Body Language

[ClinPsycMasters]

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What are your views on relying heavily on patient's body language and nonverbal behavior?

I find it challenging for several reasons:

1. I need more mindfulness training to be able to take in the more subtle cues.

2. There is so much variation in nonverbal behavior, specially when you are dealing with international clientele.

3. Interpreting body language can be fairly subjective.

What do you think? And any good book you may recommend?

 

[TexasPhysician]

http://www.amazon.com/Emotions-Reve...ng-Communication/dp/0805083391/ref=pd_sim_b_5

http://www.amazon.com/What-Every-BODY-Saying-Speed-Reading/dp/0061438294/ref=ntt_at_ep_dpt_1

Body language and other non-verbal behaviors are VERY important to recognize in my opinion. It can be the difference between a poor clinician and a good clinician. Many non-verbal behaviors are similar amongst all patients regardless of ethnicity/background. Its not very subjective if you can recognize it.

The part I find subjective is if you are trying to determine if someone is lying. That can be subjective and hard to do.

Basic non-verbal cues can be essential to becoming a good clinician. Say you are treating a patient for depression and you bring up smoking cessation. If the patient immediately gives you a look of disgust, you need to be able to back-off quickly or at the very least change your approach. If not, you put your patient in a defensive position, and risk losing him/her because of your verbal attack at such a difficult time. This isn't the greatest example but it gets the point across.

I'd recommend reading a couple books on identifying emotions and then follow-up with motivational interviewing techniques. Both will help you in practice and complement each other.

 

[ClinPsycMasters]

Thank you for your reply. I already have Ekman's book. He's a legend in the field. The other book also seems very helpful.

As far your "depressed patient" example, I think that some people are much better at masking their emotions. Some do express disgust, for instance, is such intensity that you can read it from 50 feet away. 🙂 Some, however, are very much in control of their reactions, and it makes it very hard to detect how they truly feel. I once saw a great salesman for assessment and I had a feeling he was trying to "sell" me particular emotions...and some I did "buy." And he wouldn't take them back. 🙂

 

[TexasPhysician]

Thank you for your reply. I already have Ekman's book. He's a legend in the field. The other book also seems very helpful.

As far your "depressed patient" example, I think that some people are much better at masking their emotions. Some do express disgust, for instance, is such intensity that you can read it from 50 feet away. 🙂 Some, however, are very much in control of their reactions, and it makes it very hard to detect how they truly feel. I once saw a great salesman for assessment and I had a feeling he was trying to "sell" me particular emotions...and some I did "buy." And he wouldn't take them back. 🙂

And it takes plenty of practice...obviously. The more long-term each patient becomes, the better you will become with each. You are right in that each person is a little different. I think there are many more differences between random people than between ethnicities. With more practice you will pick up minor things quickly.

Even if I think someone is lying, I won't call them out on it blatantly until I establish a good rapport. For example: After seeing Jane Doe for 4 visits though, I have no trouble calling her out on something if she acts different. Otherwise I'll try to work around the lies until I find what I'm looking for.

After all, it is our job to get in other peoples' business. 🙂

 

[ClinPsycMasters]

Thanks for your views. I agree that establishing rapport should take precedence. In addition, after several sessions (at least), I've learned more about the person and his unique pattern of nonverbal expression. Not everybody who lies sweats profusely and swallows. And vice versa, not everybody who perspires is lying.

 

[hippiedoc13]

There is a tremendous amount you can tell about a person with nonverbal information. I can do a great deal of the mental status exam without ever speaking to the patient. I always tell my medical students that they are already experts on mental status exam--we are implicitly doing them on each other all the time. I tell them that in teaching them to do and document a mental status exam, I am mostly going to teach them how to become aware of (and then accurately describe) many of the things they already notice. For practice, I will have them sit in our nursing station on the inpatient unit, which is glass windows on 3 sides (we call it the "fishbowl") and pick a patient to watch for a few minutes. Then I make them tell me everything they can about the patient (including their mental status exam) without ever talking to them. I have found that doing this a couple times helps a lot of them key in on the non-verbal stuff that they initially have a hard time paying attention to when they're trying to interview and listen to what a patient is saying.

 

[Ibid]

Its difficult to look for lies when you are telling them yourself. No offence intended but just look at the lies we might be telling and sometimes with good reason.

1. I am competent. Truth - you might not feel you are but can’t always say so.

2. This is a conversation that will be kept confidential to the best of my ability with in the law. Truth - I will pretty much give this conversation up very easily in a whole range of circumstances but I wont go into them all because that will ruin the process.

