When a Patient attempts to give you information he is likely to have thought out very carefully what he wants to say prior to the session. Usually this is based on what he thinks you want to hear. When you meet your Patient there will be certain things that you will want to hear also, however these may not be the same things that the Patient thinks you want to hear. This means that a certain amount of the Patient’s information will be contrived. Patients seek help from a therapist because they feel that they cannot help themselves. Yet when they ask for help they have to use the same vocabulary and concepts to describe their problems that have previously not been helpful in solving their problems. This puts Patients at a disadvantage because they can only talk about their problems from their own limited frames of reference.
This blog post will teach you how to observe and understand non-verbal communication so that it naturally becomes part of your everyday way of seeing how people interact. It will help you understand someone’s motives, beliefs and thoughts as it will allow you to compare what a person is saying verbally with what they are saying unconsciously non verbally. This skill is essential for anyone in the caring professions where empathy and rapport is important. Understanding a client or patient’s true feelings opens doors in communication allowing people to feel confident in sharing more about themselves and their problems..
You will need to make a commitment to watching how people communicate, and so it will take time. But the effort will be worth it as you will be able to understand people much better and make more informed decisions, especially in therapeutic contexts.
Calibrating to Positive & Negative Response Cues
When a Patient attempts to give you information he is likely to have thought out very carefully what he wants to say prior to the session. Usually this is based on what he thinks you want to hear. When you meet your Patient there will be certain things that you will want to hear also, however these may not be the same things that the Patient thinks you want to hear. This means that a certain amount of the Patient’s information will be contrived. Patients seek help from a therapists because they feel that they cannot help themselves. Yet when they ask for help they have to use the same vocabulary and concepts to describe their problems that have previously not been helpful in solving their problems. This puts Patients at a disadvantage because they can only talk about their problems from their own limited frames of reference. It is your job as a therapist to observe the Patient very carefully as they talk and ask the right questions to get new answers that can then be used to help the Patient. Many of these answers will not come neatly packaged as words, many will be in the form of gestures, changes in muscle tone, alterations in respiration etc. The nonverbal aspect of their communication will usually not be contrived in the same way as their verbal account. It is difficult for a Patient to deliberately manipulate their non-verbal communication because it is usually unconscious and therefore natural. When Patients communicate they give non-verbal signals related to the content of their verbal communication. You should really learn to pay attention to the non-verbal communication as often this information will give you important clues about the nature or cause of the Patient’s problem and how it is being maintained.
When I first started practising as a therapist I would often sense that some Patients were not being totally honest with me. At the time I didn’t know how I knew this, I just felt it. I would often have an uncomfortable feeling when they said something
I that didn’t seem quite right. Many times I just wanted to stop them and say “wait a minute I don’t think you really believe that”. I always used to kick myself when I didn’t probe deeper because (usually ) those particular sessions didn’t really get anywhere. I had to learn to trust my intuition. Intuitive learning is only possible through experience. You cannot be intuitive about a subject you know absolutely nothing about. Continual exposure to a subject and risk taking within the boundaries of that subject will teach you to be intuitive. What I was noticing during my early training was incongruency in the Patient’s behaviour. I was picking up unconsciously a mis-match between what they were saying and the way they were saying it, however I didn’t realise how I was picking it up at the time. Through disciplining myself to pay attention to the fine details of communication I was able to realises how I was doing it and then streamline my observation skills further. Initially I started by re-playing the audio tapes of sessions and listening to exactly what the Patient had been trying to say. I took apart every word and listened to any changes in voice tonality, significant pauses and hesitations. I did this because I thought at the time that the Patient’s communication was mainly verbal. I then realised that tonality and hesitation were really non-verbal aspects of the communication because they contained actual content. They were forms of expression that were telling me how to interpret the content of the communication that I heard through the Patients actual words I found this “taking apart” process so useful that I decided to do it with the other non-verbal aspects of my Patients’ communications. Therapists could not buy video cameras then so it all had to be done whilst it was happening. This was very difficult at first because I kept losing track of what my Patient was saying because I was paying so much attention to what their hands or breathing were doing. However I eventually mastered it and then it became automatic.
