“A picture says more than a thousand words” (Anon)
Verbal and non-verbal communication in the therapeutic relationship!
Early in my career as a homeopath I noticed that attentive listening is an element in the therapeutic relationship that can create, or damage the patient-practitioner dynamic. The active, visual expression of listening attentively can move mountains, while the lack of it can instigate a distance and retreat.
I had noticed this when a patient, the moment I lowered my head to jot down my notes, resorted to giving only monosyllabic responses to questions that I now had to pose in order to promote her discourse with me. She had changed, her voice had a new sound pitch and when I looked up, I noticed her posture had changed. With arms crossed in front of her chest she appeared to have moved away, and she now had a somewhat hurried air about her that signalled to me ‘I just want to get this over and done with’.
I learned two very valuable things that day! One, you are loosing something if you are distracted, even if its just to take notes, and two, look at how body-language talks! In retrospect, these were two of the most important insights I have gained and although sensitized for the latter I am struggling still to pair the two, as is needed in a homeopathic case-taking.
It cannot be denied that taking notes is diverting attention from the patient, not only visually by taking the eyes from the patient to the paper, but also by focusing the thoughts on the notes to be written. For me this is a bit of a mini-break or rupture; a gap that disrupts the patient-practitioner engagement, if only for a moment, but not necessarily without impact. I have therefore taken cases where, depending on the patient, his history and the dynamic attained, I stopped taking notes during the session, and completed my notes after the patient had left. This procedure has been a tremendous advantage at times with a valuable effect on the therapeutic relationship, and as a consequence on the successful development of the treatment for the patient!
There are nuances in a patients composure, hues of a change in comportment and hints of an emotional sensation that can impact, promote or alter a case-taking! Therefore, the non-verbal expressions may be just as important in a case-taking, if not more important; as they are largely unconscious, that is, not deliberately induced and without intention .
The verbal discourse, is a precise communication that is willingly produced and is usually led by the intent of active thought produced in the brain . The non-verbal expression on the other hand, is less deliberate, it is impulsive and therefore conducted with less awareness . In health care, the cues communicated non-verbally in the “ attitudes, emotions and affect” of a patient, may be expression of fears or sentiments that not necessarily are in accord with the spoken word [2, (p.76)]. To the skilled practitioner the unspoken message, told by a patients body-language, may confirm or conflict with the vocal utterances [2, 3].
For the practice of homeopathy it is evident what Kulkani  says of body-language. He sees non-verbal communication as “a bridge between mind and body” (n.p.), and sickness is conveyed not merely in the vocal recitations of the patient, but across his entire totality. Therefore, so Kulkani  continues, “the essence of the sick individual can be understood through the cluster of gestures and postures, being represented consistently” (n.p.). The interpretation of this message that is conveyed in the non-verbal expressions must thus be considered in relation to the presenting situation, its context and the habitual environment of the patient .
Research has shown that “the majority of communication occurs through non-verbal messages” [3, (p. 75]. Power  mentions, that this may be up to 70%, but stresses that this figure is one difficult to verify, and further emphasizes the opinion that vocal and non-verbal communication coexist. In human communication it is the face that is the prime bearer of non-verbal messages . Yet, a patients facial expression or bodily posture can speak a different language from that expressed in vocal speech . Consequently, attention needs to be paid to both, and awareness should be sensitized for the fact that non-verbal messages generally “override verbal messages” [2, (p.76)].
Non-verbal communication: Communication without linguistic content.
– Eye contact
– Facial expressions
– Interpersonal distance
As important as non-verbal communication may be to the practitioner, when he may perceive it in his patient, as important it is in the creation and maintenance of the therapeutic relationship. It is not solely the practitioner who takes note of his counterpart in the therapeutic union, it is likewise the patient who observes and perceives the practitioner in the consultation , .
It is a practitioners comportment, posture, and gesture, his non-verbal language that may or may not convey to the patient, what is required to make the patient-practitioner union a trusting and comfortable environment. The attainment of a true ‘union’, may be decisive of the satisfaction a patient experiences with the treatment, the adherence to a regime and the outcome of the intervention .
Patients are sensitive to non-verbal expressions of their practitioner or therapist. They may interpret certain behaviour as “interpersonal distance”(, p.85) , or a respective closeness. This may destroy or facilitate a therapeutic relationship  and may impact how much a patient is willing to share with the practitioner , .
For example, loosing eye contact may negatively impact the comfort-zone of the patient that has developed in the therapeutic encounter. The patient may see attention taken off their case and may as a consequence reduce his or her engagement in the therapeutic space . For the practitioner, diverting his visual attention by looking away, may lead to him missing important non-verbal cues from the patient . The same may happen with inconsiderate gestures, or a deterring posture , .
Silverman  therefore suggests that practitioners should avoid taking notes, or even looking at them while the patient is speaking, in order to convey to the patient that they are attentively listening.
Travaline, Ruchinskas and D’Alonzo  suggest for general practitioners, that they should develop key skills to employ for an effective communication in the therapeutic relation. They stress that the patient-physician encounter is a “two-way exchange of non-verbal information” (p.16), and emphasize the attentiveness of the physician to the patients, and their own non-verbal language . They further point out that such elements may be learned in order to be employed purposefully and consciously to help create a comfortable space in the therapeutic relationship .
The therapeutic relationship is a place that requires trust and comfort to develop in order for the patient to feel able and confident about conveying his or her story . This is not something that is readily attained, but needs to be facilitated. Attentive listening, and paying close attention to ones own body language, besides investigating that of the patient, may promote a trusted union between practitioner and patient. Depending on the dynamic in the consultation, taking notes may disturb the therapeutic union, and sensitive employment of body language, as a tool, may aid in creating a trusted space. I have noticed, that “a picture says more than a thousand words”, and value body language a great deal for it. I pay attention to mine, and take note of my patients. I take notes while seeing my patients, but, depending on the situation complete my case-taking after the consultation, or in instances, where the therapeutic union is left undisturbed.
 Kulkani, A. (2008) The unspoken language Hpathy last accessed November 2010, available at URL: http://www.hpathy.com
 Silverman, J. (2010) Doctors’ non-verbal behaviour in consultations: look at the patient before you look at the computer British journal of general practice February 2010 [online] last accessed November 2012, available at DOI: 10.3399/bjgp10X482293
 Brody, M. (2003) Chapter 4: The Nurse-Client Relationship Nursing Fundamentals – Rick Daniels pp.68-89 New York: Delmar Cengage Learning
 Power, M. (1998) Chapter 11: Non-verbal communication Working through communication Paper 12 last accessed November 2011 at URL: http://epublications.bond.edu.au/working_through_communication/12
 Marcinowicz, L., Konstantynowicz, J., & Godlewski, C. (2010) Patients’ perception of GP non-verbal communication: a qualitative study British journal of general practice February 2010 [online] last accessed November 2012, available at DOI: 10.3399/bjgp10X483111
 Travaline, J., Ruchinshas, R., & D’Alonzo, G. (2005) Patient-physician communication: Why and how J Am Osteopath Assoc. January 1, 2005 vol. 105 no.1, pp.13-18