Basic Terminology of Nonverbal Behavior

Before proceeding, it may be expedient to examine the definition of nonverbal behavior, for this term can have different meanings. In their excellent book, Nonverbal Communications: Science and Applications, Matsumoto, Frank, and Hwang provide a lively, descriptive definition:

Nonverbal behaviors intrigue us. We see the way a person looks, the way he or she moves, and how he or she sounds. Nonverbal messages are transmitted through multiple nonverbal channels, which include facial expressions, vocal cues, gestures, body postures, interpersonal distance, touching and gaze. We call these channels because, like channels on a television, they are each capable of sending their own distinct message.”⁴

Operationally, in our book we will view nonverbal behavior as the general category of all behaviors displayed by an individual other than the actual content of his or her speech. Note that, as Matsumato and colleagues state, various factors can impact upon nonverbal behaviors, including such elements as the speed and intensity of a person’s movements, interpersonal distance, and the pacing, loudness, and tone of voice used when speaking. To effectively address these elements from a clinical perspective, I have found it useful to split the broad category of nonverbal behavior into two general subcategories: (1) nonverbal communications and (2) nonverbal activities.

A Cautionary Note on Interpreting Nonverbal Behaviors and Nonverbal Research

As clinicians we are interested in understanding the significance of both nonverbal communications (emblems) and nonverbal activities (illustrators, regulators, adaptors, and affective displays). It is important to keep in mind that nonverbal activities are generally multiply determined. It seems unwise to begin assuming that one “knows” exactly what any given nonverbal activity means. Even nonverbal activities generally viewed as obviously representing a specific mood state, such as laughter, can be misinterpreted, depending upon the interpersonal and cultural context of the laughter. The kulturbrille effect can be quite striking here.

For instance, in the Japanese culture laughter generally means what it does in Western culture – the patient is finding something to be humorous. But this common affective display has several uncommon uses, from a Western interviewer’s perspective, in the Japanese culture. It can be utilized as a way of covering up or controlling displeasure, as well as concealing embarrassment, confusion, and shock.¹¹ An interviewer unaware of these uses of laughter could view a Japanese patient who is laughing intermittently in an initial session to be demonstrating a powerful degree of blending, when, in reality, the patient is feeling highly uncomfortable and will not be making a second appearance with this particular clinician.

In this regard, Wiener and associates criticized some psychoanalytically oriented researchers as immediately positing unwarranted unconscious meanings to nonverbal activities.¹² Considering this context one is reminded of the old psychoanalytic saw in which the astute clinician detects that the patient is experiencing severe marital discord because she is playing with her wedding band. Such interpretations of nonverbal activities are invaluable if kept in perspective. However, the clinician needs to think about other possible causes of the stated activity. For instance, this patient may be playing with her wedding band because she feels intimidated by the interviewer. She releases her anxiety by playing with objects in her hands. Normally she rolls a pencil back and forth, but because no pencil is available, she twists her ring. Other interpretations may be equally correct. To ignore these other possibilities while assuming the marriage is troubled is to ignore sound clinical judgment. On the other hand, having considered the various possibilities, the experienced clinician may gently probe to sort out which is correct and may indeed uncover marital discord.

From this discussion, it is reasonable to make the following generalization: Nonverbal communications are relatively easily deciphered (but even here there are caveats), whereas nonverbal activities should be cautiously interpreted, because more than one process may be responsible for the behavior. This point deserves emphasis because both in clinical and popular literature, the idea that exact meanings of nonverbal activities can be directly read is put forward by some authors. They imply that one can read a person like a book. In a similar vein, the concept of “body language” suggests that nonverbal activities are more codified than they actually are.

A similar degree of caution is required as one surveys the research concerning nonverbal behavior. The body of research appears both vast and promising, but there exist many limitations. Nonverbal interactions are so complex that it remains difficult to successfully isolate variables to study. For instance, suppose a piece of research was designed to prove that it was the paralanguage (how the words were said) of the second interviewer in our opening clinical vignette that directly increased blending. An attempt to isolate this single variable would prove difficult, for a variety of other variables could have had an impact, such as the interviewer’s physical attractiveness, the distance between seats, and even the fact that there were two interviews.

Even when one successfully isolates the relevant variables, the very act of isolation poses serious problems. Nonverbal elements seldom function as isolated units.¹³ Instead, the various nonverbal elements exert their influences jointly, making the findings of research based on single channels such as paralanguage or eye gaze somewhat artificial. A different approach, the functional approach, attempts to study the various nonverbal elements as they function in unison.

