Iatrosedation by Dr Nathan Friedman

Nonverbal Empathic Strategy

It was stated that the iatrosedative interview technique is composed of 2 strategies:

  • a verbal fact-finding interpretive strategy
  • a nonverbal empathic strategy

It was further stated that these were separated for the purpose of discussion but the separation is artificial, since verbal and nonverbal communications are in reality inseparable. The crucial function of nonverbal communication is the transmission of feelings. The major feelings to be communicated to the fearful patient by the doctor are:

  1. attentiveness and concern
  2. acceptance of the patient and his problem
  3. supportiveness
  4. involvement with the intent to help

These feelings and nonverbal statements are created through the process of listening, “hearing” what you are listening to, then responding empathetically. Listening is the act of turning your attention to another person and permitting him to speak. “Hearing” is understanding what he is saying. Although these are nonverbal behaviors, they were discussed as part of the verbal factfinding strategy because the “hearing” is a prerequisite for responding by facilitating the telling of the story, offering support and commitment. Reflecting and reacting to the patient’s feelings and story by face, voice and body is responding nonverbally to what one “hears.”

The principal factor in listening is being attentive. This requires concentration, discipline and the intentional use of your behavior. Attentiveness is communicated in 2 ways:

  1. Through your physical presence (physical demeanor and posture)
  2. Through your psychological presence (“hearing” the total communication of the patient, both verbal and nonverbal.)

Physical Attending Skills

The skilled use of one’s face, voice, and body will result in a posture of involvement. This is the medium that will communicate whether you really are or are not involved with your patient. The nonverbal signals you send out will either verify your words of concern and support or belie them.

Man’s richest sign system is his head and face. The voice and body have almost as much value as the face in the wordless communication that plays such a powerful role in the creation of an empathic climate in which the doctor and patient will interact. There are many components of nonverbal communication.

Some of the significant ones considered here are:

  1. Eye contact
  2. Facial expression
  3. Vocal characteristics
  4. Body orientation
  5. Trunk lean
  6. Proximity (distance)

Haase and Teffer carried out research on the nonverbal components of empathic communication. The intent of the study was to explore the relative contribution of verbal and nonverbal behaviors to the communication of empathy. Their findings were:

  1. A verbal message of medium empathic value can be altered favorably by maintaining good eye contact, forward trunk lean, good body orientation, and good distance.
  2. Conversely, high levels of verbal empathy can be reduced to unempathic messages when the communicator utters the message without eye contact, in a backward trunk lean, rotated away from the addressee, and from a far distance.

These findings add to the existing knowledge of the power of nonverbal communication, colloquially alluded to as “body language.”

Eye contact

Eye contact is a crucial key in the communication system. It is virtually impossible to create a sense of attentiveness and interest in a person if you are not looking at him. “Looking at him” means making eye contact!

This mutual looking tends to increase when the participants like each other and when they are involved in their interaction. It lessens when touchy subjects come up or unpleasantness develops between the interactants. A “noncollision course” is taken, a lowering of the eyes, a “dimming of the lights.”

Good eye contact does not mean staring or constant eye contact. This is very disconcerting. It should be varied. You should permit your eyes to drift to an object not too far away and then return to the patient. As in all nonverbal behaviors, this should be done naturally, in a relaxed, comfortable manner. The eyes contribute to the facial expression in many ways. For example, in smiling, they can either lend warmth or put a chill on the smile. If when the mouth expresses a smile and there is no expression around the eyes, the smile tends to be “icy”.

Facial Expressions

The face can be the best expression of emotions but it can also be a superb mask. However, it is the most difficult of our nonverbal behaviors to monitor.

We are aware of what our eyes are doing, how our voice sounds, what movements we make, but the face is the one expressor from which we get no feedback. Hence, it is the most vulnerable area of our behavior. Many doctors avoid facial risks by wearing a noncommittal mask, a sort of professional “poker face.” Generally, unless one has learned to pay attention to his nonverbal communications, he is almost totally ignorant of his facial behavior. Consequently he may be sending signals facially that he doesn’t intend to, or may be inadequately expressing what he would prefer to say.

Facial expressiveness in skilled attending is used in 2 basic ways: (1) to send messages and (2) to respond appropriately to messages being received.

