In Therapy: Understanding and Working With Body Language

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Body language is another source of patient information therapists must "listen" to. While seemingly a straightforward concept, body language can be tricky to work with. For example, it's easy to make assumptions about patient body language and jump to conclusions. Also, therapists might infer information from patients' body language, but not do anything with it. On the other hand, a therapist may not realize what their own body language communicates to a patient.

Thing aren't always as they seem

One of my supervisees, Bonnie (name changed here), was convinced her patient was withholding information because of folded arms:

"I've met with Jason (name changed here) a few times now, and he's always sitting with his arms crossed," said Bonnie. "The conversation flows, but I'm worried he might not be speaking honestly."

"Could he just be comfortable?" I asked.

"Well, when people are 'crossed off' that's a sign they're withholding something, isn't it?"

"I've been sitting with my arms folded while we've been talking this evening. Does it make you question our interaction?"

"No, but, I don't know, it's different from a patient. He could be being defensive about a topic that he feels vulnerable about and not really saying what's going on. His crossed arms are the giveaway. You and I are just talking," replied Bonnie.

"How do you sit when you're with patients?" I inquired.

"Relaxed in the chair, maybe cross my legs."

"So you're not leaning towards Jason in a stereotypical 'listening therapist' pose?"

"No."

"Does that mean you're not interested in the patient?"

"No."

"So what you're saying is, you may be jumping to a conclusion?"

"I suppose," replied Bonnie.

"It's easy to do at the start," I went on. "You're working with all kinds of information and signals and may read too much into stuff, wanting to make sure you don't miss anything.

"Now, if Jason were sitting with arms folded and being tight-lipped, often lost eye contact, or seemed to change his story, then we'd have some real reason to think he's closed off or disingenuous," I said. "For now, how about giving the benefit of the doubt? You be comfy and relaxed into your chair, and he can sit with his arms folded. Without other evidence, there's no point in scratching where it doesn't itch. If you confront him on the arms being crossed, he could feel you're scrutinizing him, and it could fray the rapport."

Working with patients' body language

It's great to recognize body language, but if it's not worked with, it's a wasted opportunity. Body language may not be verbal, but that doesn't mean it's off-limits to talk about. So often it seems that "working" with body language means noticing someone is getting tense or irritated, and taking that as a cue to back off about a topic. While that's probably a good idea, it's also not a signal to do a 180 from the topic. If something is creating that response in a patient, it's clearly grist for the therapy mill. But how?

A good starting point is acknowledging that the patient appears distressed. Then, just as a therapist would do when someone verbalizes distress, start processing.

Therapists may be uncomfortable with a patient appearing in distress, or assume the patient isn't OK talking about it further, so they want to get off the topic. However, the patient may wish to work through what's happening. If a therapist is reactive to their own anxiety about a patient's discomfort and comments, and says, "I can see it's making you upset; we don't have to talk about it" and then switches gears, it's likely at the peril of good treatment.

First, it suggests it's not acceptable to show emotions or vulnerability. Second, it could lead a patient to lose faith in the therapist. They may perceive, "They're supposed to help me work through this and learn how to deal with these feelings when they come out, and they can't deal with it."

Instead, consider the following example to help learn about safely mining body language for therapeutic material: Justin, age 15, looked away and began biting his lip as the therapist inquired what he meant by, "I can't get a lot of stuff out of my head." Then Justin turned red, and his eyes welled up. "We don't have to keep talking about it," said the therapist; "Tell me how the new medication change has been for you."

A more effective approach would be to work with Justin's presentation: "Justin, I can tell there's something tough on your mind from your demeanor. When you're ready, what can you tell me about what's going on in there?"

This allows the therapist to stick with it, but not pointedly talk about "it," which is clearly upsetting to Justin. The therapist shifts to focusing more on processing Justin's experience, which is likely going to be more revealing of what is setting him off.

If Justin still struggled to articulate his experience, the therapist could reroute by noting, "Today's a tough session for you; thanks for sticking with it. I know you're trying to get something across to me, and it's challenging right now, but I do want to understand. If those emotions you're showing had words, what would they be trying to explain to me?

Therapist, monitor thyself

Yawning, looking about the room, doodling, squirming, hand wringing, and playing with cuticles are just some of the things a therapist may do that send troubling messages to patients.

Though they may be innocent behaviors, such as yawns sneaking in at the end of a long day, these actions convey boredom and discomfort with a patient and their material. Even if a patient's material wells up angst in the therapist, it's imperative that the therapist remain composed. If a patient sees a therapist become fidgety, they may stop sharing, at the peril of their treatment, for fear of provoking anxiety in the therapist. If they are already anxious, they may feed off the therapist's anxiety, compounding the discomfort.

The aim is for the therapist to become sufficiently aware of their reactions and vulnerabilities and bring them to supervision if they are hindering therapeutic interactions. Paying attention to such things will not only help interactions with the patient, but can be opportunities for growth for the therapist to resolve their own underlying anxieties.