Finally, two cultural elements of academia impact on the quality of nonverbal research. First, the most common sampling methods used in many studies tend to focus upon Western cultures, and even within that sample it is common practice to recruit subjects from undergraduate students – hardly a group that is representative of the general population.¹⁴ Second, like many other research arenas, research in nonverbal behavior has a paucity of replication studies, i.e., where published research is repeated to ensure that the results are valid. In fact, much of the research has not been duplicated for a variety of reasons including: funding agencies are sometimes unwilling to support replication studies; researchers often do not want to replicate the work of others, but would rather “do their own research”; and academic institutions tend to value and reward “original research” more highly. Thus, in both the academic and popular literature, findings about nonverbal communication are sometimes cited as being “evidence based,” when the research may have been of poor quality and/or may never have been replicated.

These research issues are worth mentioning because it is important for the clinician to realize that relatively limited knowledge exists on nonverbal behaviors that can be called “factual.” It is safe to say that this body of exciting research is still in its adolescence. In this regard, the material of this chapter is best viewed as opinion concerning an evolving craft or art. The material itself is culled from a variety of sources, including clinical work, supervision, research literature, personal communications, and even popular literature^15,16 if it seems to shed light on clinical issues. But despite the lack of an extensively validated evidence base, I want to reassure the reader that my trainees and I have found the following material on nonverbal behavior to be invaluable, both in interviewing and in ongoing psychotherapy.

Organization of the Chapter

The chapter is divided into three sections. In Part 1, the classic fields of study in nonverbal behavior will be briefly surveyed, emphasizing those theoretical foundations that are immediately clinically relevant. As with previous chapters, we shall develop a concrete language through which to study the phenomena in question. The following three areas will be addressed: (1) proxemics (the study of the use of space), (2) kinesics (the study of body movement), and (3) paralanguage (the study of how things are said).

Using our understanding of these three cornerstones of nonverbal study, in Part 2 we shall adopt a functional perspective, carefully investigating the interplay of these areas as directly applied to clinical practice. The broad clinical tasks studied include assessing the nonverbal behaviors of patients, actively engaging patients, and calming potentially violent patients.

In Part 3, we will wrap up the chapter by exploring a remarkably exciting new arena for clinical interviewing, the web and its associated world of wireless connectivity, from texting to chatting. We will find that, within this world, many of the possibilities and limitations are directly related to nonverbal issues.

Kinesics

Kinesics is the study of the body in movement. It includes “gestures, movements of the body, limbs, hands, head, feet, and legs, facial expressions (smiling, frowning, furrowing the brow, etc.), eye behavior (blinking, direction and length of gaze, and pupil dilation), and posture.”²³ In short, kinesics is the study of how people move their body parts through space with an added attempt to understand why such movements are made. Both nonverbal communications and nonverbal activities are broadly subsumed under the term kinesics. As a field, it is a natural companion to proxemics. Like proxemics, it had its own avatar, Ray T. Birdwhistell, who first elaborated his work in 1952 with the book Introduction to Kinesics: An Annotation System for Analysis of Body Motion and Gesture.²⁴

Birdwhistell was an anthropologist and emphasized understanding body movements in the context of their occurrence. He also pioneered the study of videotapes in an effort to decipher the subtle nuances of movement. Through his microanalysis he attempted to define the basic identifiable units of movement. For instance, he coined the term “kine” to represent the basic kinesic unit with a discernible meaning.²⁵

Albert Scheflen, a student of Birdwhistell’s, expanded these notions to the study of broad patterns of kinesic exchange between people. In this context, Scheflen postulated that kinesic behavior frequently functions as a method of controlling the actions of others.²⁶ By way of example, hand gestures and eye contact may be used to determine who should be speaking at any given moment in a conversation (“regulators” as defined by Ekman and Friesen).

Kinesics plays a role in all interviews. Specific activities may shut down or facilitate the verbal output of any given patient. Early kinesic studies emphasized the accurate description, delineation, and definition of facial/body movements and gestures (the explicit aspects of kinesics). More recently, researchers and clinicians have come to realize that “how” movements are done may be as important as “what” movements are done. This newer aspect of kinesic study has been called the “implicit behavioral qualities” of movement.²⁷ Some studies suggest specifically that dynamic qualities such as speed, acceleration, complexity, and symmetry of body and facial expressions may have a great impact on how nonverbal behaviors are interpreted (both how we interpret our patients and how they interpret us).²⁸ A smile done with abruptness by a harried clinician when first meeting a patient in the waiting room may be far more disengaging than engaging.

