -n o s i s o f p s y c h o p a t h o l o g y , T y p e A / B p e r s o n a li t y , a n d p a i n.T h e g r e a t m a j o r i t y o f re s u l ts r e p o r t e d h e r e c o m e f r o m o b -se rv a t io n a l r a th e r t h an ex p e r im en ta l s t u d i e s an d a r e t h e re -fo re co r r e l a t i o n a l i n n a tu re . B ecau se o f t h i s , co n c lu s io n sab o u t cau se an d e f f ec t can b e t en t a t i v e a t b es t . T h e v e ryim p o r t an t i s su e o f ex p e r im en ta l v e r su s co r r e l a t i o n a l r e -sea rch i s d i scu ssed i n t h e co n c lu s io n o f t h i s a r t i c le .

N o n v e r b a l B e h a v i o r : A n t e c e d e n t s a n d O u t c o m e sPsychotherapy

T h e i m p o r t a n c e o f n o n v e r b a l b e h a v i o r i n p s y c h o t h e r a p yan d co u n se l in g se t t i n g s h as n o t b een o v e r lo o k ed (G lad s t e in ,1 9 7 4 ; H e im an n & H e im an n , 1 9 7 2 ) , a l t h o u g h a t t en t i o n t ot h is c o m m u n i c a t i o n c h a n n e l l a g s b e h i n d r e s e a r c h o n v e r b a lb e h a v i o r i n p s y c h o t h e ra p y . F o r e x a m p l e , W i e n e r , B u d n e y ,W o o d , an d R u sse l l ( 1 9 8 9 ) r ev i ew ed a se l ec t ed p o r t i o n o fs t u d i e s o f n o n v e r b a l b e h a v i o r i n p s y c h o t h e r a p y a n d c o n -c lu d ed th a t t h e re w as a d ea r th o f r e sea rch s tu d i e s u s in g ah y p o th es i s - t e s t i n g ap p ro ach . E d u ca to r s i n t r a in in g p ro g ram sh av e b een s t ro n g ly en co u rag ed to i n c lu d e sp ec i f i c m o d u leso n n o n v e r b a l c o m m u n i c a t i o n i n t h e c u r r i c u l u m ( K a g a n &K ra th w o h l , 1 9 67 ; W ein e r , 1 9 75 ). T h e v as t m a jo r i t y o f s t ud -i e s o n n o n v e r b a l b e h a v i o r h a v e f o c u s e d o n c u e s t h a t p r e d ic tp o s i t i v e ev a lu a t i o n s o f t h e rap i s t s ' em p a th i c q u a l i t i e s , t h a t i s ,n o n v erb a l cu es t h a t a r e b e l i ev ed to b e e s sen t i a l i n p ro v id in ga b en e f i c i a l t h e rap eu t i c en v i ro n m en t . I n ad d i t i o n , an ecd o t -a l r e p o r t s d e s c r i b e n o n v e r b a l b e h a v i o r i n p s y c h o t h e r a p y(S ch e f l en , 1 9 6 6 ) . H o w ev er , w i th r e sp ec t t o n o n v erb a l b e -h a v i o r i n th e p s y c h o t h e r a p y s e t t i ng m u c h r e m a i n s u n k n o w n .Antecedents o f Nonverba l Behavior

In a f ew s tu d i e s , i n v es t i g a to r s h av e ex am in ed th e ch a rac -t e r i s t ic s o f t h e rap i s t s o r co u n se lo r s t o d e t e rm in e h o w th esech a rac t e r i s t i c s p red i c t t h e rap eu t i c sk i l l . U n fo r tu n a t e ly , t h i sw o r k h a s b e e n m e a g e r a n d r e s u lt s h a v e n o t b e e n p r o m i s i n g .F o r e x a m p l e , r e s e a r c h e r s f o u n d t h a t s t u d e n t e v a l u a t i o n so f c o u n s e l o r e x p e r t n e s s w e r e n e g a t i v e l y r e l a t e d t o l e v e l


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N o n v e r b a l B e h a v i o r a n d C l i n i ca l In t e r a c t io n 23

of counse l o r t r a i n i ng and expe r i ence ( S chmi d t & S t r ong ,1970) . T he under gr adua t es , however , wer e no t c l i en t s andt ended t o f ocus on t he p r esen t a t i on s t y l e o f t he counse l o r ,pa r t i cu l a r l y counse l o r s ' mor e g l oba l nonver ba l behav i o r( i .e . , appea r s a t t en t ive , had war m f ac i a l expr es s i on) . O t he ri nves t i ga t o r s have f ocused on counse l o r s ' sk i l l s i n s end i ngnonv er ba l messages ( encod i ng sk i ll s ) and sens i t i v it y t o c li -en t nonver ba l behav i o r ( decod i ng sk i l l s ) , a sk i ng whe t he rgr ea t e r s ens i t i v i t y i n encod i ng o r decod i ng nonver ba l mes -sages l eads t o mor e f avo r ab l e i mpr es s i ons . No ev i dence wasf oun d t ha t e i the r encod i ng o r decod i ng sk i l l s wer e r e l a t ed t oj u d g e s ' e v a l u a ti o n s o f c o u n s e l o r e m p a t h y , g e n u i n e n e s s , o rexpe r t nes s ( H i l l , S i ege l man , Gr onsky , S t u r n i o l o , & F r e t z ,1981) . S i mi l a rl y , good and po or decoder s , d i f f e r en t i a t ed byscor es on t he P r of i l e o f Nonver ba l S ens i t i v i t y (P ON S t e st ;Rosen t ha l , Ha l l , D i M at t eo , Roger s , & Ar che r , 1979) , d i dno t d i f f e r in r a t ings g i v en t hem by c l i en t s o r obse r ve r s , nori n f r equenc i es o f nonver ba l cues i nd i ca t i ve o f empa t h i cqua l i t ie s ( L ee , Ha l lbe r g , Kocs i s , & Haase , 1980) . How ever ,g o o d d e c o d e r s o n t h e P O N S t e s t d id r e c e i v e h i g h e r s u p er -v i so r ' s r a t ings o f e f f ec t i venes s ( Rosen t ha l e t a l ., 1979) . F i -n a l ly , w h e r e a s c o u n s e l o r g e n d e r w o u l d b e a n o b v i o u s v a r i -ab l e f o r cons i de r a t i on i n s t ud i e s o f t he counse l i ng dyad ,t he r e a r e on l y a f ew s t ud i e s in whi ch g ender has been s t ud-i ed . I n t he i r s t udy on t ouc h ( desc r i bed l a t e r ) , A l agna , W hi t -che r , F i she r , and W i cas ( 1979) f ou nd t ha t t he e f f ec t o f touchwas g r ea t e r f o r oppos i t e - gender dyads .N o n v e r b a l B e h a v i o r a s a P r e d i c t o r

E ar l y s t ud i e s on t he t he r apeu t ic s t y l e o f t he p r ov i de r con-cen t r a t ed on ve r ba l behav i o r , and seve r a l measur es wer e de -ve l oped based on t he con t en t o f t he t he r ap i s ts ' ve r ba l iza t ionswi t h r e spec t to t he degr ee o f em pa t hy , war mt h , genu i neness ,and so for th (Carkhuff , 1969; Goodman, 1972; S t rupp, 1960;Truax & Carkhuff , 1967; see reviews in Kies ler , 1973, andMatarazzo, 1978) . Dur ing the las t two decades a t tent ion hasbeen d i r ec t ed towar d t he nonv er ba l compo nen t o f t he t he r apyencounter , wi th the ma jor focus on the therapis t, ra ther than thecl ient , again emphasiz ing empathic qual i t i es .

One c l ea r l i mi t a t i on i n t he l i t e r a t u r e on t he r ap i s t s ' non-ve r ba l behav i o r i s t he p r edomi nance o f ana l ogue s t ud i e s( 80% o f s tud i e s r ev i ewed) com par ed w i t h s tud i e s o f ac tua lt he r apy consu l t a t i ons . T h i s d i s advan t age r e s t r i c t s conc l u -s i ons t ha t can be d r awn r ega r d i ng t he gene r a l i zab i l i t y andva l i d i t y o f fi nd i ngs. Con s i s t en t ev i dence has been f oun d i nana l ogue r e sea r ch f o r s eve r a l t ypes o f nonver ba l behav i o r ,and t hese r e su l t s can p r ov i de t he g r oundwor k f o r i nves t i ga -t i ons o f ac tua l t he r apy encoun t e r s . T he summ ar y o f re su l t sp r ov i ded he r e i s based p r i mar i l y on ana l ogue s t ud i e s , bu twher e poss i b l e , f i nd i ngs f r om ac t ua l t he r apy ses s i ons a r ei nc l uded . Nea r l y a l l the s t ud i e s on nonv er ba l behav i o r havebeen con duc t ed i n t he cou nse l i ng f i e ld . T he r e a r e t wo t yp i -ca l pa r ad i gms used i n e i t he r ana l ogue o r ac t ua l t he r apys t ud ies . One i s a na t u ra l h i s t o r y appr oach i n w hi ch t he f r e -quenc i es o f t he r ap i s t s ' mo vem ent and pos t u r es a r e r e l a t ed t o

as ses sment s o f t he r ap i s ts ' sk i ll s i n be ing , f o r exam pl e , em-pa t h i c , f ac i li t a ti ve , war m, e f f ec t i ve , and genu i ne . T he o t he rappr oach i s mor e expe r i ment a l and i nvo l ves mani pu l a t i onof spec i f i c nonver ba l behav i o r s t o de t e r mi ne t he i r r o l e i ncommuni ca t i ng pos i t i ve qua l i t i e s o f t he t he r apeu t i c i n t e r -act ion.