Non-verbal communication is usually unconscious
When the Patient communicates he is unaware of his non-verbal communication. However this non-verbal communication usually mirrors the verbal content. If non-verbal communication mis-matches the verbal communication it suggests incongruity. Incongruity is a mis-match between the conscious and unconscious understanding of the problem. For example, a Patient may be thinking of one thing, whilst at an unconscious level be “thinking” another; he may be totally unaware of his unconscious representation. When he communicates, his unconscious mind delivers the non-verbal component whilst his conscious mind gives the verbal component. Therapists should pay attention to both aspects.
You may have heard someone saying of another person “Oh he’s a dead give away” or “I can read him like a book”. These are phrases which describe a person who is totally unaware of their non-verbal communication to the extent that they have no control over it and others can see what they are really trying to say. These people usually have difficulty lying because their non-verbal communication mis-matches their verbal communication so much.
As therapists we are not blessed with this kind of person as our Patients. In fact often our Patients will be doing everything they can to control how they communicate. Despite this, their non-verbal communication will usually be reliable if you can actually see it. This is because non-verbal communication is hard to control consciously, even for Patients wanting to safeguard their secondary gains.
I knew someone who used to lie a lot. I noticed that when they lied their mouth would twitch at one corner. You might think that having seen this tell talc sign I should have keep it a secret from them so that I could catch them out. I was more interested in just stopping them from lying. So how did I do it? I told them how I knew they were lying. I told them about that little twitch. From then on, any time they started to lie their mouth would twitch and they would become acutely aware of it happening. The harder they tried to stop it twitching the worse it would get. Eventually they had to stop lying. The conscious mind has difficulty controlling the unconscious mind.
Patients comment non-verbally on what they are saying.
The therapist should think of the non-verbal communication almost as a running commentary on what the Patient is actually saying. A positive phrase or statement accompanied by a negative facial expression demonstrates incongruity between the thinking at the conscious and unconscious level. The therapist should attempt to think of the non-verbal aspect almost as a subscript to the main communication. I had a Patient who kept putting her hand over her mouth every time she talked about her husband. It became so obvious to me that I found it funny. I had difficulty stopping myself laughing every time she did it. It was quite subtle in that most people would not have noticed it. She was totally unaware that she was doing it. You can learn to recognise incongruities by watching for repeated gestures or movements. Sometimes it may be an aggressive voice tonality that is repeated or even a kind of facial expression that seems wrong. You need to see at least two examples of it occurring before you can call it a pattern. Once you have identified it keep a mental check to see how often it occurs and when. There will be some part of the verbal communication that triggers it usually. As with the above example of the woman talking about her husband. These non-verbal signals are also kinds of metaphors that may even tell you how the Patient really thinks about the subject they’re discussing. The woman who was covering her mouth each time was saying “I don’t want to talk about this”. So her hand over the mouth was an indication to me that a. she didn’t want to talk about her husband and b. her husband was connected to the problem in some way and c. This was one of her ways of communicating non-verbally that I should look out for in the future. If I had seen her cover her mouth when she talked about holidays for example, I could then wonder if maybe the combination of her husband and her holiday are somehow responsible for her problem. Or whether the hand over the mouth is just a general mechanism to protect herself. Of course you shouldn’t get carried away and think that all non-verbal signals are an unconscious message. A hand covering the mouth sometimes is a way of covering a embarrassing teethe smile. Or a Patient sitting with their arms folded might mean they are cold (not defensive as many non-verbal communication books suggest. All non-verbal communication has to be seen in context to b understood properly
Non-verbal communication is more reliable than verbal communication.