Both explicit and implicit kinesic factors can greatly change the meaning of the words spoken by either the patient or the clinician. Once again cross-cultural factors may lead to significant misunderstandings if the kinesic norms of a culture are not understood. A poignant example of this kinesic kulturbrille effect is described by Elizabeth Kuhnke:

Maria was working in Japan with a Japanese colleague, preparing a patient presentation. She asked him if he was pleased with the work they had done together. He told her that, yes, he was. A couple of days later Maria heard through the grapevine that her colleague wasn’t happy with the result and wanted to rework the presentation. When she asked him why he’d told her that it was all right when it wasn’t, he replied: “But I told you with sad eyes, Maria.”²⁹

Besides yielding information that may help the clinician to foster engagement, the study of kinesics can provide valuable insights into the feelings and thoughts of patients. Freud phrased it nicely when he stated, “He that has eyes to see and ears to hear may convince himself that no mortal can keep a secret. If his lips are silent, he chatters with his fingertips; betrayal oozes out of him at every pore.”³⁰

Paralanguage

The study of paralanguage focuses on how words are delivered. It may include elements such as tone of voice, loudness of voice, pitch of voice, rhythm and fluency of speech.³¹ You will sometimes see paralanguage called vocalics or paralinguistics in the literature.³² The power of paralanguage is immense and popularly acknowledged. Phrases such as, “It’s not what you said, but the way you said it, that I don’t like,” are considered legitimate complaints in our society. Moreover, actors and comedians are well aware of the power of timing and tone of voice as it impacts upon the meaning of a statement. The comedian Jon Stewart is phenomenally adept at changing meaning through the use of paralanguage, transforming a statement that sounds complementary, at first glance, into a wickedly funny sarcastic slight, with a delightful twist in his tone of voice.

By way of illustration, the phrase “that was a real nice job in there” appears complimentary at first glance. But one cannot determine its meaning unless one hears the tone of voice used in its conveyance. It could be far from pleasant if it was said with a sarcastic sneer by a displeased supervisor following an interview observed via a one-way mirror.

Besides the tone of the voice, speech is characterized by a number of other vocalizations. Although not words per se, vocalizations can play an important role in communication. One set of vocalizations consists of “speech disturbances.”³³ Under the heading of flustered or confused speech, these disturbances include entities such as stutters, slips of the tongue, repetitions, word omissions, and sentence incompletions, as well as familiar vocalizations such as “ah” or “uhm.” Such disturbances occur roughly once for every 16 spoken words. As would be expected, under stressful conditions these disturbances increase significantly. Thus they can serve to warn the clinician of patient anxiety as the interview proceeds.

There is more to vocalizations than just their appearance or lack of it. Some vocalizations serve to enhance blending, as seen with the frequently used facilitatory statements “uh huh” and “go on.” But, once again, the way in which these vocalizations are used can significantly alter their effectiveness, as shown in the following vignette.

The interviewer in question possessed a pleasant and upbeat personality. He was a caring clinician, but he found patients shutting down at times during his interviews. Videotape analysis revealed an interesting phenomenon. As he listened to patients, he frequently interspersed his silences with the vocalization “uh huh.” His “uh huhs” were said quickly with a mild sharpness to his voice. He also used vocalizations such as “yep” and “yeah,” also stated with a curt tone of voice.

The net result was the creation of the feeling that he was in a hurry, wanting just the facts. And that is exactly what his patients gave him. This habit, combined with a tendency to over-utilize note taking, fostered a business-like persona, despite his natural warmness in daily conversation. It was a habit well worth breaking and once again highlights the power of paralanguage.

Cross-cultural differences also affect paralanguage. Sue and Sue describe the variations in paralanguage that can interfere with the blending or assessment process when working with people outside the clinician’s culture. For instance, silences are frequently interpreted as moments when the patient, for conscious or unconscious reasons, is holding back. Silence may also signal that the patient is ready for a new question. At other moments, silence can create a feeling of uneasiness in both interviewer and interviewee. But, as Sue and Sue clearly state, the obvious may be too obvious, once again demonstrating the potentially disruptive power of the kulturbrille effect.

Although silence may be viewed negatively by Americans, other cultures interpret and use silence much differently. The English and Arabs use silence for privacy, whereas the Russians, French, and Spanish read it as agreement among parties. In Asian culture silence is traditionally a sign of respect for elders. Furthermore, silence by many Chinese and Japanese is not a floor-yielding signal inviting others to pick up the conversation. Rather, it may indicate a desire to continue speaking after making a particular point. Oftentimes, silence is a sign of politeness and respect rather than lack of desire to continue speaking. A counselor uncomfortable with silence may fill in and prevent the patient from elaborating further. An even greater danger is to impute false motives to the patient’s apparent reticence.³⁴

Immediacy is a term describing the sensation that one is in the immediate presence of another person and the positive or negative feelings of warmth, closeness, involvement, and acceptance experienced in that presence, as created and/or reflected by their nonverbal behaviors. It is a major component (in addition to the actual words being exchanged) of what we have been calling blending. As such, the ability to interpret and use the nonverbal cues of immediacy is one of the keys to identifying the underlying real engagement of our patients.