G e n e r a l o r i e n t a t i o n t o t h e c l i e n t. T he o r i en t a t i on o f i n -t e r ac t an ts t o each o t he r p r ov i des bo t h a gene r a l backgr oun di n whi ch t o i n t e r p r e t spec i f ic nonver ba l behav i o r s an d a s e to f spec i f ic behav i o r s r e l a t ed to t he degr ee o f psycho l og i ca lc l osenes s be t we en i n t e r ac t an ts t ha t can i n f l uence t he i n te r -ac t i on i t se l f . Or i en t a t ion i nc l udes t he d i s t ance be t w een i n -t e r ac t an t s , t he degr ee t o whi ch t hey f ace one ano t he r , andpos i t i ons o f a r ms and l egs . I n a psycho t he r apy se t t i ng t het he r ap i s t can f ac i l i t a t e c l i en t engagement by o f f e r i ng anopen , w ar m, t r us t i ng env i r onm ent i n whi ch s i gn i fi can t t he r -apeu t i c wor k can be accompl i shed . I mmedi acy i s a t e r mof t en used t o r e f e r t o behav i o r s t ha t desc r i be a pos i t i ve ,i nvo l ved r e l a t i on be t ween i n t e r ac t an ts and i nc l udes suchcues a s c l ose p r ox i mi t y , f o r war d l ean , open a r m and l egpos t u r es , f ac i ng one ano t he r , eye con t ac t , and pos t u r a l r e -l axa t i on ( Ander sen , 1985 ; M ehr ab i an , 1972) . M an y o f t hesebehaviors have quadrat ic re la t ionships , ; ' for example, " toomuch" o r " t oo l i t t l e " d i s t ance be t ween i n t e r ac t an t s can ber ega r ded a s equ a l l y nega t ive . T he de f i n i t i on o f t oo muc h o rt oo l i t tl e canno t be d e l i nea t ed p r ec i se l y because i n t e r ac t an tva r i ab l e s such a s age , gende r , e t hn i c i t y , t op i c , and s t a t usgr ea t l y i n f l uence o r i en t a t i on cues , a s we l l a s many o t he rnonver ba l cues .

S eve r a l i nves ti ga t o r s have been con ce r ned wi t h t he coun-se l o r ' s ove r a l l o r i en t a t i on t o t he c l i en t . F or exampl e , bo t hpa t i en t and con t r o l g r oups r a t ed c l ose compar ed wi t h f a ri n t e r ac t i on d is t ances a s i nd i ca t i ve o f t he t he r ap i s t 's g r ea t e rl i k i ng f o r t he c l i en t ( Ke l l y , 1972) . However , D i nges andOet t i ng ( 1972) showed t ha t a ve r y c l ose d i s t ance p r oducedh i ghe r anx i e t y ra t i ngs by j udges , e sp ec i a l l y f ema l e judges .I n s t ud i e s i nvo l v i ng sys t ema t i c mani pu l a t i ons o f behav i o r ,r e sea r che r s f ound t ha t t he mos t i mpor t an t cues f o r expr es -s i ng empa t hy , genu i neness , and r e spec t wer e f o r war d t r unkl ean , c l ose d i s t ance , and eye con t ac t ( Haase & T epper ,1972; Her m ansson , W ebs t e r , & M cF ar l and , 1988; T eppe r &Haase , 1978) .

T he r e a r e on l y a f ew s t ud i e s conce r ned wi t h pos i t i ons o fcounse l o r s ' a r ms and l egs . Not su r pr i s i ng l y , g i ven t he em-phas i s i n t he popu l a r medi a , ma i n t a i n i ng an open- a r m pos -t u r e r a the r t han a c l osed on e ( f o l ded a r ms) p r od uced r a t i ngsof g r ea t e r empa t hy and war mt h ( S mi t h - Hanen , 1977) . P sy-ch i a t r i c nur ses i n ac t ua l t he r apeu t i c s e s s i ons who wer ej udged a s h i gh l y empa t h i c exh i b i t ed s i gn i f i can t l y l e s s l egmovement ( swi ng i ng c r os sed l eg , sh i f t i ng pos i t i on) t hannur ses who wer e judg ed a s l e s s empa t h i c ( Har d i n & H a l a r is ,1983) . F r eque ncy o f mov em ent a l so s eems t o be a c r it i ca lva r i ab l e i n f l uenc ing eva l ua t i ons o f counse l o r s . M or e ac t i vecounse l o r s wer e j udged a s mor e w ar m, ene r ge t i c , t r us t wor -t hy , r e spons i ve , and agr eeab l e ( F r e t z , Cor n , & T uemml er ,


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1979; Rol l , C r owl ey , & Rapp l , 1985 ; S he r e r & Roger s ,1980; S t rong, Taylor , Brat ton , & Lope r , 1971). Th erapis t sgene r a l l y mode r a t e t he i r beha v i o r on t he bas i s o f t he type o fc l ien t . T he r ap i s t s e xh i b i t ed d i f f e r en t f r equenc i es o f ce r t a i nnonver ba l behav i o r s when i n t e r ac t i ng w i t h psych i a t r i c pa -t i en t s ve r sus con t r o l s , t ha t i s , i nc r eased smi l i ng , head o r i -en t a t ion , hand t app i ng , and f oo t mov eme nt s ( F a i r banks ,M cG ui r e , & Har r i s , 1982) . F i na l ly , w i t h r e spec t t o pos i t ion-i ng and movement i n t he counse l i ng se t t i ng , pos i t i ve a s so-c i a t ions have b een r epor t ed be t we en em pa t h i c qua l i ti e s andi n t e r ac t i ona l congr uence ( pos t u r a l sha r i ng be t ween c l i en tand therapis t ) (Cha rny, 1966; Ma urer & Tindal l , 1983;T r ou t & Rosenf e l d , 1980) .

On t he bas i s o f t hese s t ud i e s , we woul d expec t t ha t t hemos t ben e f i c i a l t he r ap i s t - to - c l i en t o r i en t a t ion beh av i o r s i n -c l ude ma i n t a i n i ng a d i s t ance o f appr ox i m a t e l y 4 ft , f o r war dl e an , o p e n - a n n p o s t u r e w i th m o d e r a t e a r m m o v e m e n t ( e .g . ,hand ges t u r es ) , l e s s l eg movement , and a h i gh degr ee o fpos t u r a l congr uence be t ween t he r ap i s t and c l i en t .

Specific nonverbal indices o f empathic q ualities. I nves -t i ga t o r s have exami ned t he i mpac t o f spec i f i c behav i o r s onj u d g e s ' i m p r e s si o n s o f c o u n s e l o r e m p a t h y a n d e f f e c ti v e -nes s . Nonv er ba l behav i o r s gene r a l l y i n t e r p r e t ed a s ind i ca t -i ng pos i t i ve a f f ec t ( smi l i ng and head nodd i ng) r e su l t ed i nh i ghe r r a t i ngs o f counse l o r empa t h i c qua l i t i e s ( D 'Auge l l i ,1974; F r e t z e t a l . , 1979) , a s d i d eye con t ac t ( Haase & T ep-per , 1972; Sea y & Al tekru se, 1979; Tepp er & Haase, 1978;T i p t on & Rymer , 1978) , and hand ges t u r es a s soc i a t ed w i t hspeech ( S i ege l & S e l l , 1978) . T hese s ame a f f il i a ti ve behav -i o r s ( nodd i ng , smi l i ng , eye con t ac t ) a l so r e su l t ed i n mor epos i t i ve eva l ua t i ons o f counse l o r a t t r ac t i venes s and pe r -suas i venes s ( C l a i bor n , 1979 ; L aCr osse , 1975 ; S chmi d t &S t r ong , 1971) . E ye con t ac t was show n t o be pos i t i ve l y r e -l a t ed to r a t ings o f counse l o r r e spec t and genu i neness ( Ke l l y& T r ue , 1980) .

E mpa t h i c qua l i t i e s a r e exh i b i t ed i n mor e sub t l e cues a swe l l . F or exam pl e , us i ng on l y pho t ogr aphs o f t he r ap i s t s 'f aces whi l e t hey i n t e r ac t ed w i t h ac t ua l c l i en t s , j udges ac -cur a t e l y eva l ua t ed t he r ap i s t empa t hy , genu i neness , andwarmth (Shapi ro, Foster , & Powel l , 1968) . Cl ients andcounse l o r s m ay use d i f f e r en t cues t o j udge t he va l u e o f t hei n t e r ac t i on . Counse l o r and c l i en t nonver ba l behav i o r s wer ef ound t o be c or r e l a t ed w i th m easur es o f the deg r ee o f t he r a -peu t i c wor k accompl i shed and t he degr ee o f suppor t f e l t byc l i en ts ( H i l l & S t eph any , 1990) . T he r ap i s t nodd i ng was a s -soc i a t ed w i t h c l ien t f ee l ings o f suppor t and ac comp l i shmentof t he r apeu t i c wor k , wher eas t he r ap i s t s pe r ce i ved mor et he r apeu t i c wor k accompl i shed when c l i en t s ' speech e r r o r swer e g r ea t e s t ( H i l l & S t ephany , 1990) .

W i t h r e spec t t o phys i ca l con t ac t , t he p r edomi nan t be l i e fi n psycho t he r apy p r ac t i ce and educa t i on i s t ha t t he r ap i s t -c l i en t touch i ng i s cons i d e r ed t aboo and o f t en t hough t t o bed i s r up t i ve t o t he t he r apeu t i c p r oces s ( W ei ne r , 1975 ; W ol -be r g , 1967) . I n an ana l ogue and an expe r i ment a l s t udy ,t ouch r e su l t ed i n pos i t i ve e f f ec t s , a l t hough i n a quas i coun-

se l ing s t udy t he r e was no e f f ec t f o r touch i ng ( S t ockwel l &Dye , 1980) . P a t t i son ( 1973) f ound t ha t c l i en t s engaged i ns i gn i f i can t l y mor e s e l f - exp l o r a t i on when t ouched on t hehand , f o r ea r m , o r uppe r back du r i ng g r ee t i ng , in t e r v i ew , andt e r mi na t i on phases . A l t hough t he t ouch cond i t i on d i d no tr e su l t i n mor e pos i t i ve c l i en t pe r cep t i ons o f counse l o r em-pa t h i c qua l i ti e s when ac t ua l t he r apy ses s ions we r e i nvo l ved( P a t ti son , 1973) , re su l t s o f t he ana l ogue s t udy d i d showmo r e pos i t i ve eva l ua t i ons o f counse l o r s who t ou ched c l i en t scom par ed wi t h t hose w ho d i d no t ( A l agna e t a l. , 1979). I nt he l a t t e r s t udy , t he s t r onges t e f f ec t s f o r t ouch i ng o ccur r edwhen counse l o r s ' gende r was oppos i t e t ha t o f t he c l i en t .