When the doctor turns his attention to his patient at their first meeting, the facial signals most people would like to see are warmth, interest and alert intention of being involved. Facial responsiveness should mirror the feelings of the patient to varying degrees; that is, concern should be reflected by concern and not by apathy, a faint smile or exaggerated interest. The face is an instrument of wide range from broad to very subtle communication, some almost imperceptible. It is wise to remember the admonition, “Be careful what you say with your face when talking with your mouth!”

Vocal Characteristics

The voice can be used like a musical instrument. It alters the meaning of words, either giving the lie to them or making them ring true. In our culture, we ascribe certain characteristics to voice sounds. The voice of authority generally is characterized as being low in pitch, resonant and used with measured tempo. A fast, high-pitched, squeaky voice is often associated with immaturity.

In attending, it is desirable to speak at an even tempo with moderate volume, at as low a pitch and with as much resonance as is consistent with your voice. There should be variations of these qualities to reflect and support the meaning of the words. Above all, one must be on guard to avoid mixed messages wherein the voice and the face are saying something different than the words. One of the most common examples of a mixed message is that conveyed by the doctor who, hoping to assure the patient, says with disinterest in his voice and looking away, “Don’t worry, everything will be all right!”

One of the more penetrating studies performed to determine which message is dominant when 2 incongruent ones are sent was done by Mehrabian. He set up situations in which the facial and vocal expressions were in conflict with the verbal messages. His conclusions indicate that in the communication of feelings, the words were responsible for only 7 % of the impact, the vocal expressions produced 38% of the effect, and the facial expressions 55%. Hence, if your face and voice do not match your words, you would best say nothing! On the other hand, the verbal promises of help and protection assume greater significance if supported by empathic nonverbal communication. In short, it is how something is said, not what is said that builds or destroys relationships.

Body Orientation

Facing patients squarely tells them that you intend to pay attention. If you sit with your body rotated away from the patient, you are “turning away”, thus creating an atmosphere of inattentiveness. This inattentive orientation is intensified if your position is at a 90 degree angle or less. In addition, such a position makes good eye contact difficult and strained.

If the interview is taking place in the dental treatment room you should be in a position between 7 and 8 o’clock. Should you use your consultation room it would be preferable not to sit behind a desk. Two armchairs can be used in approximately the same position as above. In my opinion the interviews would take place in the treatment room. If the patient is fearful, the operatory may stimulate the expression of anxiety in which case the issue is confronted. Sitting comfortably in a consultation room, which tends to be a more relaxed and social environment, provides little provocation to discuss one’s fears.

Body Distance or Proximity

How close one sits in a situation such as we are discussing influences the communication. The degree of proximity engenders different feelings in different cultures. Hall reports that most Americans tend to deal with space in the following way:

  1. Intimate zone: ranging from contact to 18 inches. This is the zone for handling secrets and whispered conferences.
  2. Casual-Personal zone: ranging from 1+1/2 to 4 feet. This is the region for normal personal interaction.
  3. Social-Consultative zone: ranging from 4-12 feet. This is the area for handling impersonal business.
  4. Public zone: ranging from 12 feet to the limits of hearing. This is the region of the public speaker addressing an audience.

A distance between 3-and-a-half to 6 feet is appropriate when conducting the interview in the dental operatory. The distance will vary depending on your comfort with the patient with whom you are interacting. The more your interest rises, the closer you will tend to be. As with eye contact, facial expression and body orientation, there is the matter of a dynamic process; that is, you should not be fixed and rigid about any of these physical attendance components but maintain a moderate degree of fluidity.

Trunk Lean

A forward lean is a powerful message of interest. Somehow it is difficult to be indifferent while leaning forward and listening to another person. The forward lean of the body is an eloquent statement of attentiveness. The reverse of this, leaning backwards and folding one’s arms, is a statement of casual interest at best and inattentiveness at worst.

The trunk lean is an effective facilitator. If a patient is speaking and pauses, merely leaning forward slightly will act as a request to “tell me more.” Not only does it act as the body language of “tell me more”, it also indicates interest and empathy.

Another of the many components of “body language” is tactile communication. During an interview, support, concern, and empathy can be conveyed by touching the forearm of the patient. This is the most acceptable and least intimate area of the body for tactile communication. Needless to say, in the clinical encounter tactile communication is constant. The delicacy or roughness of one’s “touch” conveys a great deal of information to the patient about the doctor’s presence and, more significantly, the doctor’s awareness of the patient’s presence.