Nonverbal Communication

Because Ellen does not know ASL and cannot communicate directly with Jean, both the counselor and the client will rely heavily on interpreting cues provided by nonverbal communication. However, when counseling a patient who is a member of Deaf culture, nonverbal communication may be more difficult to understand because the Deaf culture has social rules which might seem rude for those unfamiliar with its norms. For example, common means of getting one’s attention in the Deaf community include touching the person, stomping the foot, banging a fist on a table, or waving the hand in front of the face (Kehl & Gartner, 2009). A genetic counselor who is not familiar with these social norms may misinterpret the meaning of a deaf client’s actions as anger or annoyance, even though these actions are considered appropriate and polite ways of getting another’s attention in the Deaf community.

Communication occurs through the use of language and various aspects of nonverbal communication. Nonverbal communication is defined as the aspect of the communication process where messages are exchanged through techniques that are not a part of the spoken language (Hickson, Stacks, & Moore, 2004). While verbal and nonverbal behaviors are different aspects of communication, these components are not mutually exclusive. According to Esposito (2007), nonverbal behaviors often emphasize verbal expressions and reflect intrapersonal, interpersonal, and environmental relationships. Nonverbal behaviors can be divided into four categories: kinesics, proxemics, paralinguistics, and appearances (Hu, 2007).

Before looking at each category in further detail, the cultural stage must first be set. The majority of human communication, both verbal and nonverbal, is culturally molded and trained (Esposito, 2007). Because all behaviors occur in a cultural context, it is important to recognize the cultural differences between those involved in the communication process. The objective aspects of culture, including clothing, food, and artifacts, can be easily seen and recognized by people of other cultures. Although cultural stereotypes may originate at this level, few cross-cultural misunderstandings occur at the objective cultural level. However, the subjective aspects of a culture, referring to values, ideals, attitudes, roles, etc., are less easily understood by people of other cultures and provide the basis for much misunderstanding between people of different cultures. Understanding and appreciating the subjective aspects of another culture can pose a great challenge to healthcare professionals. Despite this, achieving insight at this level is important in establishing appropriate rapport and therapeutic partnerships (Singh, McKay, & Singh, 1998). Specific cultures may have unique characteristics when we consider the four categories of nonverbal communication.

Kinesics

The study of kinesics, more commonly referred to as body language, includes examining body orientation (posture), eye contact, or any type of bodily movement. When we examine how people communicate through use of their kinesics, we can learn about a client’s personality or their emotional state of mind (Hickson, et al., 2004). Much information can be determined from attention to body movements and facial cues, as many gestures carry an intended meaning. Several body movements may convey similar meaning. For example, in Euro-American cultures, gestures of smiling, laughter, engaged body position (forward lean or open posture), and frequent eye contact are perceived as conveying intimacy and non-dominance. In contrast, kinesics such as a stoic facial expression, staring or lack of eye contact, and a disengaged body position tend to convey dominance, disinterest, or emotional distance (Burgoon, Birk, & Pfau, 2006; Mehrabian & Williams, 1969) in Euro-American cultures.

Eye contact is a particularly important aspect of interpersonal communication and perception (Webster & Sundaram, 2009). The amount of eye contact considered to be “appropriate” varies widely from culture to culture. For example, a person from the United States might interpret lack of eye contact as a sign of anxiety, lack of interest, or even deception. In Western cultures, people are taught to show attention and interest by looking directly at the person they are addressing. However, a Chinese American may interpret lack of eye contact as a sign of respect (McCarthy Veach, LeRoy, & Bartels, 2003). In some holistic cultures, people are taught that it is rude to look directly at others when talking to them, especially parents, elders, and other persons of high status (including health care providers) (Resta, 1992).

Proxemics

The study of proxemics refers to the perception and use of personal and interpersonal space between individuals (Sue & Sue, 2003). Clear norms exist concerning the use of physical distance in personal interactions. Four interpersonal distances have been established that are characteristic of Western culture: intimate, contact up to 18 in; personal, from 1.5 ft to 4 ft; social, from 4 ft to 12 ft; and public (lecture and speeches), greater than 12 feet (Hall, 1969).

Different cultures maintain different standards of personal space. Comfortable personal distances depend on social situations, gender, and individual preferences. These preferences must be interpreted against a given cultural framework (Esposito, 2007). Individuals from most Western cultures tend to prefer greater interpersonal distance than members of many other cultural groups. Latino/Latinas, Hispanics, and Middle Easterners may be more comfortable with less distance and may prefer seating arrangements that reflect that preference. For example, a person may not feel comfortable in a health care setting where a desk is placed between them and the person they are speaking to, while Euro-Americans may prefer to keep a desk between themselves and others (Sue & Sue, 2003). It is always best to let the client(s) choose where they would feel most comfortable in the genetic counseling setting.

Paralinguistics

The term paralanguage, also referred to as vocalics, is used to refer to other vocal cues that individuals use to communicate, other than words. For example, loudness of voice, pauses, silences, hesitations, rate, and voice inflections are all included under the term paralinguistics (Hickson, et al., 2004). Paralanguage coincides with conversation conventions such as how we greet and address others or take turns in speaking. It can communicate a variety of different features about a person, such as age, gender, and emotional responses, as well as the race and gender of the speaker (Banks & Banks, 1993).