F i na l l y , aud i t o r y cues ( t one o f vo i ce ) a l so a r e c r i ti ca l i nt he t he r apeu t i c s et ti ng . F or exampl e , peak and p oor psych o-t he r apy hour s wer e d i f f e r en t i a t ed on t he bas i s o f aud i t o r ycues such a s voca l s t r e s s , i n t ens i t y , and p i t ch l eve l ( Dun-can , R i ce , & But l e r , 1968) . Dur i ng peak hour s , t he r ap i s t ssounded se r i ous , war m, and r e l axed , wher eas dur i ng poorhour s , t he r ap i s t s ' vo i ces sou nded du l l , f la t, and u n i nvo l ved .S i mi l a r l y , when t he r ap i s t s t a l ked w i t h i npa t i en t s ( vs . ou t pa -t i en t s ) t hey communi ca t ed mor e anx i e t y ( B l anck , Rosen-t ha i , Vann i ce l l i , & L ee , 1986) . Because medi ca l and psy-cho t he r ap y pa t ien t s gene r a l l y have a mode r a t e - t o - h i gh l eve lo f anx i e t y , t hey a r e l i ke l y t o l ook f o r any mani f e s t a t i on i nt he t he r ap i s t 's o r phys i c i an ' s be hav i o r t ha t i nd i ca t e s conce r nor empa t hy , a s we l l a s d i s i n t e r e s t o r l ack o f genu i neness .M u ch a t t en t ion i s pa i d t o t he v o i ce , a s i t ca r r ie s t he ve r ba lm e s s a g e , a n d b e c a u s e p e o p l e o f t e n b e l ie v e t h e v o i c e t o b e amor e r e l i ab l e i nd i ca t o r o f one ' s t r ue f ee l i ngs .The relationship between nonverbal and verbal behav-ior. W hat abou t t he r e l a t i onsh i p be t ween nonver ba l andver ba l behav i o r i n t he r apy se t t i ngs? How does nonver ba lb e h a v i o r m o d i f y v e r b a l b e h a v i o r o r v i c e v e r s a ? C o m p a r e dwi t h ve r ba l behav i o r , nonver ba l behav i o r s eems t o p l ay adomi nan t r o l e i n t he expr es s i on o f empa t h i c qua l i t i e s ( H i l l& G or ma l l y , 1977 ; T epper & Haase , 1978) and i n a t t ri bu-t i ons o f expe r t nes s and a t t rac t i venes s ( Bar ak , P a t k i n , &Del l , 1982 ; T yson & W al l , 1983) . A l t hough t he r e i s r e sea r chev i dence t ha t does no t suppor t t h i s c l a i m ( Naga t a , Nay , &S e i dman , 1983) , such s t ud ie s a r e t he excep t i on . As r e su l t shave shown i n s i mi l a r s t ud i e s i n soc i a l and deve l opment a lpsycho l ogy ( Bugen t a l , Kaswan , & L ove , 1970 ; M ehr ab i an ,1972) , incons i s t en t cues f r om coun se l o r ve r ba l and nonver -ba l channe l s p r odu ce nega t i ve eva l ua t i ons ( bu t s ee t he s t udyof Ha l l , Ro t e r , & Rand , 1981, d i s cus sed l a t e r ) . Counse l o r swho g ave i ncons i s t en t messages wer e pe r ce i ve d as l e ss gen-u i ne and caused c l i en t s t o r eac t by i nc r eas i ng t he i r d i s t ancef r om t he counse l o r (Gr aves & Ro bi nson , 1976) . I n an i nno-va t i ve s t udy , j udges r a t ed t he i mpac t o f v i sua l, aud i o , o rl ex i ca l cues ex h i b i t ed by Car l Rog er s i n f i l med i n t e r ac ti onswi t h a c l i en t ( S t r ahan & Z yt owsk i , 1976) . W hen p r ov i dedwi t h on l y aud i o cues , Roger s was r ega r ded a s mor e i ndec i -s i ve and i ncompe t en t , bu t when bo t h aud i o and v i sua l cueswer e p r esen t ed , he was j udged a s war m and l e s s d i s t an t .Based o n t hese r e su lt s , Robbi ns and Haa se ( 1985) sugges t ed


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t ha t nonver ba l cues ( eye con t ac t , ges t u r es , f o r war d l ean ,smi l e s ) a re mo r e s a l i en t t han ve r ba l cues ( f o r examp l e , psy-cho l og i ca l j a r gon , i n t e r p r e ta t i ons , s e l f - d i sc l osur e , and r e -f lect ions) .

T o sum mar i ze , spec i f i c t he r ap i s t nonver ba l behav i o r s t ha tmay f u r t he r t he t he r apeu t i c p r oces s i nc l ude a moder a t eamo unt o f head nodd i ng and smi l ing ; f r equen t , bu t no t s ta r -i ng , eye con t ac t ; ac t i ve , bu t no t ex t r em e , f ac i a l r e spons i ve -nes s ; and a war m, r e l axed , i n t e r e s t ed voca l t one . T ouch i ngt he c l i en t appea r s t o have som e bene f i t , p r ov i d ed t he t ouch-i ng i s b r i e f and i nvo l ves t he c l i en t ' s mor e pub l i c body sur -f aces ( hand , shou l de r , uppe r back) . W i t h r ega r d t o t ouch i ng ,t he c l i en t ' s gende r , e t hn i c i t y , and age may s i gn i f ican t l y a l te rt he i n t e r p r e t a t i on o f t ouch i ng by t he c l i en t .

I n conc l us i on , our cur r en t knowl edge o f t he e f f ec t s o fcounse l o r s ' nonver ba l behav i o r s o r sk i l l s i n enhanc i ng t het he r apeu t i c r e l a t i onsh i p i s f a r f r om compl e t e . One o f t hemos t c r i t i ca l a r eas o f mi s s i ng i n f o r ma t i on i s t he r o l e o fnonver ba l behav i o r s i n ac t ua l t he r apy se t t i ngs . Gr an t ed ,t hese a r e m or e d i f f i cu l t s t ud i e s t o conduc t , bu t such s t ud i e swi l l p r ov i de us w i t h m or e d e f i n i ti ve ideas abou t t he e f f ec t so f n o n v e r b a l b e h a v i o r i n a h e l p i n g e n v i ro n m e n t . A n o t h e rgap i s t ha t we know cons i de r ab l y mor e abou t t he r ap i s t s 'n o n v e r b a l b e h a v i o r t h a n w e d o a b o u t c l i e n t s ' b e h a v i o r o rt he i n t e r ac t i on o f t he r ap i s t and c l i en t nonver ba l behav i o r s .

T he Medi ca l Se t t i ngAs s t a t ed ea r l i e r , t he t wo- way f l ow of nonver ba l cues

b e t w e e n p r o v i d e r a n d p a t ie n t i s n o w r e c o g n i z e d a s h i g h l yi mpo r t an t in med i ca l t r a in i ng and m edi ca l p r ac t i ce ( L i pk i n ,Qui l l , & Na podano , 1984; N ova ck e t al ., 1993 ; Rot e r &Hal l , 1992; S im pso n et a l ., 1991; Zinn , 19 93) . This recogni~t i on has a l so l ong ex i s t ed i n t he nur s i ng p r of es s i on , whi chhas t r ad i t i ona l l y be l i eved t ha t op t i mi z i ng i n t e r pe r sona l r e la -t i ons and see i ng t o t he pa t i en t ' s psychosoc i a l hea l t h a r ei n t egr a l t o t he r o l e f unc t i ons o f t he nur se ( e .g . , B l ond i s ,1977; Clemen t , 1987; Ol iver & Red fern, 1991; Salye r &Stuar t , 1985) .

M edi ca l ed uca t o r s a r e u r g i ng phys i c i ans t o adop t t he rap-por t - and empa t hy- bu i l d i ng behav i o r s t ha t have been i den t i -f i ed a s r e l evan t i n bo t h psyc ho t he r apy and m edi ca l s e t t ings .T hese i nc l ude a t t en t i ve l i s t en i ng and no t t a l k i ng t oo much ,avo i d i ng exc es s i ve no t e t ak i ng and cha r t r ead ing , e s t ab l i sh -i ng eye con t ac t , lean i ng f o r w ar d , e s t ab l ish i ng an appr opr i a t ei n t e r pe r sona l d i s t ance , encour ag i ng t he pa t i en t t o speak byus i ng f ac i l i t a t o r s such a s smi l e s , nods , and "uh- huh" r e -sponses , and showi ng a f f ec t . E duca t o r s a l so po i n t t o t hec l i n i c i ans ' need t o be good obse r ve r s o f t he pa t i en t ' s non-ve r ba l cues . Qui l l ( 1989) , i n an a r ti c l e on ba r r ie r s t o doc t o r -p a t ie n t c o m m u n i c a t i o n , i d e n t if i e d " v e r b a l - n o n v e r b a l m i s -m a t c h " - - d i s c r e p a n c y b e t w e e n t h e p a t i e n t ' s w o r d s a n dn o n v e r b a l s i g n a l s - - a n d n e g a t i v e e m o t io n s i n t h e p a t ie n t a st w o b a r r i e r s t h a t t h e p h y s i c i a n c a n o v e r c o m e b y c a r e f u lobse r va t i on o f t he pa t i en t f o l l owed by appr opr i a t e ve r ba land nonver ba l r e sponses .

T hough i n t e r e s t i n t he t op i c o f nonver ba l behav i o r i shigh, the qua nt i ty of emp ir ical research i s s t i ll small . In ar ev i ew o f com mu ni ca t i on s t ud i e s i n medi ca l p r ac t i ce , Ro t e r ,Ha l l , and Ka t z ( 1988) no t ed t ha t amo ng 61 s t ud i e s tha t usedl i ve obse r va t i on o r e l ec t r on i c r ecor d i ngs o f phys i c i an-pa t i en t d i a l ogue , t hose t ha t coded nonver ba l cues wer e t oof ew f o r i nc lus i on i n t he i r me t a - ana l y t ic sum mar y ( Ha l l , Ro-t e r , & Ka t z , 1988) . I n t he yea r s s i nce t he Rot e r and Ha l lr e v ie w s , n o t m u c h h a s c h a n g e d . M o s t s t ud i e s o f p r o v i d e r -pa t i en t communi ca t i on a r e based on aud i o t apes t ha t a r eana l yzed f o r ve r ba l beh av i o r us i ng a va r i e t y o f cod i ng s t ra t -eg i e s such a s t he Ro t e r I n t e r ac ti on Ana l ys i s S ys t em ( Rot e r ,1977) , a con t en t ana l ys i s sys t em based on B a l es ' I n t e r ac t i onP r oces s A na l ys is . O t he r c r i t i c i sms o f t he ex i s t i ng l i te r a t u r ei nc l ude i t s gene r a l l y a t heor e t i ca l na t u r e , i t s emphas i s ono b s e r v e r s ' c o d i n g o f t h e p h y s i c i a n ' s b e h a v i o r w i t h o u t a d e -qua t e con ce r n f o r t he pa t i en t ' s r eac t i ons and i n t e r p r e t a t ions ,emphas i s on f i r s t o r s i ng l e medi ca l encoun t e r s , and l ack o fr e sea r ch on t he t wo- way and con t i ngen t ( i . e . , s equen t i a l )na t u r e o f phys i c i an- p a t i en t i n t e r ac t i on ( S tr ee t , 1990) . An-o t he r a r ea o f deba t e , a l t hough no t one t ha t f ocuses spec i f i -ca l l y on nonver ba l behav i o r , conce r ns t he mer i t s o f quan-t i t a t i ve ve r sus qua l i t a t i ve appr oaches ( e .g . , Hea t h , 1986 ;M i sh l e r , 1984) . T he p r esen t r ev i ew i s based on l y on quan-t i t a t i ve s t ud i e s . I n t he f o l l owi ng sec t i ons , we d i scus s non-v e r b a l b e h a v i o r b o t h a s a c o n s e q u e n c e o f a n t e c e d e n t v a ri -ab l e s and a s a p r ed i c t o r o f o t he r ou t comes i n phys i c i an-pa t i en t encoun t e r s .A n t e c e d e n ts o f N o n v e r b a l B e h a v i o r