3. This is a non sexual relationship. Truth - I am going to do my best to keep my hands off you but when the sessions are over all bets are off.

4. I will be non-judgemental. Truth - I am a product of my upbringing, I can’t really expunge myself of the totality of my personal belief system so I’ll just pretend.

Moral - Any one who manages to pretend to themselves, that spending time in little room with a wierdy beardy who hasn't fully grasped the no touch rule is an answer to their problems, is probably well versed in lying to themselves and others.

 

[ClinPsycMasters]

For practice, I will have them sit in our nursing station on the inpatient unit, which is glass windows on 3 sides (we call it the "fishbowl") and pick a patient to watch for a few minutes. Then I make them tell me everything they can about the patient (including their mental status exam) without ever talking to them. I have found that doing this a couple times helps a lot of them key in on the non-verbal stuff that they initially have a hard time paying attention to when they're trying to interview and listen to what a patient is saying.

Sounds like an excellent idea.

 

[masterofmonkeys]

There is a tremendous amount you can tell about a person with nonverbal information. I can do a great deal of the mental status exam without ever speaking to the patient. I always tell my medical students that they are already experts on mental status exam--we are implicitly doing them on each other all the time. I tell them that in teaching them to do and document a mental status exam, I am mostly going to teach them how to become aware of (and then accurately describe) many of the things they already notice. For practice, I will have them sit in our nursing station on the inpatient unit, which is glass windows on 3 sides (we call it the "fishbowl") and pick a patient to watch for a few minutes. Then I make them tell me everything they can about the patient (including their mental status exam) without ever talking to them. I have found that doing this a couple times helps a lot of them key in on the non-verbal stuff that they initially have a hard time paying attention to when they're trying to interview and listen to what a patient is saying.

That is a seriously awesome teaching technique. Thanks a ton for that.

 

[TenaciousGirl]

Some, however, are very much in control of their reactions, and it makes it very hard to detect how they truly feel.

But even this can tell you A LOT about a person and their process of emotion/reaction. For example, when a pt sits there and speaks with a monotone voice of how they witnessed some horrific incident and they say it with a blank face ... that says a lot.

Or even people who have over-controlled hostility ... it says a lot.

Sometimes it's the lack of reaction that speaks louder than the reaction.

And for some good observational tips, watch the movie Maverick. He's got it down. 😀

 

[ClinPsycMasters]

Yes, the very fact that someone is not willing to appear vulnerable or show his true feelings, does tell me something about that person. However, that is not enough. I may not able to get past their defense, to be able to truly help them. This happens, at times, with very intelligent but paranoid people. Some people whose livelihood and very survival has depended on how well they can read people and hide their own emotions/vulnerabilities, can present significant challenge. Think poker players...and high stakes.

 

[whopper]

Very important.

A lot of the mental status exam should be based on the patient's body language. In forensic psychiatry this is especially important because many patients malinger. You cannot often take what the evaluee says at face value.

Body language, like most aspects in the mental health sciences should be based on 2 models: behavior based on the general population (and how this applies to the person), and the person's own idiosyncratic behavior that may not be seen in others in the population.

In violent people, there's one model that analyzes the person's behavior. This model emphasizes categorizing the person as perpetrator of affective violence vs. predatory violence. In this model, body language is very important. In affective violence, the person is noticeably angered (angry affect, increased BP, possible sweating, threats, defensive/offensive body posture). In predatory violence, the person is not noticeably angered, and is seen as calm before and after the attack.

In perpetrators of predatory violence, determining safety is especially difficult phenomenon because it's much more difficult to tell if the person will attack another ahead of the attack.

Its difficult to look for lies when you are telling them yourself. No offence intended but just look at the lies we might be telling and sometimes with good reason.

According to studies, psychiatrists were not able to demonstrate we were any better at telling if someone was lying than a college student. The college student is by no means a complement to us (as if they're better educated than others) because college students were the control population in the study. The only group to show a statistical improvement over the college students were law enforcement that regularly interrogated suspects. (I need to double check the exact profession because it's been a few months since I read the study).

For that reason, we in the mental health profession should not be in a position to tell if someone is telling the truth or not unless we can point to specific obejctive reasons (E.g. psychological testing, contradicting statements made by the person, atypical signs and symptoms).

Do not ever think that you can tell if someone is lying simply because you are a psychiatrist. I would believe that a psychiatrist, who knows a person very very well could tell better than a random person, but that's not because the psychiatrist is somehow better than anyone else. It's because anyone who knows someone else very very well would be able to tell better.