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Nonverbal Behavior

How do you analyze nonverbal behavior?

John slams the door each time he enters my office; Hal has body odor; Janet brings coffee to her session and spills it in the waiting room; Barbara puts her feet up when she sits on my couch without taking off her shoes. What does it mean and how should I handle it with the patient?

Crossing one's arms across the chest might mean the patient is not open to pursuing a particular avenue of exploration; however, it might mean the office temperature is too cold. So it’s important not to jump to any conclusions and make facile interpretations about nonverbal communications.

The majority of interpersonal communication is nonverbal. Most nonverbal behaviors are unconscious and give us a glimpse into the patient’s attitude and emotional state. They may belie a patient's anxiety regarding a specific topic and/or shed light on the transference. Yet the emphasis in the clinical setting is disproportionately placed on verbal interactions. (Gretchen N. Foley, MD and Julie P. Gentile, MD, “Nonverbal Communication in Psychotherapy, Psychiatry. 2010 Jun; 7(6): 38–44. Published online 2010 Jun.)

Drawing attention to a person’s nonverbal forms of communication can lead to important insights about the unconscious dynamics of the patient and between patient and therapist. However, the patient may take interpretations about nonverbal behavior as a criticism—particularly when the behavior belies aggressive or sexual feelings. So what should a therapist do?

I do not point out nonverbal behavior to a patient the first time I notice it. Slamming the door once might mean you were holding coffee and a briefcase and couldn’t grab the door handle. But letting the door slam regularly indicates that it has some psychological meaning. However, particularly because it makes me angry, I have to choose my words carefully when I make the intervention.

I want to say: “What’s the matter with you? Someone else is having their therapy session and it’s rude to let the door slam.”

But I actually say: “I’ve noticed that you let the door slam when you enter the office. Do you have any thoughts about that?”

The patient may still get defensive and still feel accused of doing something “bad,” but you need to let that play out.

Therapist: “I’m not criticizing you, but I think there is something we can learn from understanding why you let the door slam when you enter the office.”

Patient: “Yes, you are criticizing me and saying I do something that’s rude.”

Should I act like it’s NOT rude to let the door slam? No, that would not be helpful to the patient.

Therapist: “I am not trying to teach you etiquette, I don’t think you purposely slam the door. I think it’s unconscious and we could learn something about you if we could put the etiquette aside and think about whether there is some meaning to you letting the door slam. It’s an opportunity to learn something. Do you let the door slam everywhere or just here?”

Patient: “Hmm…I’m not sure. That would be pretty bad if I go around slamming doors everywhere. I guess I will have to pay more attention.”

That wasn’t so bad. But what about the person who has stifling body odor? How am I going to talk to him about that?

Therapist: “I’d like to talk to you about something that may be difficult for both of us.”

Patient: “Uh, oh. What’s that?”

Therapist: “Do you know that you have body odor?”

Patient: “Well, I have had this problem since I was a kid. I sweat a lot and I can’t help it.”

Therapist: “That must be upsetting. I’m sorry about that. But considering that you have this problem, how often do you shower?”

Patient: “I shower every morning.”

Therapist: “And how often do you change your shirt?”

Patient: (Silent for a few moments.) “Well, I guess I should change it every day or more than once if it’s hot outside.”

Therapist: “Are you saying that you don’t?”

Patient: “No…I don’t.”

Therapist: “So what do you make of that?”

Patient: “Maybe there’s a part of me that wants to smell. Wants to say ‘Fuck you.’”

Therapist: “And why would you want to say that?”

Patient: “Because it’s a lot of trouble and it’s not fair. Why should I have to shower all the time and change my shirt because it’s wet?”

Therapist: “I understand that it isn’t fair that you have this condition. And I understand that it’s a pain in the neck to have to shower more than once a day and change your shirt more than once a day. But it sounds like you want to take it out on the people around you.

Patient: “Yes, it’s a big ‘Fuck you’ and I think I do that about a lot of things…”

In both examples, bringing the nonverbal behavior to the attention of the patient led to important insights. It also strengthened the therapeutic alliance because we found a way to talk about something difficult without either of us losing control; it created a process that we could go back to the next time there was something difficult to discuss. And it created trust between us because the patients did not have to hide their anger or act it out. They were able to talk about it with me. Clearly, pointing out nonverbal behavior is an important part of psychoanalysis and any psychodynamic treatment.

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