R ol e . Ver ba l in t e r r up t ions be t w een ph ys i c i an and p a t i en ta r e o f con s i de r ab l e i n t e r e s t because o f t he i r pos s i b le r e l a t i ont o i s sues o f pow er and do mi nan ce w i t h i n t he i n t e rac t i on( Henl ey , 1977) . Resea r ch on t he r e l a t ion o f phys i c i an andpa t i en t r o l e s t o i n t e r r up t ions i s i nconc l us i ve t hus f a r ; W es t( 1984) f ound t ha t phys i c i ans i n t e r r up t ed pa t i en ts m or e t hanv i ce ve r sa ; I r i sh and Ha l l ( 1994) f ound t he oppos i t e ; andS t r ee t and Bul l e r ( 1987) f ound no d i f f e r ence . S t r ee t andBul l e r ( 1987 , 1988) a l so f ound t ha t phys i c i ans exceededpa t i en t s on soc i a l t ouch i ng , ve r ba l f ac i l it a t o r s such a s "uh -h u h , " " m m m m , " a n d " r e a l l y , " p a u s e s d u r i n g t h e i r o w nspeech , and i l l us t r a t i ve ges t u r es , bu t used f ewer adap t o r s( se l f- and o b j ec t - t ouch i ng) t han pa t i en ts . T h e t em por a l pa t -t e r n o f nonver ba l ac t i ons a l so d i f f e r ed be t ween phys i c i ansand pa t i en ts ; phys i c i ans wer e l i ke l y t o g r oom t hem se l ves a st hey began a ve r ba l i n t e rchange , w her eas pa t i en t s exh i b i t edm o r e h a n d - t o - s e lf t o u c h in g w h e n r e s p o n d i n g t o p h y s i c ia n s( Har r i gan , 1985) . T he phys i c i an appea r ed t o be mor e r e -l axed and con t r o l l i ng i n the i n t e r ac t i on , wher eas t he pa t i en texh i b i t ed m or e s i gns o f be i ng d i s t re s sed o r i l l a t ea se .

Cor r e l a t i ons be t ween phys i c i ans ' and pa t i en t s ' nonver ba lbehav i o r s w er e obse r v ed i n S t r ee t and Bu l l e r ( 1987 , 1988),w i t h pos i t i ve cor r e l a t ions sugges t i ng m a t ch i ng o r r ec i p r oc i -t y f o r m o s t v a r ia b l e s e x a m i n e d - - f o r e x a m p l e , v e r b a l i n te r -r np t i ons , i l l us tr a t ive ges t u r es , bo dy o r i en t a ti on , and gaz i ng


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away . E v i denc e o f r ec i p r oc i t y was a l so f ound i n H a l l, Ro t e r ,and Rand ( 1981) , wher e j udg es ' r a t ings o f e l ec t r on i ca l l yf i l t e r ed speech sampl es ( on sca l e s such a s ange r and anx i -e t y ) wer e pos i t i ve l y cor r e l a t ed be t ween phys i c i an and pa -t i en t . L i t t l e ev i dence emer ged f o r r ec i p r oc i t y i n ana l ogousr a t i ngs o f t yped t r ansc r i p t , sugges t i ng t ha t phys i c i an-pa t i en t ma t ch i ng o r r ec i p r oca t i on may be a l a r ge l y nonver -b a l p h e n o m e n o n .

Al t hough such cor r e l a t i ons sugges t d i r ec t mut ua l i n f l u -ence , t he exac t causa l pa t te r ns a r e no t known . Co nt r a r y t o thepopul a r co ncep t i on o f m edi ca l v i s i t s a s a f f ec t i ve l y neu t r a l ,t hey appea r i ns t ead to be dyn ami c and a f f ec t i ve on bo t hs i des . M os t p r ovoca t i ve i s t he poss i b i l i t y t ha t t he pa t i en ti n f l uences the phy s i c i an a s we l l a s t he ph ys i c i an i n f l uenc i ngt he pa t i en t . An obv i ous ques t i on conce r ns t he i mpac t o f acyc l e o f nonv er ba l r ec i p r oca t i on on t he qua l i t y o f ca r e ; f o rexam pl e , does a pa t i en t who co nve ys i rr i ta t i on o r emot i ona ld e t a c h m e n t t h ro u g h n o n v e r b a l c u e s p r o d u c e a p h y s i c i a n w h oi s equa l l y i r r i t a t ed o r de t ached and who t hen cu t s t he v i s i tshor t, f a i l s t o exp l a i n m edi ca t i on s i de e f f ec t s , o r r educes t hepa t i en t s ' mot i va t i on t o compl y w i t h medi ca l adv i ce?

Gender. In West 's (1984 ) s tudy o f inter rupt ions , there wasan imp or tant qual i f icat ion to the overal l f inding that physic ian sinter rupted more than pat ients : for the few female-physiciandyads in the sample, pat ients inter rupted physic ians more,which was interpreted as di srespect for female physic ians .How ever , I ri sh and H a l l ( 1994) f ound on l y qua l if i ed suppor tfor such an ef fect , and, moreover , they suggested a l ternat iveinterpreta tions for inter rupt ive b ehavio rs ( see la ter ) .

Gen der has a l so been ex am i ned i n r e l a t i on t o ve r ba l f ac i li -t a t o rs , a f f ec t convey ed t h r ough f i lt e r ed speech r a t ings , sp eechd i s f luenc i e s , acous t ic measur em ent s , sm i l ing , nodd i ng , andt ouch i ng . Har r i gan , Gr amat a , L uc i c , and M ar go l i s ( 1989)f ound n o s i gn i f i can t phys i c i an sex d i f f e r ences i n ampl i t ude ,pi tch, speec h ra te , or di sf iuencies . In Hal l , I r ish, R oter , Ehr l ich,and M i l le r ( 1994) , r a ti ngs o f f i l te r ed speech show ed a num berof e f f ec t s , t he mo s t s t r i k ing o f whi ch r evea l ed an exces s o funf r i end l i nes s , i n t e r e st , anx i e t y , and bor ed om i n t he sp eech o ff ema l e phys i c i ans addr es s i ng ma l e pa t i en t s , and an exces s o fb o r e d o m a n d d o m i n a n c e i n t h e v o i c e s o f th e m a l e p a t i e n ts i nthose interact ions . H al l e t al . di scussed thes e ef fects in termsof r o l e o r expec t a t i on s t r a ins i n i n t e r ac t i ons be t ween f em a l ephys i c i ans and ma l e pa t i en t s . I n t ha t s ame s t udy , f ema l ephys i c i ans wer e a l so f ound t o use mor e ve r ba l f ac i l i t a t o r st han ma l e phys i c i ans , t o smi l e mor e ( h i ghes t w i t h ma l epa t i en t s ) , and t o nod mor e ( h i ghes t w i t h f ema l e pa t i en t s ) .

Other group differences. S hr eve , Har r i gan , Kues , andK a n g a s ( 1 9 8 8 ) f o u n d t h a t p a ti e n ts w i t h " h i d d e n " o r s e c o n d -a r y agendas w er e mor e l i ke l y to use hand- t o - bo dy t ouch i ngbo t h dur i ng t he r eve l a t i on o f t he s econdar y agenda anddur i ng t he g r ee t i ng phase o f t he v i s it . Hooper , Com s t ock ,G o o d w i n , a n d G o o d w i n ( 1 9 8 2 ) f o u n d t h a t p a t i e n t s w h ow e r e m o r e w e l l -d r e s s e d a n d n e a t r e c e i v e d m o r e " n o n v e r b a la t t en t i on" (gaze and bod y pos i t ion) f r om phy s i c i ans , wher e -as t he i r age and e t hn i c i t y d i d no t have an e f f ec t . T h i s r e -search f i t s wi th a smal l analogue l i t era ture on appearance

va r i ab l e s : Had j i s t avr opou l os , Ross , and von Baeyer ( 1990)f ound t ha t pho t os o f mo r e a t t r ac t ive pa t i en ts w er e a t t r ibu t edl ower pa i n and l e s s nega t i ve a f f ec t i ve expe r i ence s by ph ys i -c i ans . Nor dho l m ( 1980) f ound t ha t hea l t h p r o f es s i ona l sendor sed t he s ame "phys i ca l a t t r ac t i venes s s t e r eo t ype"abou t pa t i en t s - - a t t r i bu t i ng be t t e r ove r a l l qua l i t i e s t o mor ea t tr a c ti v e i n d i v i d u a l s - - t h a t h a s b e e n a m p l y d o c u m e n t e d i nnonc l i n i ca l s t ud i e s ( s ee Knapp & Ha l l , 1992) .

T o s u m m a r i ze t h e e v i d e n c e o n a n t e ce d e n t s o f n o n v e r b a lbehav i o r , t he mos t num er ous f i nd i ngs t o da t e a r e f o r phys i -c i an and pa t i en t gende r . W i t h t he exc ep t i on o f Ha l l e t a l . ' s(1994) f indings for f i l t ered speech ra t ings , these resul t s tendt o cor r obo r a t e o t he r s t ud ie s t ha t f i nd f ema l e phys i c i ans t o bemor e pos i t i ve and / o r r e spons i ve t han ma l e phys i c i ans i nt he i r ve r ba l communi ca t i ons ( e .g . , Ro t e r , L i pk i n , & Kor s -gaard, 1991) .

