Keywords

1 Exploring Nonverbal Empathy

Interpersonal communication is an exchange of information between two or more people [1, 2]. Successful interpersonal communication occurs when all parties within a conversation understand what is being sent and received through verbal and nonverbal communication [1, 3]. Suppressing emotional expressions can lead to impaired interpersonal communication [4, 5]. Although much emphasis is placed on health-care providers’ verbal empathy, nonverbal modalities of communication significantly influence the patient’s perception of the provider’s empathy [6,7,8]. Nonverbal empathy accounts for 45% of the variability in how empathy is perceived by the person who receives the communication, while verbal messages account for 22% [6]. This chapter will examine the nonverbal expression of empathy. We describe how these nonverbal modalities influence empathic communication with patients and how they can be enhanced through teaching.

2 What Is Nonverbal Communication?

“Nonverbal communication takes place every time one person interacts with another, it may be intentional or unintentional, and it is part of the rapid stream of communication that passes between two interacting individuals” [9, p. 386]. It is necessary to understand the channels of communication to understand nonverbal empathy, which goes beyond the written or spoken word. Nonverbal communication encompasses aspects of body language including facial expression, eye contact, posture, gestures, and interpersonal distance [9]. Nonverbal communication involves cues that are encoded and communicated continuously by the sender, either consciously or unconsciously, and subsequently decoded by the receiver [9]. Communication, including its nonverbal component, allows us to construct or reconstruct individual and common histories [10]. Nonverbal cues define, condition, constrain, and help regulate communication, cueing hierarchy and priority among communicators [11]. A summary of the characteristics of nonverbal communication, their definitions, and where known, anatomical and physiological correlates, is presented in Table 3.1.

Table 3.1 Characteristics of nonverbal communication
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2.1 Processes Involved in Meaningful Communication

Perception is an active process of giving meaning to sensory input by selecting, organizing, and interpreting people, objects, events, situations, and other phenomena [1]. Processes of perception are continuous, cohesive, and serve as the passage for effective interpersonal communication [24]. There are three pathways to perception: selection, organization, and interpretation [1], as illustrated in Fig. 3.1.

Fig. 3.1
A diagram illustrates the pathways of perception, which include organization, interpretation, and selection. Factors influencing perception include physiology, gender, culture, and age.

Pathways to Perception (Figure created based on text in Wood [1], Interpersonal Communication: Everyday Encounters)

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Selection involves noticing how an individual communicates their message, how gestures are presented, words are chosen, and how others perceive such information. Selection represents narrowing one’s attention to certain stimuli (e.g., the position of a patient, or sounds/noises a patient makes when in a particular state), and which stimuli become relevant to act upon (e.g., determining a patient’s diagnosis). What we select to notice influences the way we approach individual situations [1, 24, 25].

Organization is defined as perceiving information and attributing meaning through interaction between the person’s experiences and ideas [26]. There are four types of organizational strategies that help us understand interpersonal properties: prototypes, personal constructs, stereotypes, and scripts [1]. Prototypes are clear and descriptive example that represent an ideal model of a category, e.g., coworkers, patients, physicians, etc. [1]. Prototypes assist in deciding which category a phenomenon fits [1]. Personal constructs is used to evaluate an individual’s particular qualities, e.g., how intelligent, kind, responsible, reliable, and trustworthy is this person? [1]. Once an individual has been categorized, they are stereotyped to perform a particular way. Stereotypes are based on our perceptions of similarities between people or on social perspectives that we have internalized, which may be accurate or inaccurate [1]. Scripts are the final cognitive schema used to organize perception. Scripts consist of sequences of activities used that we are expected to perform while completing a task, in a particular environment, and in encountering any particular situation [1].

Interpretation is the process that assigns meaning to stimuli that we have noticed and organized, such that our perceptions make sense to us [1, 24].

Factors That Influence Perception

Everyone perceives information differently, as influenced by factors like physiology, gender, age, culture, and expectations [1, 9, 25, 27]. Sensory abilities and physiology differ. A patient’s physiology, specifically his/her emotional state, may influence the way health-care professionals perceive the patient’s condition (e.g., medical diagnosis or use of medications affects perception) [2, 9]. Similarly, when tired or under stress, a health-care professional is more likely to perceive things negatively [2]. Men and women, possibly influenced by gender and culture, interpret nonverbal communication cues differently. Women smile more, approach closer than men and respond more positively to touch when considered friendly and appropriate [9]. Culture and expectations come into play as people are more likely to appropriately perceive others’ nonverbal behavior if they are culturally, linguistically, and racially similar [9, 28]. Health-care providers must be aware that there is the potential for cultural misinterpretation of their communication. Expectations may influence the way nonverbal communication is perceived, for example, how empathic a physician may be when communicating diagnostic results to a patient. If specific characteristics reveal a diagnosis, the patient is more likely to reproduce or become aware of additional symptoms associated with an already established diagnosis [1]. As an individual ages, facial expressions, body language, and paralinguistics are altered and may affect how people express themselves. Overall, older individuals have lower empathic accuracy than younger individuals. However, the decline in empathic accuracy is less evident in older physicians compared to nonmedical controls [27]. In sum, nonverbal communication has a complex structure and intertwined anatomical, physiological, social, and personal underpinnings that color its perception and manifestations in patients and health-care professionals alike.

