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Chapter: Psychiatric Mental Health Nursing : Therapeutic Communication

Nonverbal Communication Skills

Nonverbal communication is the behavior a person exhibits while delivering verbal content.



Nonverbal communication is the behavior a person exhibits while delivering verbal content. It includes facial expression, eye contact, space, time, boundaries, and body movements. Nonverbal communication is as important as, if not more so than, verbal communication. It is estimated that one third of meaning is transmitted by words and twothirds is communicated nonverbally. The speaker may ver-balize what he or she believes the listener wants to hear, whereas nonverbal communication conveys the speaker’s actual meaning. Nonverbal communication involves the unconscious mind acting out emotions related to the ver-bal content, the situation, the environment, and the rela-tionship between the speaker and the listener.


Knapp and Hall (2009) listed the ways in which non-verbal messages accompany verbal messages:


·    Accent: using flashing eyes or hand movements


·    Complement: giving quizzical looks, nodding


·    Contradict: rolling eyes to demonstrate that the mean-ing is the opposite of what one is saying


·    Regulate: taking a deep breath to demonstrate readiness to speak, using “and uh” to signal the wish to continue speaking


·    Repeat: using nonverbal behaviors to augment the ver-bal message, such as shrugging after saying “Who knows?”


·    Substitute: using culturally determined body move-ments that stand in for words, such as pumping the arm up and down with a closed fist to indicate success



Facial Expression


The human face produces the most visible, complex, and sometimes confusing nonverbal messages. Facial move-ments connect with words to illustrate meaning; this con-nection demonstrates the speaker’s internal dialogue. Facial expressions can be categorized into expressive, impassive, and confusing:


·    An expressive face portrays the person’s moment-by-moment thoughts, feelings, and needs. These expres-sions may be evident even when the person does not want to reveal his or her emotions.


·    An impassive face is frozen into an emotionless deadpan expression similar to a mask.


·    A confusing facial expression is one that is the opposite of what the person wants to convey. A person who is verbally expressing sad or angry feelings while smiling is exhibiting a confusing facial expression.


Facial expressions often can affect the listener’s response. Strong and emotional facial expressions can persuade the listener to believe the message. For example, by appearing perplexed and confused, a client could manipulate the nurse into staying longer than scheduled. Facial expressions such as happy, sad, embarrassed, or angry usually have the same meaning across cultures, but the nurse should identify the facial expression and ask the client to validate the nurse’s interpretation of it—for instance, “You’re smiling, but I sense you are very angry” (Sheldon, 2008).


Frowns, smiles, puzzlement, relief, fear, surprise, and anger are common facial communication signals. Looking away, not meeting the speaker’s eyes, and yawning indicate that the listener is disinterested, lying, or bored. To ensure the accuracy of information, the nurse identifies the non-verbal communication and checks its congruency with the content (Sheldon, 2008). An example is “Mr. Jones, you said everything is fine today, yet you frowned as you spoke. I sense that everything is not really fine” (verbalizing the implied).


Body Language


Body language (gestures, postures, movements, and body positions) is a nonverbal form of communication. Closed body positions, such as crossed legs or arms folded across the chest, indicate that the interaction might threaten the listener who is defensive or not accepting. A better, more accepting body position is to sit facing the client with both feet on the floor, knees parallel, hands at the side of the body, and legs uncrossed or crossed only at the ankle. This open posture demonstrates unconditional positive regard, trust, care, and acceptance. The nurse indicates interest in and acceptance of the client by facing and slightly leaning toward him or her while maintaining nonthreatening eye contact.


Hand gestures add meaning to the content. A slight lift of the hand from the arm of a chair can punctuate or strengthen the meaning of words. Holding both hands with palms up while shrugging the shoulders often means “I don’t know.” Some people use many hand gestures to demonstrate or act out what they are saying, whereas others use very few gestures. The positioning of the nurse and client in relation to each other is also important. Sitting beside or across from the client can put the client at ease, whereas sitting behind a desk (creating a physical barrier) can increase the for-mality of the setting and may decrease the client’s willing-ness to open up and communicate freely. The nurse may wish to create a more formal setting with some clients, however, such as those who have difficulty maintaining boundaries.


Vocal Cues


Vocal cues are nonverbal sound signals transmitted along with the content: voice volume, tone, pitch, intensity, emphasis, speed, and pauses augment the sender’s mes-sage. Volume, the loudness of the voice, can indicate anger, fear, happiness, or deafness. Tone can indicate whether someone is relaxed, agitated, or bored. Pitch varies from shrill and high to low and threatening. Intensity is the power, severity, and strength behind the words, indicating the importance of the message. Emphasis refers to accents on words or phrases that highlight the subject or give insight into the topic. Speed is the number of words spo-ken per minute. Pauses also contribute to the message, often adding emphasis or feeling.


The high-pitched rapid delivery of a message often indicates anxiety. The use of extraneous words with long, tedious descriptions is called circumstantiality. It can indicate the client is confused about what is important or is a poor historian. Slow, hesitant responses can indicate that the person is depressed, confused and searching for the correct words, having difficulty finding the right words to describe an incident, or reminiscing. It is impor-tant for the nurse to validate these nonverbal indicators rather than to assume that he or she knows what the client is thinking or feeling (e.g., “Mr. Smith, you sound anxious. Is that how you’re feeling?”).


Eye Contact


The eyes have been called the mirror of the soul because they often reflect our emotions. Messages that the eyes give include humor, interest, puzzlement, hatred, happi-ness, sadness, horror, warning, and pleading. Eye contact, looking into the other person’s eyes during communica-tion, is used to assess the other person and the environ-ment and to indicate whose turn it is to speak; it increases during listening but decreases while speaking (DeVito, 2008). Although maintaining good eye contact is usually desirable, it is important that the nurse doesn’t “stare” at the client.




Silence or long pauses in communication may indicate many different things. The client may be depressed and struggling to find the energy to talk. Sometimes pauses indicate the client is thoughtfully considering the question before responding. At times, the client may seem to be “lost in his or her own thoughts” and not paying attention to the nurse. It is important to allow the client sufficient time to respond, even if it seems like a long time. It may confuse the client if the nurse “jumps in” with another question or tries to restate the question differently. Also, in some cultures, verbal communication is slow with many pauses, and the client may believe the nurse is impatient or disrespectful if he or she does not wait for the client’s response.


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