F i nd i ngs f o r pa t i en t appea r ance a r e a l so p r omi s i ng andcou l d p r ov i d e i mpor t an t l i nks t o t he l a r ge soc i a l psycho l og i -cal l i t era ture on physical a t t ract iveness and social s t igmas.Becau se nonc l i n i ca l s tud i e s p r ov i de muc h ev i dence r e la t i ngnonv er ba l behav i o r t o a f f i li a t ion and l i k ing ( e .g . , Ander sen ,1985) , and because phy s i c i ans ' l i k i ng o f pa t i en t s va r i e s bo t hbe t ween phys i c i ans and be t ween pa t i en t s w i t h i n phys i c i ans(Hal l , Epste in, DeCiant i s , & McNei l , 1993) , there are s t rongr easons t o be l i eve t ha t nonver ba l cues i nd i ca t i ve o f l i k i ng ,a t t r ac t i on , i n t e r e s t , and appr oach p l ay a c r uc i a l bu t a s ye tunappr ec i a t ed r o l e i n t he p r oces s o f medi ca l ca r e . One pos -s i b l e d i r ec t i on f o r such an avenue o f r e sea r ch i s i n t hed e v e l o p m e n t o f u n o b t r u s iv e ( n o n v e r b a l ) i n d i ca t o rs o f p a -t i en t and p r ov i de r r eac t i ons and a t t i t udes , whi ch cou l d beused a s a compl ement t o s t anda r d pape r - and- penc i l mea-sur es . F or exampl e , Ha l l , I r i sh , Ro t e r , E hr l i ch , and M i l l e r( i n p r es s ) f ound t ha t , pa r t i cu l a r l y among f ema l e pa t i en t s ,g r ea t e r s a t i s f ac t i on appea r ed t o be r e f l ec t ed i n a mor ef r i end l y and ca l m vo i ce t one .Nonverbal Behavior as a Predictor

N o n v e r b a l c o m m u n i c a t i o n d u r i n g t h e m e d i c a l e n c o u n t e r,and t o a l e s se r ex t en t phys i c i ans ' sk i l l s i n nonver ba l com-muni ca t i on ( a s ses sed i n a t e s t i ng s i t ua t i on) , have been r e -l a t ed t o s eve r a l ou t come va r i ab l e s , mos t commonl y pa -t ients ' sa t i s fact ion wi th thei r care . Greater sa t i s fact ion hasbeen a s soc i a t ed w i t h g r ea t e r phys i c i an nonver ba l i n t e r e s t ,l e s s t ime r ead i ng t he pa t i en t 's cha r t , l e s s t ouch by t he phy s i -c i an , mor e phys i c i an i mmedi acy ( e .g . , f o r war d l ean) , mor enods and ges t u r es by phys i c i ans , and c l ose r i n t e r pe r son-a l d i s t ance w i t h t he phys i c i an ( Bens i ng , 1991 ; L a r sen &Smith, 1981; Roter , Hal l , & Katz , 1987; Smi th, Pol i s , &Hadac , 1981 ; W ei nbe r ge r , Gr een e , & M aml i n , 1981) . I nadd i t i on , t he r apeu t i c qua l i t i e s ( war mt h , i n t e r e s t , empa t hy)of phys i c i ans have been a s ses sed on t he bas is o f nonver ba lbehav i o r s d i sp l ayed ( Har r i gan & Rosen t ha l , 1983) . F or ex-ampl e , phys i c i ans w ho d i r ec t l y f aced t he i r pa t ien t s , engagedi n a moder a t e l eve l o f eye con t ac t , and ma i n t a i ned an a r mpos t u r e i nd i ca t i ve o f a r ead i nes s t o ac t wer e r ega r ded a smor e empa t h i c , i n t e r e s t ed , and war m ( Har r i gan , Oxman, &


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Nonverbal Behavior and Clinical Interaction 27

Rosen t ha l , 1985) . T hus i t appea r s t ha t phys i c i an nonver ba lc u e s a s s o c i a t e d w i t h i m m e d i a c y o r p o s i t i v e i n v o l v e m e n t( t ouch be i ng a poss i b l e excep t i on) enhance t he pa t i en t ' spos i t i ve f ee l i ngs abou t t he v i s it .

F or t he mos t pa r t , co r r e l a t i ons be t wee n nonve r ba l behav-i o r a n d s u b s e q u e n t ra t in g s o r o u t c o m e s h a v e n o t b e e n e x a m -i ned f o r moder a t i ng e f f ec t s o f o t he r va r i ab l e s . As an ex-cept ion, Hal l e t a l . ( in press) looked separate ly a t a l lc o m b i n a t io n s o f p a ti e n t a n d p h y s i c i a n g e n d e r a n d f o u n d t h a tf o r dyads i nvo l v i ng one o r mor e m a l es , mor e ve r ba l i n t e rr up-t i ons ( by e i t he r pa r t y ) wer e a nega t i ve p r ed i c t o r o f s a t is f ac -t i on , sugges t ing t ha t i n t e r r up t i ons may h ave s i gn i f ied domi -n a n c e o r c o m p e t i t io n ; o n t h e o t h e r h a n d , f o r f e m a l e - f e m a l edyads t he r e l a t i on be t w een i n t e r r up t i ons ( by e i t he r pa r t y ) andsat i s fact ion was s igni f icant ly posi t ive , suggest ing that inter -r up t i ons ma y be a s i gn o f pa r t i c i pa t ion o r en t hus i a sm. W hi t -che r and F i she r ( 1979) a l so l ooked sepa r a t e l y a t ma l e andf emal e pa t i en t s wh en eva l ua t i ng t he e f f ec t s o f a t ouch i n t e r-ven t i on by nur ses . I n t ha t s t udy , f ema l e pa t i en t s r e spondedmu ch mo r e f avor ab l y t han ma l e pa t ien t s , w i t h t he ma l e andf emal e r e su l t s t end i ng t o go oppos i t e each o t he r .

T he combi na t i on o f cues i n d i f f e r en t channe l s ma t t e r ed i nthe sat i s fact ion s tudy o f Hal l e t a l. (1981) ; pat ients were m ostsat is fi ed when t he phys i c i an used m or e pos i t i ve wor ds bu tmor e nega t i ve vo i ce t one , sugges t i ng t ha t t h i s combi na t i onconveyed s i mul t aneous accep t ance and conce r n . Cons i s t en twi t h t h is , when phys i c i ans ' vo i ces we r e mor e anx i ous , a lco-ho l i c pa ti en ts w er e mo r e comp l i an t in t he s t udy o f M i l moe ,Rosenthal , Blane, Chalet s , and Wolf (1967) .

P h y s i c i a n s ' s k i ll s i n n o n v e r b a l c o m m u n i c a t i o n h a v e b e e nr e l a t ed to s a t i sf ac t ion , compl i ance , and ph ys i c i ans ' w or k l oadi n t h e i n n o v a t iv e r e s e a r c h p r o g r a m o f D i M a t t e o a n d c o l -l eagues ( D i M at t eo , T a r an ta , F r iedma n , & P r i nce , 1980 ; D i -M at t eo , Hays , & P r i nce , 1986). T hese r e sea r che r s , us ing as t anda r d i zed t e s t o f nonver ba l decod i ng ab i l i t y ( t he P ONSt es t) , f ound t ha t phys i c i ans w ho w er e mor e accur a t e a t j udg-i ng i n t e r pe r sona l cues exp r es sed by t he bod y had m or e s a t i s-f i ed pa t i en t s. T h ey a l so f ou nd pos i t i ve a s soc i a t i ons be t weenphys i c i ans ' ab i l i t ie s t o expr es s nonver ba l em ot i on cues i n aposed t a sk and pa t i en t s ' s a t i s f ac t i on , pa t i en t s ' succes s i nk e e p i n g s c h e d u l e d a p p o i n t m e n t s, a n d t h e p h y s i c i a n s ' w o r k -l oad ( sugges t i ng t ha t phys i c i ans w i t h good encod i ng sk i l l smay be mor e popu l a r ) . I t r ema i ns f o r f u t u r e r e sea r ch t oi l l umi na t e t he p r oces ses by whi ch phys i c i ans ' nonver ba ldecod i ng and encod i ng sk i l l s a r e t r ans l a t ed i n t o e f f ec t i vebehav i or s w i t h pa t i en t s dur i ng i n t e r pe r sona l i n t e r ac t i on ; ar easonab l e s cena r i o is t ha t good- de cod i ng phys i c i ans uset he i r he i gh t ene d awar enes s o f pa t i en t s' f ee l i ngs and i n t en-t i ons to gu i de t he i r own v e r ba l and non ver ba l r e sponses , andt ha t those ph ys i c i ans w i t h be t t e r dev e l oped ex pr es s i on sk i l lsa r e b e st a b l e to c o n v e y m e s s a g e s o f e m p a t h y , w a r m t h , c o n -ce r n , good chee r , suppor t i venes s , o r d i s appr ova l wh en appr o-pr i a te . I f t he a f f ec t i ve l y neu t r a l phys i c i an was eve r an i dea l ,t hese r e su l ts s t r ong l y i nd i ca t e t ha t i t shou l d no t be . R e l a t ingt o pa t ien t s t h r ough exp r es s i ve nonver ba l cues appea r s t o bean essent ia l ski l l for the physic ian.

A f i na l ca t egor y o f ou t co me i s one w i t h f ew s t ud ie s bu tposs i b l y f a r - r each i ng i mpl ica t i ons . T wo s t ud i e s have f o undt ha t nonver ba l behav i o r a l one can i n f l uence j udgm ent s o fc l i n i ca l compe t ence made by p r of es s i ona l medi ca l eva l ua -t o r s . I n one o f t hese , ac t o r s memor i zed t he exac t ve r ba lr e sponses o f su r ge r y s t uden t s ' o r a l exami na t i ons and r een-ac t ed t hem, va r y i ng eye con t ac t and r a t e o f speech . T hesev i deo t apes w er e t hen j udged b y a na t i ona l pane l o f c l i n i ca lsu r ge r y f acu l t y r epr esen t i ng 46 i ns t i t u t i ons . T he nonver ba lbehav i o r mani pu l a t i on mad e a s i gn i f i can t d i f f e r ence in ove r -a l l s cor es a s s i gned t o t he exami na t i ons ( Rowl and- M or i n ,Bur cha r d , Gar b , & Coe , 1991) . I n t he s econd s t udy on t h i st op i c , b r i e f exce r p t s o f an ac tua l pa t i en t - m edi ca l s t uden ti n t e r v i ews wer e r a t ed f o r non ver ba l behav i o r . T hese r a t i ngswer e f ou nd t o be s i gn i fi can t p r ed i c t o r s o f t he s t uden t s ' ove r -a l l g r ade on c l i n i ca l compe t ence g i ven by t he i r p r o f es sor s( Rosenb l um e t a l . , i n p r es s ) . T he poss i b l e r e l evan ce o f t hesef i nd ings f o r phy s i c i an- p a t i en t r e l a ti ons , spec i f i ca l l y a tt r ibu-t i ons made by pa t i en t s abou t phys i c i ans ' compe t ence , i sobv i ous . ( F or f u r t he r d i s cus s i on o f t he r e l a t i on o f t a sk-r e l e v a n t a n d s o c i o e m o t i o n a l b e h a v i o rs i n p h y s i c i a n - p a t i e n tre la t ions , see Hal l e t a l . , 1988.)