One can argue, and indeed, Peter Andersen, the author of one of the core textbooks on nonverbal communications, has done so, that the most central function of nonverbal behavior is the exchange of immediacy.³⁵ Immediacy results from the interface of factors from all three of our core elements of nonverbal behavior (proxemics, kinesics, and paralanguage). Immediacy can be communicated by how close we sit or how far forward we decide to lean (proxemics). Our emblems, illustrators, regulators, adaptors, and affective displays all play a marked role in the conveyance of immediacy (kinesics). Tone of voice, loudness, and pacing of speech further sculpt the sensation of immediacy (paralanguage).

A variety of nonverbal behaviors impact on immediacy.³⁶ Eye contact, and even pupil dilation, contribute to it. In a classic study, Hess and Goodwin³⁷ showed subjects pictures of mothers holding their infants. The pictures were identical except for one small detail – in some photographs the mother’s pupils had been retouched to appear larger. The response by the subjects was remarkable, with an overwhelming number perceiving that the mothers with enlarged pupils loved their babies more. This phenomenon has not gone unnoticed by marketers, who frequently increase the size of the pupils of individuals in their advertisements using Photoshop, in an effort to entice the consumer into a “closer relationship” with the model or celebrity who is plugging their product.

Other immediacy behaviors include smiles, head nodding, hand gestures, synchronicity of nonverbal behaviors between conversants, and paralanguage. Touch remains one of the most powerful indicators of immediacy and, consequently, should be used very cautiously by clinicians, a topic we shall address later in this chapter.

As we saw with empathic statements, one can ascribe a valence to immediacy behaviors ranging from low valence (the behaviors are not particularly powerful at communicating immediacy) to high valence (the behaviors strongly communicate immediacy). As with empathic statements, there is a time and place for both low- and high-valenced immediacy behaviors, a critical principle for understanding how to effectively engage patients battling with paranoid process or on the brink of violence, another topic we shall soon examine in detail in Part 2 of this chapter.

Uncovering Hidden Psychotic Process

To begin our discussion, we will look at another statement by Sir Denis Hill: “An important difference between the disturbed mental states which we term ‘neurotic’ and those we term ‘psychotic’ is that in the latter, but not in the former, those aspects of nonverbal behavior which maintain social interactional processes tend to be lost.”⁴¹ An awareness of these potential deficits in the psychotic patient can alert the clinician to carefully probe for more explicit psychotic material in a patient whose psychotic process is subtle.

Perhaps an example will be useful at this time. I was observing an initial assessment between a talented trainee and a woman in her mid-20s. The patient had been urged to the assessment by her sister and a close friend. Apparently the patient’s mother was currently hospitalized with major depression.

By the end of the 50-minute intake, the clinician seemed aware that the patient was probably also suffering from major depression or some form of a mood disorder. But the severity of the patient’s condition did not seem to have registered and the clinician was about to recommend outpatient follow-up. However, the patient’s nonverbal behavior was telling the clinician to take another look.

In the immediately subsequent second interview, which I performed, the patient disclosed a recent weekend brimming with psychotic terror. She had felt that her long-dead father had returned to the house to murder her. She was so convinced of this delusion that she had shared her secret with several young siblings, not a good idea if one is trying to get baby brother and sister to sleep. Eventually she ran from her house to escape her father’s wrath. Even in the interview she could not clearly state that her father’s return was an impossibility, although she hesitatingly said she thought it was.

Let us return to the interview in order to uncover the nonverbal cues that suggested the possibility of an underlying psychotic process. The patient, whom we shall call Mary, answered honestly and appeared cooperative. She displayed no loosening of associations or other overt evidence of thought process disorganization, but she demonstrated some oddities in her communicational style. With regard to paralanguage, she demonstrated long pauses (about 4 to 8 seconds) before beginning many of her responses. This gave her a somewhat distracted appearance as if muddled by her thinking. This effect was heightened by a mild slowing of her speech as well as a flattening of the tone of her voice.

As we have seen, silences, especially of this length, are generally avoided in daily conversation. Everyday social protocol would ordinarily pressure Mary to answer more quickly. This breakdown in normal communicational interaction was one suggestion that all was not well and represents a disruption of the empathy cycle. Her body also spoke to her internal turmoil.