Whenever there is incongruity the therapist should believe the non-verbal component of the communication rather than the verbal component. As the non-verbal component is unconscious it is more likely to be honest. This doesn’t mean that the Patient is deliberately attempting to lie. The Patient may consider that he has full conscious understanding. However, his unconscious mind knows different (and usually better). Patients reveal their inner feelings so well with non-verbal communication that it is often possible to identify what a Patient is feeling or even thinking simply by paying attention to their non-verbal cues. By noticing a Patient’s facial expression when they’re talking about positive things and their facial expression when talking about negative things it should be possible for the therapist to identify whether the Patient is thinking positively or negatively in the future simply by watching their facial expression.
This skill is well worth developing as many Patients are not aware at a conscious level of what is troubling them at a deeper unconscious level and their non-verbal cues give away clues as to what might be wrong. Ideo-motor signalling and automatic writing are two hypnotic techniques for evoking unconscious communication and are also non-verbal communications. The only difference being that they are deliberately induced by the therapist rather than presented naturally by the Patient although both classes of these hypnotic phenomena can appear spontaneously during trance.
I had a Patient once who complained about being depressed. She was very unkempt, dressed like a tramp, looked as if her hair hadn’t been washed for weeks and used the most foul language I have ever heard. Throughout the interview she seemed unable to be specific about what was troubling her. Much of the time was spent looking at the floor. I noticed that whenever we spoke of her depression she would pick and scratch an unpleasant sore on one of the fingers of her left hand. I also noticed that when we spoke about men she would literally dig her heels into the carpet. Questions about sex or violence would produce more picking of her sore and digging in of heels. After about an hour of getting hardly any verbal responses to my questions I decided to challenge her “Why don’t you tell the f***ing bastard to get the f***ing hell out of your life?”. She suddenly burst into tears and said “Because I love him, the f***ing bastard”. It turned out that she was being regularly being beaten up b\’ her husband. She wanted to get rid of him but was still in love with him. She had removed her wedding ring some months before but still felt that it was there on her finger. Her sore was caused by the continual picking of the place where her ring used to be as if it were still there The digging in of her heels could have either been a sign that she was scared to talk about her problem or that she was frustrated with her dilemma.
Organic Metaphors and Symptom Based Metaphors.
As part of their non-verbal story telling, Patients will often include, gestures, movements or “throw away” comments about physical symptoms when talking about their problem. The Patient will usually be unaware that there is any connection between the gesture or comment and the content being talked about at that time. For example, a Patient may make a “throw away” comment about the muscular tension in his shoulders as he is talking about having taken on a new job which “carries” additional responsibility. The Patient might be saying indirectly that he is carrying the weight of the world on his shoulders at work and that this is producing physical tension in the shoulders. Patients can either draw attention to an organic metaphor through direct touch (massage) or by mentioning it, usually the Patient uses touch without being aware they are doing it.
The Patient may not recognise the relevance of the comment about his shoulders as he talks about his work. Alternatively, rather than commenting on the tension in this shoulders, he may just rub or massage his shoulders for a few moments without realizing it as he is talking about work. The pain in his shoulders is called an organic metaphor. It is a symptom of the problem and the Patient is using the commenting or massaging as a way of communicating a message to the therapist, which says; “I am having difficulty carrying all of this responsibility at work”.
You should not assume that all of the Patient’s gestures, aches and pains are organic metaphors that comment on what they feel at an unconscious level. You need to see the behaviour (gesture, pain, itch, etc) repeated a number of times in relation to a particular topic of conversation before concluding that it is a possible organic metaphor. One example demonstrated at a particular point in the therapy may raise your suspicion but you should not assume anything until you see it repeated when similar topics are being discussed.
Autonomous physiological changes such as sweating, hyperventilation and coughing fits, if occurring at specific times during an interview, can also be classed as organic metaphors in that they are communication that whatever is being discussed at that moment is relevant for the therapy.