T h e C o n s t r u ct o f R a p p o r tT he co ns t r uc t o f r appor t i s va l uab l e to t he unde r s t and i ng o fany i n t e r ac t i on , bu t i t i s c r uc i a l t o t he unde r s t and i ng o fc l i n i c i an- p a t i en t i n t e r ac ti on . I n the f o l l owi ng pages w e dea lwi t h concep t ua l i s sues su r r ound i ng r appor t and r e l a t ed con-cep t s , and we summar i ze some empi r i ca l f i nd i ngs . How-eve r , our f ocu s i n t h i s s ec t i on w i l l no t be r e s t r i c ted exc l u -s i ve l y t o t he c l i n i ca l con t ex t . I t w i l l be use f u l t o beg i n w i t hsome t ypes o f de f i n it i ons o f r appor t .

DefinitionsT hr ee t ypes o f de f i n i t ions o f r appor t sho u l d be d i s t in -

gu i shed : t he s ens i ti z i ng , t he concep t ua l , and t he ope r a t i ona l .Sensitizing Definitions

Sensi t iz ing def ini t ions are abs t ract def ini t ions that pointus i n a gene r a l d i r ec t ion o f mean i ng bu t l ack concep t ua lclar i ty . Such def ini t ions are useful for l imi t ing the universeof d i s cour se ; f o r t he con s t r uc t o f r appor t a s ens i ti z i ng de f i n i-t i on mi gh t be "a good r e l a t i onsh i p . "Conceptual Definitions

F or many scho l a r l y and sc i en t i f i c pur poses , s ens i t i z i ngde f i n i ti ons w i ll no t wor k f o r ve r y l ong . W e mu s t beco me l e s svague i n f o r m ul a t i ng our concep t ua l de f in i t ions . Concep t ua lde f i n i ti ons o f r appor t va r y som ewh a t amo ng r e sea r che r s bu tt he one we wi l l use i s t ha t o f L i nda T i ck l e - Degnen ( 1989 ;T i ck l e - Deg nen & Rosen t ha l , 1992) . H i gh l eve l s o f r appor ta r e cha r ac t e r i zed by : ( a ) h i gh l eve l s o f mut ua l a t t en t i venes sor i nvo l vem ent , ( b ) h i gh l eve l s o f pos i t i v i ty o r war mt h , and( c ) h i gh l eve l s o f behav i o r a l coor d i na t i on . Behav i or a l coor -d i na t i on i t s e l f requ i r e s de f i n i t ion . I n t e r ac t i ons a r e m or e b e -


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28 Hall , Harrigan, and Rosenthal

h a v i o r a l l y c o o r d i n a t e d a s t h e y b e c o m e m o r e p a t t e r n e d o rs y n c h r o n i z e d i n f o r m a n d i n t im i n g . T w o m a j o r c o m p o n e n t so f b e h a v i o r a l c o o r d in a t i o n a r e ( a ) " b e h a v i o r m a t c h i n g " o rs im i l a r i t y an d (b ) " in t e r ac t i o n a l sy n c h ro n y , " w h ich i s ch a rac -t e r i z ed b y i n t e r a c t i on r h y t h m , s i m u l t a n e o u s m o v e m e n t , a n db eh av io ra l m e sh in g (B ern i e r i , 1 9 8 8; B ern i e r i & R o sen th a l ,1991 ; Condon , 1982 ; Kendon , 1970) .Operational Definitions

S p ec i f i c o p e ra t i o n a l d e f in it i o n s o f r ap p o r t m ay v a ry w id e -l y f r o m s t u d y t o s t u d y . S o m e t i m e s r a t i n g s b y o n e o r b o t hp a r t i c ip an t s s e rv e a s t h e o p e ra t i o n a l i za t i o n s ; so m et im es r a t -i n g s b y o u t s id e o b se rv e r s a r e em p lo y ed . S t an d a rd i zed i n -s t r u m e n t s a s s e s s i n g m o o d s o r o t h e r s t a t e s c a n a l s o b e e m -p lo y ed ( e . g . , B a r r e t t -L en n ard , 1 9 6 2 ; T ru ax & C ark h u f f ,1 96 7 ). N o n e o f t h ese o p e ra t i o n a l i za t i o n s i s i n t r i n s i ca l ly b e t -t e r o r w o r se t h an o th e r s , an d i t m ay o f t en b e d es i r ab l e t oe m p l o y s e v e r a l o f t h e m . O n e m e t h o d o l o g i c a l i s s u e s h o u l db e n o t ed , h o w ev er . T h a t i s su e h as t o d o w i th t h e r e l i ab i l i t yo f t h e o p e ra t i o n a l i za t i o n . W h en a s in g l e p a r t i c ip an t ( e . g. ,t h e p a t i en t ) m ak es r a t i n g s t h e re i s n o th in g w e can d o t oi n c r e a se t h e r e l i a b il i ty o f t h e r a t i n g s - - t h e r e i s j u s t o n e p a -t ie n t. H o w e v e r , w h e n w e e m p l o y e x t e r n a l o b s e r v e r s a n d th ere l i ab i l i t y o f t h e r a t i n g s i s i n q u es t i o n , w e can ad d o b se rv e r sto i n c rease t h e r e l i ab i l i t y o f t h e o v e ra l l s co re o n r ap p o r t .In c reas in g r e l i ab i l i t y t y p i ca l l y i n c reases t h e co r r e l a t i o n o fr ap p o r t w i th o th e r v a r i ab l e s .Empathy

T h o u g h c l o s e l y r e la t e d t o t h e c o n c e p t o f r a p p o rt , e m p a t h yi s n o t q u i t e t h e sam e th in g . E m p a th y i s u su a l ly d e f in ed co n -cep tu a l ly a s u n d e r s t an d in g an o th e r ' s f ee l i n g s an d th o u g h t san d , i n ad d i t i o n , ac tu a l l y ex p e r i en c in g t h a t o th e r ' s f ee l i n g san d th o u g h t s , a t l ea s t to so m e d eg re e (H ar r ig an & R o sen th a l ,1 9 8 6 ) . E m p a th y i s l i k e ly t o b e s t ro n g ly co r r e l a t ed w i th r ap -p o r t i n t h e c l in i ca l co n t ex t , b u t i t d i f fe r s o n t h e d im e n s io n o fm u tu a l i t y . R ap p o r t i s a m u tu a l co n s t ru c t ; i t is a d esc r ip t i o n o fan i n t e r ac t i o n t h a t d o es n o t ap p ly t o c l i n i c i an a lo n e o r t op a t i en t a lo n e . O n ly d y ad s (o r l a rg e r g ro u p s ) can sh o w rap -p o r t. E m p a t h y , h o w e v e r , c a n b e s h o w n b y j u s t o n e o f t h ep a r t i c ip an t s . B ecau se t h e em p a th i c c l i n i c i an i s l i k e ly t o b ea t t en t iv e t o an d p o s i t i v e t o w ard t h e p a t i en t , b eh av io r th a t w i l lb e r ec ip ro ca t ed b y t h e p a t i en t , t h e re i s l i k e ly t o b e a s t ro n gco r re l a t i o n b e tw ee n th e em p a th y l ev e l o f t h e c l i n i c i an an d th el e v e l o f r a p p o r t o f t h e d y a d .

Posit ivi ty and Nonverb al BehaviorSom e Meta-Analytic Results

A p r e l i m i n a r y m e t a - a n a l y s i s h a s b e e n c o n d u c t e d t h a t s u m -m a r i z e s t h e r e l a t i o n sh i p b e t w e e n s p e c if i c n o n v e r b a l b e h a v -io r s an d p o s i t i v i t y , o n e o f t h e t h r ee ch a rac t e r i s t i c s o f r ap p o r t(T ick l e -D eg n en , R o sen th a l , & H ar r ig an , 1 9 8 9 ) , b ased o n aw id e r an g e o f s e t t i n g s , n o t o n ly c l i n i ca l . I n t e r ac t i o n a l b e -h a v i o r s c r e a t in g a m o r e p o s i t i v e i m p r e s s i o n i n t h e o b s e r v e rin c lu d ed sm i l i n g , h ead n o d d in g , an d fo rw ard l ean , a l l w i th

l a rg e e f f ec t s i zes (m ed ian co r r e l a t i o n o f ab o u t . 5 0 ) , d i r ec t edg az in g an d d i r ec t b o d y o r i en t a t i o n (m ed ian co r r e l a t i o n o fab o u t . 4 0 ) , an d p o s tu re m i r ro r in g an d u n c ro ssed p o s tu r in g o fth e a rm s (m ed ian co r r e l a t i o n o f ab o u t . 2 5 ) . I n g en e ra l , t h em ag n i tu d es o f t h ese r e l a ti o n sh ip s w e re su b s t an t i a l l y la rg e rw h e n t h e o b s e r v e r o f t h e n o n v e r b a l b e h a v i o r w a s a n e x t e r n a lo b se rv e r r a th e r t h an a p a r t i c ip an t o b se rv e r . T h e re w a s a l so at en d en cy fo r t h e m ag n i tu d es o f t h ese r e l a t i o n sh ip s t o b eh ig h e r fo r t h o se s tu d i e s sh o w in g g re a t e r eco lo g i ca l an d in t e r -nal val id i ty .Interactional Synchrony

E a r l i e r w e n o t e d t h a t b e h a v i o r a l c o o rd i n a ti o n w a s o n e o fth ree cen t r a l c r i t e r i a o f rap p o r t . B e h av io ra l co o rd in a t i o n i t -s e l f w a s d e f i n e d b y t w o m a j o r c o m p o n e n t s : ( a ) b e h a v i o rm a tch in g an d (b ) i n t e r ac t i o n a l sy n ch ro n y . B ecau se b eh av io rm a t c h i n g c a n b e s u b s u m e d c o n c e p t u a l l y u n d e r i n t er a c t io n a lsy n ch ro n y , i t i s t h e l a t t e r w e d esc r ib e h e re .