There may be complex yet unspoken rules regarding when to speak or yield to another person. For example, in the U.S. people generally tend to feel uncomfortable with a pause or silent stretch in the conversation, and may feel obligated to fill it with more talk (Sue & Sue, 2003). From a genetic counseling perspective, silence should not be considered to be a sure sign for the counselor to take up the conversation. Many crucial indications as to how the other person is feeling or what they are thinking can be missed with persistent talking. People of British and Arab descent may use silence for privacy, while individuals of Russian, French, or Spanish background tend to interpret silence as agreement among participants (Hall, 1969).

Another important aspect of paralinguistics is the amount of verbal expressiveness. The amount of verbal expressiveness in the U.S., relative to other cultures, is quite high. Most Euro-Americans are encouraged from a young age to enter into conversations, ask questions, and state their thoughts, feelings, and opinions. Individuals from other cultures may consider Euro-Americans to be arrogant, immodest, rude, and disrespectful based on differences in “acceptable” levels of verbal expressiveness (Sue & Sue, 2003). The volume at which people articulate their ideas, thoughts, and opinions can vary widely. In Asian countries, people tend to speak more softly and they may interpret the loud volume of an American visitor to aggressiveness, loss of self-control, or anger. When compared to Arabs, however, people in the U.S. may be considered to be soft-spoken (Sue & Sue, 2003).

Appearance

Physical appearance is another nonverbal element that plays an important role in the communication process. This area of nonverbal communication may be slightly uncomfortable to individuals who were taught “not to judge a book by its cover.” Because physical appearance may be the first nonverbal cue to be noticed, it can have a profound impact on relationships. Physical appearance communicates meaning and intent, which can lead to insight, or stereotypes (Hickson, et al., 2004). What is most important to remember is that there are two components to physical appearance: what you are trying to convey, and what is actually being received (Sue & Sue, 2003).

The type of attire considered appropriate for members of a culture varies. For example, for some women of the Islamic faith, it is viewed as inappropriate and sexually impure to reveal any skin. Therefore, the typical dress is a burka. However, in the U.S., dress is viewed as a form of self-expression and personal choice. The attire worn or the amount of skin shown often depends on the social situation.

Healthcare professionals need to consider the verbal and non-verbal cultural context of communication because they provide the basis for understanding and appreciating client behavior (Singh, et al., 1998). Nonverbal behavior is a valuable source of information for counselors, especially when concerning the client’s emotional state. However, it can easily become a source of misunderstanding when the counselor reacts inappropriately to nonverbal signals (Vogelaar & Silverman, 1984). Dynamics and intent of nonverbal communications can vary across generations. Communication methods change in emphasis and meaning as generations interact with other generations, more dominant cultures, and even with people of the same generation. Differences in communication methods are influenced by the degree to which people are immersed in traditional cultural practices (Singh, et al., 1998). Therefore, it is our responsibility when striving to interact with patients in a culturally sensitive manner (Vogelaar & Silverman, 1984) to adapt our style of communication to the client’s style. Never expect clients to adapt to your style (McCarthy Veach, et al., 2003).

Deaf Culture and Communication

Consider the array of communication styles that people use on a daily basis. Our communication behaviors may be so routine that we forget that they are culturally-based specifically in the dominant hearing community. For example, nodding by the client, which often indicates understanding, cannot be used as a proxy to indicate comprehension when the client is deaf (Israel, et al., 1992). How open are you to considering the range of communication patterns that you might encounter? Consider how you might react to variations in communication that might be typical for individuals in the culturally Deaf community. The following table compares general communication styles and behaviors among members of the hearing community and the culturally Deaf community. While every individual is unique, consider your attitudes toward differences in communication styles.

 

*Start American Sign Language. (2008). Deaf Culture, Retrieved from http://www.start-american-sign-language.com/deaf-culture.html on
June 24, 2010 **from Meador, H. E., & Zazove, P. (2005). Health care interactions with deaf culture. Journal of the American Board of
Family Practice, 18(3), 218-222.

High Context vs. Low Context Communication

Vivian Ota Wang (2009) and other authors distinguish between low and high context languages. Low context languages such as Danish, German and English convey information primarily through direct verbal and written communication, and background information must be made explicit. Other languages, such as Japanese, Chinese, Vietnamese, French, Spanish, and Greek are high context, where the surroundings and the context are far more important than the literal meaning of the words, and the full message must be interpreted by the listener through nonverbal cues and indirect messages.

Do you tend to let your words speak for themselves or do you use a range of verbal and nonverbal cues? Don’t assume that your preferences will match what your client needs to gain a clear understanding. As we explain later, ASL is a high-context language. Deaf people who use ASL are high context communicators who acquire knowledge from situations and by building relations between situations. This relationship building process depends on trust and takes time to build up.

Incidental Learning

Many d/Deaf individuals lack background health information, which can make it difficult for them to report medical events, understand medical terms, or self-advocate in the healthcare setting. People who are deaf have fewer opportunities for incidental learning, which is information that hearing people absorb by listening to conversations, the media, or other sources (Harmer, 1999). Growing up, children generally learn about family history and medical conditions by “overhearing” and talking with parents as topics come up. Deaf children may not experience incidental learning, especially if parents or providers find it difficult to communicate family and person health information. Since 90% of deaf individuals come from hearing families, there may have been fewer opportunities for individuals who are deaf to discuss their health care or personal family history. In addition, there may be fewer opportunities for incidental learning about health care through the TV or radio. Misunderstanding medical words is another reason that individuals who are deaf lack background health information, which can negatively influence all aspects of their health care. The average deaf high school graduate reads at a 4th grade level (Scheier, 2009), which means that deaf individuals are at greater risk for misunderstanding medical terms.

 

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