To further illustrate how we can identify and learn from the observation of organic and non-verbal metaphors I give you this example of a successful first session interview with a very chatty and attractive modern business woman in her late 2Os. Jean, who with her hair tied in a French knot on top of her head, looked a little like a 1960’s French film star, wore a white button up collar blouse and pleated navy skirt. She first sat on the edge of her chair but soon re-positioned herself more comfortably as the session progressed. The day before, she had telephoned me requesting an urgent appointment. During her visit she complained about her work. As she complained about her workload and fellow workers she appeared to be in control of her feelings and she sat in what appeared to be a comfortable posture and made appropriate yet relaxed gestures that matched what she was saying.
She appeared to be congruent in what she was saying in that she clenched her fists when talking about her frustration over a certain deadline she had to meet and she relaxed back in the chair when she thought of having completed it in near future. It would have been very easy for any therapist to be fooled into thinking that her problems with stress were genuinely related to pressure at her place of work. Yet when I asked her how she felt about reducing her work load or changing her job she adamantly refused to accept any of these possibilities stating that she lived for her work. This gave me a clue to where the cause of her problems may lay. When I asked her about her home life she took on a rather rigid, posture attempting to look comfortably relaxed, brushing her hand back through her hair, looking up and smiling and then picking bits of cotton off of her skirt. Her verbal report about her home life was positive. She talked about how there had been some difficult times in the past but that these had now been resolved and that she felt very positive about things. Her language was vague yet positive with an emphasis on how things were now “better than ever before” and that she “couldn’t wish for a better life”.
It was obvious to me that she was consciously trying to look at ease but was giving her true unconscious feelings away through her nervous non-verbal behaviour, her vague language when talking about the past and her emphasis on “things being better. I was fascinated to know what “things” had been like in the past before they had got better. When I asked her she casually said “oh, you know, the things that happen when you first get married”. When I pushed her a little further she said well that’s in the past now and then she looked at me with one of those “let’s drop this shall we” kind of looks. So to appear to match her needs at that moment I told her that I was very interested to know about her life in the present. She looked more relaxed. But then when we approached the subject of her relationship with her husband, she casually yet quite firmly started massaging the back of her neck as she talked about how wonderfully supportive he was. She seemed unaware of her behaviour and I deliberately did not comment on it.
If I had of commented on it she might have then sabotaged her unconscious communications and I would have lost my therapeutic advantage gained in the session. When I asked about the physical symptoms of her stress, she complained mainly of the pain in her neck that seemed, to her, to come and go for no apparent reason. Further questions from me about her husband produced more neck massage from her, to which she still seemed to be unaware.
Although she never ever got as close as saying that her husband was a pain in the neck, it was obvious to me that her massaging of the area of physical tension in her life was an indirect unconscious communication that the cause of her problem lay with her relationship with her husband and that this may have been caused by unresolved relationship problems in the past. Of course, it could also have been caused by her relationships with people at work or any other relationship difficulties or concerns. It turned out that my first observations were correct and that her husband had had a number of affairs when they had first got married and had told her about them each time afterwards. Although they were both older now and he claimed to have changed she had never been able to trust him. As she was so busy at work she had been unable to pay as much attention to her husband and she was worried at an unconscious level that he might start straying again. In fact she later said that she had felt, although she had dismissed it, that he had had several affairs since he had first promised that he would remain faithful to her and that her work took her mind off of her problem. So she had put herself in a double bind.
In this case study we can see that a combination of non-verbal behaviours indicated unconscious unease about the Patients relationship with her husband. First there was the incongruency between the fact that she urgently requested an appointment and her actual account of her problem when she attended the session. During the session there was a lack of incongruency when she spoke of her stress at work. She appeared so congruent and believable that she seemed to be covering something up. Her behaviour was incongruent with the context. The incongruency was really between the way she described her problem and its perceived cause as being work related and her absolute urgency to see me for therapy in the first place. I suspected that the problem was not simply work related because her description of her problems at work just did not match the urgency with which she requested an appointment.