Although for the most part she had reasonably good eye contact, there existed protracted periods of time when she looked slightly away from the interviewer in a distracted fashion, whether she was talking or listening. This lack of “visual touching” during conversation is unusual.^42,43 In fact, if one had a sound understanding of nonverbal communications, it would have been apparent that Mary was displaying difficulties in her dialogue function, as displayed by an odd use of the nonverbal activities Ekman called regulators. As stated earlier, these regulators provide the cues for the timing of everyday back-and-forth conversation.

Frequently, before beginning to speak, the intended speaker glances away briefly. As he or she looks back, speech will begin. While talking, the speaker will frequently look away. But as the end of the speaker’s statement is reached, the speaker will look towards the listener. This glance signals to the listener that the speaker’s message is over. The speaker and the listener glance at each other’s eye regions for varying lengths of time, usually between 1 and 2 seconds, the listener giving longer contact. This complex eye duet was frequently missing with Mary. In depression, the eyes are frequently cast downward, but it was the peculiar manner in which Mary tended to stare past the clinician that hinted at the possible presence of psychotic process. As Sir Denis Hill had suggested, Mary had lost some of the nonverbal cues that maintain social interaction.

Mary was also showing disruption of other aspects in her dialogue function. In this case, the problem with “marking her speech”⁴⁴ was related to her dysfunctional use of her hand gestures as conversational regulators. For instance, hand gestures are generally made as one initiates words or phrases. As the speaker finishes commenting, the hands tend to assume a position of rest. To keep one’s hands upwards, in front of oneself, can indicate that one is not done speaking or will soon interrupt.

In Mary, these hand regulators were generally diminished. She sat stiffly with her feet flat on the floor. Her head seemed to weigh her body down as she sat slightly hunched over with her fingers interlocked. She displayed little hand gesturing, leaving the interviewer with the odd sensation that it was not clear when Mary was going to start or stop speaking. Most likely, Mary’s lack of movement was an associated aspect of her major depression, but it may also have been a ramification of her psychotic process.

A more striking nonverbal clue to the degree of Mary’s psychopathology lay in her method of dealing with unwanted environmental input, in this instance the questions of the interviewer. Apparently Mary had been concerned for some time that she might be “just like her mother,” who was currently in the hospital. In addition, her sister had experienced a psychotic depression approximately 6 months earlier. Mary had been attempting to hide from herself the evidence of her own psychotic process, while the fear of an impending breakdown nagged at her daily. During the interview, as questions directed her back into her paranoid fears, she began to realize the extent of her problems. At this moment she did something out of the ordinary.

Mary leaned forward slowly, her elbows perched upon the tops of her knees, with her head cupped between her hands. In this position her hands literally covered her ears, as if keeping out unwanted questions or thoughts. All eye contact was disrupted. Mary remained in this position for a good 5 minutes, answering questions slowly but cooperatively. She appeared detached from the world around her. This type of nonverbal adaptor has been studied under the rubric of “cut-offs.”⁴⁵ Cut-offs represent nonverbal adaptors made to dampen out environmental stress. When exaggerated to the degree of appearing socially inappropriate, as was the case with Mary, they may be indicators of psychotic process. Indeed, catatonic withdrawal represents a prolonged and drastic cut-off.

One must also attempt to compare nonverbal activities to the patient’s baseline behavior. Mary was normally a high-functioning secretary and most likely possessed better than average social skills. In this light, her preoccupied conversational attitude, and in particular her prolonged cut-off, represents very deviant behavior for her. A subsequent interview with Mary’s friend revealed that Mary had been observed at work sitting and staring at the phone for long periods.

For a moment I would like to take a brief sidetrack on the issue of cut-offs. We have been discussing dramatic forms of cut-off behavior, which may indicate underlying psychotic activity; however, mild forms of cut-off behavior occur routinely in our work with nonpsychotic individuals and frequently do not hint at psychopathology per se. These more subtle forms of cut-off are not without meaning and warrant some discussion. Morris⁴⁶ described four such visual cut-offs, to which he attaches some descriptively poetic names.

With the “Evasive Eye,” the patient shuns eye contact by looking distractedly towards the ground, as if studying some invisible object. It can create the feeling that the patient is purposely not attending to the conversation and may frequently accompany the speech of disinterested adolescents. In the so-called “Shifty Eye,” the patient repeatedly glances away and back again. With the “Stuttering Eye,” the patient now faces the interviewer directly, but the eyelids rapidly waver up and down as if swatting away the clinician’s glance. Finally, in the “Stammering Eye,” the patient once again faces the clinician but shuts the eyes with an exaggerated blink, sometimes lasting as long as several seconds.