O n e f ea tu re o f in t e r ac t i o n a l sy n c h ro n y i s " i n t e r ac t i o nr h y t h m , " a c y c l i n g o f i n te r a c t io n t e m p o s t h r o u g h o u t t h eco u r se o f t h e i n t e r ac t i o n . T h i s f ea tu re can b e o p e ra t i o n a l -i z e d b y h a v i n g o b s e r v e r s r a t e t h e d e g r e e o f t e m p o s i m i l a r i tyin t h e i n t e r ac t i o n , t h e d eg ree t o w h ich t h e i n t e r ac t an t s ap -p e a r t o " m a r c h t o t h e b e a t o f t h e s a m e d r u m m e r . " A s e c o n df e a t u r e o f i n te r a c t io n a l s y n c h r o n y i s " s i m u l t a n e o u s m o v e -m e n t , " t h e c o - o c c u r r e n c e o f p o s tu r e s a n d m o v e m e n t s . T h i sf e a t u r e c a n b e 0 P e r a t io n a l iz e d b y h a v i n g o b s e r v e r s r a t e t h ed e g r e e o f m o v e m e n t th a t a p p e a r s to b e g i n o r e n d a t th e s a m em o m e n t f o r b o th p a r t ic i p a n ts a n d / o r t h e d e g r e e t o w h i c h t h esam e b e h av io r o ccu r s fo r b o th i n t e r ac t an t s . T h e t h i rd f ea tu reo f i n t e ra c t io n a l s y n c h r o n y i s " b e h a v i o r a l m e s h i n g , " w h i c hc a n b e o p e r a t i o n a l i z e d b y o b s e r v e r s ' r a t i n g s o f t he d e g r e e t ow h i c h t h e i n t e r a c t a n t s ' b e h a v i o r s a r e s m o o t h a n d e v e n , c o -o rd in a t ed , an d in t e r tw in in g .

I n t e r a c ti o n a l s y n c h r o n y c a n b e a s s e s s e d b y u n t r a i ne d o b -s e r v e r s f r o m v i d e o c l i p s r a n g i n g f r o m a f e w s e c o n d s t o af ew m in u tes , m ak in g i t an a t t r ac t i v e , p r ac t i ca l v a r i ab l e fo ru s e i n th e s t u d y o f c l i n i c i a n - p a t i e n t i n t e r a c t io n ( A m b a d y &R o sen th a l , 1 9 92 ; K o ss & R o sen th a l , 1 9 9 4 ).

Interactional Synchro ny and Positivityin the Do ctor-P at ient In teraction

In a s t u d y o f p h y s i c i an s i n t e r ac t i n g w i th t h e i r p a t i en t s ,i n t e r a c t i o n a l s y n c h r o n y w a s a s s e s s e d s e p a r a t e l y f r o m t h ep o s i t i v i t y co m p o n e n t o f r ap p o r t (K o ss & R o sen th a l , 1 9 94 ).In t e r ac t i o n a l sy n ch ro n y w as d e f in ed a s t h e m ean o f r a t i n g sm a d e b y o b s e r v e r s o n t h e f o u r v a r i a b l e s o f t e m p o s i m i l a ri t y ,s i m u l t a n e o u s m o v e m e n t , p o s t u r e m i r r o r i n g , a n d c o o r d i n a -t i o n an d sm o o th n ess . T h e m ean o f t h e s ix i n t e r co r r e l a t i o n sam o n g th ese fo u r v a r i ab l e s w as . 8 2 .

P o s i t i v i t y w as d e f in ed a s t h e m ean o f r a t i n g s m ad e b yo b se rv e r s o n t h e 1 5 v a r i ab l e s o f h a rm o n io u s , w o r th w h i l e ,p o s i t i v e , f r i en d ly , co o p e ra t i v e , s a t i s fy in g , i n v o lv in g , ac t i v e ,sen s i t i v e , f o cu sed , r e l ax ed , n o t co ld , n o t d u ll , n o t aw k w ard ,an d n o t u n co m fo r t ab ly p aced . T h e m ean o f t h e 1 05 in t e rco r -r e l a t i o n s am o n g th ese 1 5 v a r i ab l e s w as . 9 2 .


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Nonverbal Behavior and Clinical Interaction 29

Cl ea r l y , t hen , bo t h t he cons t r uc t s o f i n t e r ac t i ona l syn-c h r o n y a n d o f p o s i t i v i t y s h o w e d v e r y h i g h i n t e r n a l c o n -s i s t ency among t he va r i ab l e s t ha t de f i ned each o f them. T h ec r i ti ca l ques t i on f o r t he v a l i d i t y o f bo t h t hese co ns t r uc t s waswhe t he r t hey w er e i n f ac t t wo cons t r uc t s o r whe t he r i n t e rac -t i ona l synchr on y woul d be i nd i s t ingu i shab l e f r om pos i t iv i t y .T o addr es s t ha t qu es t i on t he f our va r i ab l e s de f i n i ng i n t e r ac -t i ona l synchr on y wer e cor r e l a t ed w i t h t he 15 va ri ab l e s de -f i n ing pos i t iv i t y . T he mea n o f t he r e su l t i ng 60 co r r e l a t ionswas .57 , ve r y subs t an t ia l l y l ower t han t he w i t h i n - cons t r uc ti n t e r cor r e l a t i ons t ha t ave r aged abou t . 90 . Ver y s i mi l a r r e -su l t s have a l so been ob t a i ned i n r e sea r ch on nonc l i n i ca ldyads by Ber n i e r i , Dav i s , Rosen t ha l , and Knee ( 1994) .

G i ve n t he ease w i t h whi ch bo t h t he cons t r uc t s o f pos i t i v i t yand o f i n t e r ac t i ona l synchr ony can be ope r a t i ona l i zed byobse r ve r s ' r a t i ngs o f ve r y " t h i n s l i ces " o f i n t e r ac t i ona l be -hav i o r , f u t u r e i nves t i ga t o r s o f c l i n i c i an- pa t i en t i n t e r ac t i onma y we l l choo se t o empl oy bo t h v a r i ab l e s in t he i r r e sea r ch .

D i agnos t i c Re l evance o f t he P a t i en t ' s Nonver ba lBehav i or : T hr e e I l l us tr a t ions

M o s t o f t h e r e s e a rc h r e v i e w e d t h u s f a r h a s e m p h a s i z e d t h ei mpac t o f c l i n i c i ans ' beh av i o r on pa t i en t s o r obse r ve r s . Bu t ,obv i ous l y , c l i n i c i ans mus t r ead t he pa t i en t s ' needs , emo-t i ons , and i n t en t i ons - - s k i l l s t ha t t he wor k o f D i M at t eo ,r ev i ewed ea r l i e r , s t r ong l y sugges t ed a r e i mpor t an t f o r pa -t i en t s ' we l f a r e . Compar a t i ve l y l i t t l e r e sea r ch has l ooked a tt he i mpac t o f pa t ien t s ' b ehav i o r s on c l i n i c i ans ( Bul l e r &Street , 1992; S t reet , 1990). H ow eve r , s tudies on pat ientsy i e l d f i nd i ngs t ha t a r e o f g r ea t r e l evance . T hr ee i l l us t ra t i onsa r e o f f e r ed he r e : c l ues t o psycho pa t ho l og y , c lues t o t heT ype A/ B behav i or pa t t e r n , and c lues t o the expe r i ence o fpain.

PsychopathologyDet ec t i ng non ver ba l cues i nd i ca t i ve o f pa t ho l og i ca l s t a te s

can g r ea t l y a s s i s t t he p r ac t i t i one r i n de t e r mi n i ng pa t i en td i f fi cu l ti e s . G i ven t he f ac t t ha t 50% of p r i mar y ca r e consu l -t a t i ons i nvo l ve t r ea t ment o f psychosoc i a l p r ob l ems ( Baker& C assa ta , 1978) and t he f ac t t ha t phys i c i ans a r e o f t en t hef ir s t con t ac t f o r pa t i en t s su f f e r i ng f r om d i f f icu l t ie s r equ i r i ngp s y c h o t h e r a p y , a w a r e n e ss o f n o n v e r b a l b e h a v i o r a s s o c ia t e dwi t h psycho pa t ho l o gy i s e s sen ti a l . I n add i t i on t o d i agnos i s ,o t he r ou t comes such a s t r ea t ment cho i ce , r e sponse , and e f -f e c t iv e n e s s m a y o f t e n b e d e t e r m i n e d b y p a t ie n t n o n v e r b a lbehav i o r s . Ou r conce r n s i n t he p r esen t s ec t i on a r e t he i mpl i-ca t i ons o f nonver ba l behav i o r i n t he d i agnos i s o f pa t i en tdi f f icul t ies .Nonverbal Behavior in Depression

A n y o n e w h o h a s o b s e r v e d a d e p r e s s e d i n d iv i d u a l is a w a r eof t he s ad , downcas t , and gene r a l l y s l owed- down behav i orman i f e s t ed i n depr es sed s t a te s . Resea r che r s h ave subs t an t i -a t ed t h i s cha r ac t e r i s t i c pa t t e r n by showi ng ev i dence o f de -c r eased gene r a l movement , expr es s i venes s , and i n t e r ac t i on

wi t h o t he r s . I n acu t e s t ages o f depr es s i on , pa t i en t s exh i b i tdec r eased speech , hand ges t u r es , f ac i a l ac ti v i ty , and sm i l ing(Buck, 1984; Ekman & Fr iesen, 1974; El lgr ing, 1986;Fr idlund , Ekma n, & Oster , 1987; Waxer , 1976) . The re is lesseye con t ac t w i t h o t he r s bo t h when l i s t en i ng , wher e g r ea t e reye con t ac t i s expec t ed , and wh en speak i ng , wher e dec r easedeye co n t ac t is expe c t ed ( H i nch l i f f e , L ancash i r e , & Rober t s ,1970; Rut ter , 1973) . Decreased verbal product ivi ty and s lowspeech wi t h de l ays i n de l i ve r y and l ong s i l en t pauses a r e no tunc om mo n ( Ar onson & W ei n t r aub , 1972 ; P ope , B l as s, S i eg-man , & Raher , 1970) , suggest ing a low arousal or act ivat io nl eve l . Depr es sed pa t i en t s demo ns t r a t e s i gn i f ican t imp a i r menti n d i sp l ay i ng f ac i a l expr es s i ons , e spec i a l l y t hose i nvo l v i nghapp i nes s ( J aege r , Bor od , & P ese l ow, 1986). As i m pr ove-men t occur s , t he r e is an i nc r ease i n ma ny o f t hese behav i o r s ,mos t no t ab l y eye con t ac t , smi l i ng , gene r a l movement , andspeech r a t e ( E kma n & F r i e sen , 1974 ; E l l g r ing , 1986;Hi nch l i f f e , Hoo per , Rober t s , & Vaughan , 1975) . T h e de -pr es sed a l so show dec r ement s i n s ens i t iv i t y t o o t he r s ' com -muni ca t i on by f a i l i ng t o d i sc r i mi na t e among f ac i a l expr es -s i ons o f emot i on ( Co ol ey & Now i ck i , 1989) and exh i b i t i ng anega t i ve b i a s when i den t i f y i ng emo t i ons ( Col us sy & Z ur of f ,1985; Gu r e t al ., 1992) that paral le l s er rors of logic descr ib edby Beck ( B eck , Rush , S haw, & E m er y , 1979). T he dep r es sedma y no t a l ways demo ns t r a t e a d i mi n i shed sens i t i v it y to o t h -e r s ' communi ca t i on , however . Be r n i e r i and Gi l l i s ( 1993)r epor t ed r e su l t s i nd i ca t ing t ha t depr es sed i nd i v i dua l s w er em o r e a c c u r a t e i n j u d g in g t h e d e g r e e o f r a p p o r t b e t w e e n t w oconver sa t i ona l i n t e r ac t an t s , and a s t heor y o f depr es s i onwoul d sugges t , t he depr es sed f ocused s i gn i f i can t l y mor eof t en on t he nega t i ve mem ber o f the pa ir . F i na l l y , the i mp ac to f t he depr es sed pe r son ' s behav i o r on o the r s canno t be ove r -l ooked . I n f an t s o f depr es sed mot he r s exh i b i t ed a depr es sedinteract ion s tyle s imi lar to that of thei r mo thers (F ield, 1984).Nonverbal Behavior in Schizophreniaand Other Psychopathology