Secondly, there was the verbal incongruency between her account of her problem as being work related and her statement that she lived for her work. I couldn’t understand how, if she were telling the truth, she could on the one hand, complain so bitterly about her work yet state that she lived for it. Any attempt to get her to reduce her workload or change job on the understanding that her problem was work related would have failed. She really did live for her work, it was her escape from the worries of her relationship and the more overworked she was the easier it was not to think consciously about her husbands possible infidelity.
Then there was the incongruity between her apparent relaxed posture as she talked about her home life and her nervous gestures and fidgeting. This was paralleled by the mis-match between her verbal emphasis on everything being positive and her avoidance of talking about the past.
Lastly there was the incongruity between her statements about her husband being wonderfully supportive and the organic metaphor of her intense massaging of the back of her neck. The fact that her main physical symptom of stress was a pain in the neck suggested in my mind that her problem was related to her husband in some way. It was only later after much more questioning that she was able to identify for herself that her problem was caused by a fear of her husband’s potential infidelity. This insight she discovered for herself. I did not suggest it to her.
She had put herself into a double bind by working harder to avoid the anxiety of thinking about her problem but this had prevented her from consciously keeping an eye on her husband’s behaviour. This then created more anxiety which eventually drove her to seek therapy in such an urgent manner. This is not an uncommon pattern. Through avoidance the problem had worsened until she could not stand it any longer, yet even then, while in therapy, she continued to avoid addressing the cause of her problem.
Matching & Mirroring Breathing
Your clients breathing will tell you a lot about their inner state and how they are feeling. If they are talking calmly but breathing fast then they are probably holding something back. There are a number of ways you could deal with this, you could challenge them (not good) or better still get them to slow down their breathing so it matches what they are saying, they will then feel more comfortable to share what they might be holding back.
Matching on a minimal level helps enhance rapport
Therapists should train themselves to pay attention to the Patient’s breathing. By matching the same breathing pattern as the Patient the Patient unconsciously identifies that the therapist is “in harmony” with the Patient. By matching the breathing in this way the therapist can then start to slow down his own breathing. The slowing down process will help the Patient slow down his own breathing. This indirect approach to helping the Patient relax happens at an unconscious level. Naturally, the therapist shouldn’t match a Patient’s breathing if it is unusual or problematic in any way. For example if the Patient is asthmatic and breathing in an accelerated or difficult fashion. Matching a Patient’s breathing is essential when inducing hypnosis. When Patients go into trance they like to maintain contact with the therapist in some way. In fact the trance experience is exclusive for the therapist and Patient. By matching the breathing of the Patient the therapist maintains this communication with the Patient as they go deeper.
Matching And Mirroring Posture
Matching a Patient’s body posture will enhance rapport. When people are getting on well together they tend to sit in the same position as each other. You will often see this in social situations. When people talk to each other they tend to adopt the same posture. When people walk down the street together, as long as they are the same height and build, they tend to walk in step with each other. Because people naturally mirror each other when the relationship is good, therapists can mirror Patients to enhance rapport.
Mis-matching the Patient’s body posture can break rapport
Likewise by deliberately positioning ourselves so that we are not mirroring or matching the Patient, we can break rapport. The difference between matching and mirroring is simple. Mirroring is literally mirroring back the person’s body image. Matching is following the person’s movements and doesn’t require an exact mirror image. You might like to experiment matching and deliberately mis-matching people you know, to find out what happens to the conversation.
Matching the Patient’s voice tonality, tempo, pitch and volume enhances rapport
Matching the voice to an extreme could be perceived as mimicking so this should be avoided as this would break rapport. The therapist has to pace exactly the changes in tempo and pitch and decide to what extent he should match the Patient’s voice so as to avoid any interpretation of mimicking.