These four eye maneuvers represent nonverbal activities whose meaning may be multiple. They may indicate that the patient at some level no longer wants to communicate. Perhaps a specific topic has been raised that is disturbing to the patient, resulting in a nonverbal resistance. At such moments, a simple question such as, “I am wondering what is passing through your mind right now,” may uncover pertinent material. Such cut-offs may also represent objective signs of decreased blending and movement into a shut-down interview. Exaggerated examples of these cut-offs can also be part of a histrionic presentation and in this sense could also be seen in both wandering and rehearsed interviews.

Nonverbal Hints of Classic Psychiatric Diagnoses

Returning directly to the topic of nonverbal hints of psychopathology, investigators have also looked at the promising possibility that nonverbal activities could provide even more specific diagnostic clues, but at this point the research results remain tentative.^47,48 Moreover, the results appear to be in accordance with what common clinical sense would predict.

Concerning the classic psychiatric diagnoses, schizophrenia appears to be accompanied by some distinctive nonverbal behaviors. Studies show that schizophrenic presentations are marked by a tendency for gaze aversion. A flattening of affect with decreased movement of the eyebrows is noted (which can alternatively be secondary to antipsychotic medication). Patients’ postures are slumped, and they have a tendency to lean away from the interviewer. Naturally, the type of schizophrenia and the stage of the process can significantly affect the type of nonverbal behavior present, emphasizing a cautionary note to these generalizations.

Depressive disorder has also been investigated. Researchers have noted that nonverbal behaviors vary depending on whether one is observing an agitated depression or a withdrawn depression. In subgroup 1 (agitated depression), patients demonstrated “a puzzled expression, grimacing and frowning, gaze aversion, agitated movements, a crouched posture, and body leaning towards the interviewer. Subgroup 2 (withdrawn depressions) showed some increase in gaze, slowed movements, self-touching, an emotionally blank expression, and a backward lean away from the interviewer.”⁴⁹ In many respects, these findings have limited usefulness, because they simply seem to confirm the obvious.

But at a different level, especially with depressive patients, these findings emphasize the importance of nonverbal behaviors as clinical indicators of improvement.⁵⁰ The return of routine hand gesturing may herald an oncoming remission even before the patient admits to much subjective improvement. As the clinician becomes more aware of such behaviors as spontaneity of facial expression, smiling behavior, and eye contact, the informal monitoring of such cues to improvement can become a routine element of clinical follow-up.

Nonverbal Hints of Specific Personality Diagnoses

With regard to personality disorders, less research is available. Consequently, we will emphasize principles derived from clinical observations. Observations made during the 7 or so minutes of the scouting phase may provide important diagnostic clues. In this sense, these cues can help determine which diagnostic regions to emphasize in the body of the interview, for, in the limited time available, it is generally not feasible to explore all areas of personality dysfunction. The following three clinical vignettes illustrate the usefulness of nonverbal activities in suggesting the presence of possible character pathology.

In the first example, I was observing an interview performed by a psychiatric resident during morning rounds on an inpatient unit. The patient was an adolescent girl with a head of curly light-reddish hair. The interviewer was sitting on a couch in a group activity room. The patient pertly entered the room and promptly plunked down beside the clinician. At first she leaned towards him with her right arm straddling the back of the couch behind his shoulder, but she quickly withdrew the arm. Her final perch was with her right knee up on the couch resting a few inches from the clinician’s body.

In a proxemic sense, she had positioned herself well within the personal distance zone and actually very close to being within the clinician’s intimate zone. Her speech was bright and snappy, percolating from a face rich with expressions and playful eyes. All this activity occurred in a matter of a few seconds. The clinician immediately responded by leaning away from the patient and crossing his legs by placing his left ankle over his right knee. This brief territorial excursion by this patient is not a typical initial interaction, even with adolescents, who frequently feel more comfortable with “chummier” interpersonal distances. Instead, this type of interpersonal game is sometimes seen in people with underlying histrionic personality traits or borderline personality traits. This observation in no way indicates that this patient had these traits. It merely suggests that it might be worthwhile to do more specific diagnostic interviewing within these specific diagnoses.

In the second example, the patient was a woman in late middle age, with graying hair pulled back in a bun. Before the interview she had had to wait longer than usual before entering the room. Initially, the clinician gently apologized for the inconvenience with a warm smile on his face. She made cool eye contact. Her lips did not so much as consider returning his smile. She fluctuated between a baseline of mildly cooperative answers, with a reasonably lengthy duration of utterance (DOU), to brusque shut-down remarks.