Non ver ba l behav i o r s a r e i mpor t an t i n o t he r f o r ms o f psy-chopa t ho l ogy a s we l l , a l t hough r e su l t s a r e l e s s c l ea r t hant hose f o r depr es s i on . D i s r up t i on o f a f f ec t is a ma j or sour ceof d i f f i cu l ty i n s ch i zophr en i a . W h er eas c l i n ica l r ecor dsaboun d wi t h desc r i p t ions o f s ch i zophr en i c pa t i en t s ' non-ve r ba l b ehav i o r s ( f la t a f f ec t , g r imac i ng , r i g i d it y , i nappr opr i -a t e l augh t e r ), dem ons t r a t i ng t hese emp i r i ca l l y is m or e d i f f i-cu l t . A va r i e t y o f abnor mal i t i e s have been f ound : d i s t u r -b a n c e s i n s p e e c h - m o v e m e n t s y n c h r o n y ( C o n d o n & O g s t o n ,1966) , dec r eased r a t e s o f hand ges t u r es ( E km an & F r i e sen ,1974) , i nc r eased f r equenc i es o f con t i nuous s e l f - t ouch i ng( i . e . , hand- t o - hand movement s ) ( Gr and , F r eedman , S t e i n -ga r t , & Buch wal d , 1975) , l e s s f ac ia l ac t i v it y when speak i ng(El lgr ing, 1986) , and less par tner -di rected gaze (Rut ter ,1976, 1977). L ikew ise , schizoph renic pat ients show de-c r eased accur acy i n decod i ng o t he r s ' a f f ec t ( F e i nbe r g ,R i f k i n , S cha f f e r , & W al ke r, 1986 ; Z ur o f f & Col us sy , 1986) ,as have oth er psyc hiat r ic pat ients (Ros enthal e t a l. , 1979) .T hese e f f ec t s a r e no t a l ways f ound , however ( Joseph ,


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S t ur geon , & L ef t , 1992) , and t he c r i t ica l va r i ab l e s eems t obe t he phase o f s ch i zophr en i a o r t he ove r a l l l eng t h o f hosp i -ta l izat ions , i .e . , acute versus chronic (Morr i son, Bel lack, &Mueser , 1988) .

I n f o r m a t io n r e g a r d i n g n o n v e r b a l b e h a v i o r f o r o t h e r p s y -cho l og i ca l d i so r de r s i s l e s s c l ea r cu t . Depend i ng on t he de -gr ee o f anx i e t y , we may see pac i ng , hand- wr i ng i ng , f r e -quen t pos t u r e sh i f t s , dec r eased eye con t ac t , h i ghe r p i t ch ,and uncoor d i na t ed speech ( Ju r i ch & Jur i ch , 1974 ; M ahl ,1987; Scherer , 1988; S iegm an, 1987; Wax er , 1977) , butempi r i ca l s t ud i e s o f anx i e t y a r e spa r se and no t eas i l y com-par ab l e . Nonv er ba l behav i o r i d i osync r as i e s f o r c li en t s w i t ho t he r emo t i ona l d i so r de r s a r e a l so o f i n te r e s t. F or ex amp l e ,c o m p a r e d w i t h n o n p s y c h o p a t h s , p s y c h o p a t h s i n t e r a c t i n gwi t h t he r ap i s t s d i sp l ayed f ewer smi l e s , bu t mor e hand ges -t u r es , f o r war d l ean , and eye con t ac t , and r ec e i ved l e s s ve r ba lr e sponse f r om t he i r t he r ap i s t s ( R i m6, Bouvy , L ebor gne , &Roui l l on , 1978) . T he use o f a l coho l s eems t o depr es s one ' sab i l it y t o i n t e r p r e t f ac ia l expr es s i ons , e spec i a l l y ma l es ' i den-t i f i ca t i on o f ange r and d i sgus t ( Bor r i l l , Rosen , & S ummer -f i el d , 1987) ; a dec r em ent i n a f f ec t awar enes s r e l a t ed t o a l co-ho l has been demo ns t r a t ed i n o t he r s t ud ie s ( Rosen t ha l e t a l .,1979 ; Rosen t ha l & Benowi t z , 1986) .

I n summ ar y , w i t h r e spec t to nonver b a l behav i o r i nd i ces o fpsych opa t ho l ogy , t he r e s eems t o be a mo r e cons i s t en t andcoher en t pa t t e r n i nd i ca t i ve o f depr es s i on t han o f s ch i zo-phr en i a , anx i e t y s t a t e s , soc i opa t hy , o r o t he r d i so r de r s . P eop l esuf f e r i ng f r om depr es s i on exh i b i t a s l owed down, l e s s ex-pr es s i ve i n t e r ac t i ve s t y l e t ha t pa r a l le l s t he i r gene r a l i nwar df ocus . I t i s advan t ageous t ha t t h i s pa t t e r n appea r s t o be socons i s t en t ac r os s age , gende r , and cu l t u r e , g i ven t ha t depr es -s i on i s one o f t he mos t f r equen t psycho l og i ca l d i so r de r s( W ei s sman , L ea f , T i sch le r , 1988) f r om w hi ch se r i ous conse -quences such ~ s su i c i de can r esu l t . T he r e s eem t o be l e s scons i s t en t da t a w i t h r ega r d t o nonve r ba l behav i o r pa t te r ns i nt hose su f f e r i ng f r om sch i zophr en i a , and t he p r i mar y f ac t o rseems t o be t he l eng t h o f t i me f o r whi ch t he s ch i zophr en i cpa t i en t has expe r i enced dys f unc t i on ( e .g . , hosp i t a l i za t i on ,medi ca t i on use ) . Over a l l , t he mos t t yp i ca l nonver ba l cuesd i sp l ayed by sch i zophr en i c pa t i en t s a r e s t e r eo t yp i c and i d i o -sync r a t i c behav i o r s ( such a s r ock i ng o r g r i mac i ng) an d l e s si n t e r ac t i ve movement . Of pa r t i cu l a r i n t e r e s t w i t h r ega r d t ot he r apeu t i c i n t e r ven t i ons f o r s ch i zophr en i c pa t i en t s i s t he i rd i f f icu l t y in appr opr i a t e l y decod i ng o t he r s ' a f f ec t. F i na l l y ,t he a r ea o f nonver ba l behav i o r s i nd i ca t i ve o f psychopa t ho l o -g y i s o n e i n w h i c h m u c h w o r k r e m a i n s t o b e d o n e w i t hr espec t t o d i agnos i s ( e .g . , d i f f e r en ti a t i ng dement i a f r om de -pr es s i on , o r d r ug i n t ox i ca t i on f r om an x i e t y s t a t e s) and t r ea t-me nt ( e .g . , soc i a l sk i l ls t r a i n i ng f o r depr es s i ve and sch i zo-phr en i c pa t i en t s and t hose w i t h somat of or m d i sor de r s ) .

Type A/B PersonalityP er sona l i t y appea r s t o p l ay a r o l e i n t he deve l opment o f

cor ona r y hea r t d i s ease , o r CHD . M os t r e sea r ch i n t h i s a r eahas been d i r ec t ed t owar d t he T yp e A] B d i s t inc t i on t ha t wasf i rs t i den ti f ied by ca r d i o l og i s t s o ve r 30 yea r s ago ( M . F r i ed-

man & Rosenman , 1959) . I n sp i t e o f some r ecen t nega t i vef i nd i ngs , me t a - ana l ys i s r evea l s a c r ed i b l e r e l a t i on be t weenT y p e A / B a n d C H D ( B o o t h - K e w l e y & F ri e d m a n , 1 9 8 7 ).

W hy i s t he T yp e A/ B cons t r uc t r e l evan t to our i n t e r e s t inn o n v e r b a l c o m m u n i c a t io n a n d m e d i c a l c a r e ? T h e a n s w e r i st ha t p r eemi nen t among t he qua l i t i e s a sc r i bed t o T ype Ai nd i v i dua ls i s a d i s t i nc t ive no nver ba l behav i o r a l s t y l e . A l -t h o u g h a d j e c t iv e s t o o n u m e r o u s t o n a m e h a v e b e e n u s e d t od i s t ingu i sh T ype A f r om T ype B i nd i v i dua l s ( Ha l l , H . F r i ed-man , & Har r i s , 1986) , a b r i e f por t r a i t woul d dep i c t T ype Asas much mor e aggr es s i ve , hos t i l e , and i mpa t i en t t han T ypeBs . S pec i f i c qua l i t i e s i nc l ude v i g i l an t , t ense and / o r r ap i df a c ia l a n d b o d y m o v e m e n t s , e x p l o s i v e s p e e c h , s h o r t s p e e c hl a t enc ie s , and n onver b a l l y expr es sed hos t i l it y . S o cen t r a l a r et hese qua l i ti e s t o t he concep t i on o f t he T ype A i nd i v i dua lt ha t t he s t anda r d d i agnos t i c i ns t r ument , t he S t r uc t u r ed I n t e r -v i ew , i nc l udes such expr es s i ons among i t s s cor i ng c r i t e r i a .T hus , engag i ng i n ce r t a i n nonver ba l behav i o r s i s l i ke l y t oy i e l d a T ype A d i agnos i s .

S eve r a l l i nes o f ev i dence conv i nce us t ha t nonver ba l be -hav i o r i ndeed has a mean i ngf u

hall - harrigan - nonverbal behavior in clinician-patient interaction

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