Matching the voice tonality, tempo, pitch and volume of the Patient serves the same purpose as matching the breathing. The Patient unconsciously feels safe with the therapist. By matching the voice the therapist is saying that it’s OK to be the Patient. This is important when Patients come in troubled and concerned about their own self image or personality. It’s reassuring for the Patient when the therapist feeds back these minimal cues. It normalises the Patient’s problem to a certain extent.
Copying a regional accent or dialect should usually be avoided however as this may be difficult to maintain in the future, especially if the therapist were to somehow meet with two patients from different backgrounds at the same time. Accents suggesting a particular class background can be lightly modeled but not mimicked. So a slightly nasal twang could be matched, or for example an East London accent could be lightly matched, but to break out into a broad Scottish accent when you patient is from Scotland would be ridiculous.
The therapist should wait for a few minutes at the start of the session to identify what aspects of the Patient’s voice can be matched, and then gradually introduce these aspects in his own voice. This method mirrors the naturally occurring changes that occur in voice tonality etc when people are developing close rapport.
Cultural Pattern Matching is the skill of feeding back a verbal pattern that is a part of the Patient’s regional background. If the patient is talking in a strong regional accent, he will quite likely also have associated verbal phrases that are common to that region and that he uses quite frequently. For example, some young people with a very strong London accent, often punctuate their communication with the word “right?” or “you know what I mean?” at end of each sentence. The therapist can feed these back to help build rapport. Again, overuse will be perceived as mimicking.
Sometimes matching the Patient’s expectation of what the therapist’s voice will sound like is more important than matching the Patient’s actual voice. For example if the patient is expecting an authoritarian therapist and believes that this is important (maybe the Patient is very quiet and submissive and responds best to being told what to do), it might be better to match this expectation rather than match the Patient’s voice.
Matching and Mirroring Facial Expressions
In addition to breathing, voice tonality, tempo, pitch and volume, the Patient also demonstrates many other non-verbal changes. These non-verbal changes are known as minimal cues. Some minimal cues can be more difficult to spot than others.
The most obvious minimal cues to look out for are changes in muscle tone. This can be noticed in the facial muscles. You will often see a Patient “smooth over” when talking about past remembered experiences of a pleasant nature. When the Patient thinks about unpleasant memories muscle tension can also be observed. The therapist should identify these minimal cues and match them if possible. By doing this, the therapist is showing recognition of the Patient’s needs and maintaining rapport at an unconscious level. The Patient recognises, without knowing it, that the therapist is in tune with the Patient’s experiences.
Because the Patient sees the therapist demonstrating similar minimal cues, he believes that the therapist understands his situation. All of this communication occurs at an unconscious level. This unconscious communication is occurring all of the time in every day interactions.
Matching Other Minimal Cues
Other minimal cues that can be matched are: pupil dilation, sweating, eye watering, changes in blink rate, changes in skin colour, changes in pulse rate, changes in head position, eye movements similar to eye accessing cues and swallowing. These usually accompany shifts in sensory awareness from external to internal reality as in day dreaming.
Matching Pupil Dilation
To match pupil dilation the therapist can practice de-focusing on objects and remembering the sensation so it can be repeated at will. It is also possible to dilate the pupil by focusing intently on an object. A very effective way of learning pupil dilation and contraction is to use light. Light contracts the pupil and darkness dilates the pupil. If you stand in front of a mirror with a candle in a dark room and bring the candle close to your face you will see your pupils contract and dilate as you move the candle close then away from your face. You can practice this so you can recognise the difference in sensation.
If you bring the candle close to one side of your face, that pupil will contract while the other dilates. You can practice this so you can recognise the difference in sensation between the right and left eye (contracted / dilated pupils). If practiced regularly the you should be able to train yourself to contract one pupil while dilating the other!
Weird Matching (why not?)
To match sweating, the therapist can hold his breath (without being seen to do so). To match eye watering the therapists can avoid blinking. To match skin colour the therapist can recall embarrassment etc. To match pulse rate the therapists can match breathing. To general response attentiveness the therapists can put himself in and out of trance accordingly.