A peculiar piece of body movement gradually evolved as she continued with her acerbic tone of voice. She tended to lean back in her chair and gradually proceeded to stretch her legs out in front of her towards the interviewer. The movement was ingeniously slow but as steady as a barge pulling into a dock. As usually happens, the dock was gently bumped – by her feet bumping against the interviewers – at which point she did not pull away. Instead, the “dock” recoiled – with the interviewer quickly tucking his feet beneath his chair.

Her nonverbal activities may be multiply determined, but one possibility well worth exploring would be underlying passive-aggressive traits. Later historical information from the interview tended to further substantiate this diagnostic hunch.

The third and final example is a patient who carefully orchestrated a relatively unappealing opening gambit. She was a tall woman in her mid-20s with long black hair hanging limply about her body. She was dressed in jeans and a black pullover sweater. Her first noticeably unusual action consisted of reaching over to pull up a second chair, which she promptly used as a footstool. She stretched her body out, making herself conspicuously at home. This settling in did not signify the beginning of an easy engagement, because she proceeded to visually cut the female interviewer off throughout most of the interview. She would look down at her hands, frequently using the Evasive Eye movement described earlier.

All of this display was topped with a convincingly dour facial expression. Concerning paralanguage, she managed to push through her disinterested facial mask an equally disinterested and mumbling voice. Her attitude visibly disturbed the interviewer. She also demonstrated one other nonverbal communication with a set meaning. Specifically, she held her coat on her lap throughout the interview, perhaps communicating an eagerness to leave.

Her collection of behaviors, all present during the first few minutes of the interview, suggested a variety of personality traits worth exploring later. Her lack of concern for making the interviewer feel more at ease could suggest a possible hint of antisocial leanings. Along similar lines, her obvious attempt to display disinterest could be part of the manipulative trappings of a borderline personality or perhaps of a narcissistic personality. And, as we saw with our previous example, some passive-aggressive tendencies may be present. Her behaviors in no way prove that she has any of these disorders, but they do provide suggestions as to which disorders warrant additional consideration, further highlighting the importance of noting nonverbal behavior. It is also critical to remind ourselves that we must be exquisitely careful not to interpret cross-cultural differences in nonverbal behavior as hints of psychopathology.

Nonverbal Indicators of Anxiety

One of the most well-known indicators of increased anxiety remains the activation of the sympathetic nervous system, the system geared to prepare the organism for fight or flight. During the activation of this system, a variety of physiologic adaptations occur that can serve as hallmarks of anxiety. The heart will beat faster and blood will be shunted away from the skin and gut to be preferentially directed towards the muscle tissue that is being prepared for action. This shunting accounts for the paleness so frequently seen in acutely anxious people, who look like they have seen a ghost. Saliva production decreases, and the bowels and bladder are slower to eliminate. Breathing rate increases, as does the production of sweat.

This last sign, increased sweating, reminds me of one of the more striking and humorous examples of autonomic discharge I have encountered. A medical student was doing one of his first physical examinations on a real patient, which can truly be an upsetting experience, as the student frequently feels painfully inept. In this case, the patient was a child about 9 years old, who could be generally classified under the label “brat.” As the exam labored onward, with the worried mother looking increasingly fretful, the student began to sweat profusely. As the student leaned over to listen to the child’s heart, a bead of sweat fell from his forehead directly onto the child’s chest. Being a subtle kid, he immediately looked the student in the eye and in a loud voice said, “What’s a matter with you, you’re sweatin’ all over me!”

As if the poor student was not already stressed enough, that little proclamation did it. He sheepishly turned to the increasingly upset mother and produced a quick-witted white lie, “Don’t worry, I’ve got a thyroid condition.” I know this story all too well because I was the poor panic-stricken medical student. It clearly shows the truth that the autonomic system does not lie. With our patients, subtle signs of anxiety such as sweating, damp palms, and increased breathing rate can help us detect anxiety. If the anxiety represents evidence of poor blending, we may be able to purposely attend to the patient’s fears. If it represents the presence of unsettling thoughts, we may be inclined to probe deeper.

If the sympathetic system is not presented with a chance to actually get the organism into action soon enough, the parasympathetic system may try to counterbalance with a discharge of its own. In these cases, one may find a sudden urge to urinate or defecate, as people frequently feel before public performances or job interviews. If a patient begins a session by immediately requesting the need for a restroom, this may represent a clue to a higher anxiety level than the patient may verbally admit.

Desmond Morris believes that one type of nonverbal adaptor, which he refers to as “displacement activities,” can be a good indicator of anxiety.⁵¹ These displacement activities are those body movements that release underlying tension. I recently watched a businessman waiting for a meeting. As he sat in the lobby, he nervously tugged at his tie and picked at his clothes. He then hoisted his briefcase onto his lap and meticulously unloaded it piece by piece, after which he gingerly repacked the case, carefully feeling each object as he delicately reassembled his “peripheral brain.”

These behaviors were accomplishing very little in the way of needed physical functions, but they offered a calming effect of some sort for the businessman. Other typical displacement activities include smoking, twirling one’s hair, picking at one’s fingers, nail-biting, playing with rings, twitching one’s feet, tugging at the ear lobe, self-grooming activities, tearing at paper cups, and twirling and biting pens. The list could certainly be extended. For instance, Morris points out that serving drinks and holding them in one’s hands at cocktail parties probably serve to decrease people’s anxiety, as they “have something to do.”⁵²

Clinically speaking, displacement activities are worth noting during both the initial interview and subsequent psychotherapy. Each patient seems to display a unique set of displacement activities. Once decoded by the clinician, these activities can be fairly reliable indicators of patient anxiety. When suddenly increased, they may represent a more reliable indicator than the patient’s facial expression or verbal response that an interpretation was on the mark or that the patient is feeling ill-at-ease with the interviewer or the topic.

Morris also views another sub-category of nonverbal adaptors as being suggestive of possible underlying anxiety or fear, which he calls auto-contact behaviors. Auto-contact behavior consists of movements involving self-touching.⁵³ Such behaviors may consist of grooming behaviors, defensive-covering behaviors, and self-intimacies.

Self-intimacies are defined as, “movements that provide comfort because they are unconsciously mimed acts of being touched by someone else.”⁵⁴ These self-intimacies appear frequently during interviews. Patients may hold their own hands or sit with their knees pulled up to their faces, arms literally hugging their own legs. In regressed patients, one can see even more extreme forms of self-hugging as patients lay in tightly curled fetal positions.

According to Morris, with regard to frequency, the most common self-intimacies in order of most to least frequent are as follows: (1) the jaw support, (2) the chin support, (3) the hair clasp, (4) the cheek support, (5) the mouth touch, and (6) the temple support. With hair touching, there is a 3 : 1 bias in favor of women. Temple touching demonstrates the opposite bias with a preference towards men of 2 : 1. Sometimes these kinesthetic comforters can be tied into other sensory modalities as well. I remember one patient who would pull her hair across her cheek. She would simultaneously gently sniff at her hair, which she related as being very comforting. Such activity was a sure sign of her underlying anxiety, much like a displacement activity.

In this manner, nonverbal activities such as adaptors (including displacement activities and auto-contact behaviors) may serve to alert the interviewer that the patient is feeling pained or anxious. It can cue the interviewer that the patient may need some verbal comforting, perhaps prompting an empathic statement. It can also alert the clinician that powerful affective material is being approached, possibly suggesting the need for further exploration.

It is also of interest that anxiety will sometimes display itself not through the appearance of adaptors but through their conspicuous absence. When engaged in an active conversation, most people will display a normal amount of periodic displacement activity and auto-contact. If these suddenly stop or are not present from the beginning, then the person may be experiencing anxiety. In a sense, the person may be trying to avoid mistakes by doing nothing.

This “still-life response” frequently appears when people are filmed or interviewed in public. It seems to afflict interviewers even more than patients. Supervisors need to be aware that this response may be more of an artifact than a stylistic marker of their supervisees.

Another area of interest revolves around facial clues that the patient is visibly shaken or on the verge of tears. I am sure the reader is well aware of the faint quiverings of the chin and glazed quality of the eyes that frequently indicate that a patient is close to tears. But a fact not as well publicized is the tendency for people to demonstrate extremely fine muscle twitches across their faces when stressed. These frequently occur beside the nostrils and on the cheek. In people who demonstrate this tendency, these fine twitches can be extremely accurate indicators of tension.

By way of example, I was working with a young businesswoman during an initial interview. She had been referred to me for psychotherapy. She was attractively dressed with a bright disposition and her speech was accompanied by a collection of animated gestures. When asked to talk about her history, she launched into a detailed review of her life since age 16. Of note was her striking avoidance of any events prior to age 16.

When I brought to her attention that she had avoided this earlier timeframe, she responded that she did not know why and had not noticed it. I asked her if any aspects of her life seemed different before the age of 16. She commented, “Not really, although I spent more time with my father back then.” At that point a few muscle twitches appeared by her left nostril. I commented that I had a feeling she was feeling upset, and she burst into tears. Subsequent therapy revealed a complex and ambivalent relationship with her father and other male figures. Throughout therapy, these faint twitches were a sure sign of tension.