3 What Is Nonverbal Empathy?

Sapir [29] explained that humans respond to gestures using a “code” that is not written, but it is universally understood. Nonverbal empathy, as it is the case for the global concept of empathy, is challenging to fit into a unitary definition. In the following sections, we present the known components of nonverbal empathy and highlight the areas of further research and progress of knowledge that relates to empathy in health care.

3.1 The Concept of Empathy

Empathy is a basic form of human expression, which facilitates interpersonal communication [5, 30]. Empathy can be framed as the ability to accurately perceive how another person is feeling [31] and show emotion and concern for others [32]. Empathy has an affective (or emotional) component, that allows for the perception and sharing of another person’s feelings, a cognitive component that allows for the understanding another’s feelings and a behavioral component that includes verbal and nonverbal response (e.g., active listening, validation, and self-disclosure) [33,34,35]. Cognitive empathy is described as a learned intellectual process that requires understanding the feelings of another person [34, 36] and placing oneself in the other person’s frame of reference [37]. Affective empathy is described as “the unique capacity of human beings to feel and understand what another person is experiencing” [38] and as “a process for understanding an individual’s subjective experience by vicariously sharing the experience while maintaining an observant stance” [39]. Behavioral empathy was described as “close communication with another, as well as a deeper, fuller appreciation of the other as an individual” [38]. In a clinical setting, empathy requires understanding the patient’s perspective, communicating that understanding verbally and nonverbally, and acting therapeutically on that understanding [40]. This section will focus on the behavioral component of empathy, and in particular, on nonverbal communication of empathy which predicts perceived empathy by patients [41].

Preston and de Waal [42] formulated the perception-action model (PAM) of empathy as a unifying theory with behavioral, physiological, and neuroanatomical components. In this model, perception of the state of an “object” (in our case the patient) activates the “subject’s” (in our case, the health-care professional’s) somatic autonomic responses and prefrontal functioning [42], thus offering a useful conceptual framework when discussing nonverbal empathy. PAM focuses on the process where the perception of the object’s state automatically activates the subjects’ existing representation of the state, situation, or object, in turn generating autonomic and somatic responses (unless these responses are inhibited). The stronger the connection between the subject and object, the more the subject will attend to the event, the more their similar representations will be activated, and the more likely the subject’s response will occur. This response can involve emotional contagion, cognitive empathy, and helping behavior. PAM draws evidence from existing empathy theories, neuroanatomy, animal and human emotion, physiology and neurology, as well as disorders of empathy (e.g., autism, prefrontal lobe impairment due to trauma or neurocognitive disorders). According to PAM, individual experience of the emotional component of empathy is associated with similar signs of emotional arousal in the observer, as demonstrated by indices like autonomic nervous system activity, facial expression, subjective response, and central nervous system activity [42,43,44]. Empathy increases with subject’s familiarity with the object, with similarity between subject and object (e.g., in age, gender), with past experience, with salience (the strength of the signal) and with learning (as a result of teaching) [42]. Learning and reinforcing empathy throughout one’s professional life is highly relevant to health-care professionals who are thought to experience a decline in empathy as they progress in training and clinical practice [45, 46].

3.2 Evaluating Nonverbal Empathy

Facial Affective Communication

Emotional expression is a multimodal phenomenon [47] of utmost importance in expressing empathy. In particular, when working with patients, one means of expressing empathy is affective matching, and more broadly, affective communication via emotional expression. Expression of emotion involves facial muscle movements (i.e., facial expressions), vocalizations, autonomic responses (e.g., pupillary activity, blushing), movement of the extremities (e.g., clapping, opening arms), shifts in posture and head movement, gestures, and full body movements [47], as illustrated in Table 3.1. However, facial affective behavior (i.e., facial muscle movements, facial affective mirroring of the patient, and duration of facial expressions) and its relationship to empathetic responding have received the greatest amount of empirical attention [47]. For example, prior work has demonstrated that “high empathy” individuals display more facial affective behavior when exposed to emotionally evocative video clips than “low empathy” individuals [48,49,50]. Additionally, prior work has demonstrated that individuals with greater empathy are more accurate when labeling the facial expressions of others [49].

Several theories describe the mechanisms by which facial expressions coordinate social interaction and empathetic responding [51, 52]. First, in social interactions, emotional expressions via affective facial communication provide relevant information about the emotional states of both interaction partners, which allows them to predict subsequent behavior and engage in empathetic responding [53, 54]. Further, affective facial expressions convey information about the environment, which allows social partners to empathetically coordinate their actions and responses to both opportunity and threat. Finally, affective facial expressions serve as incentives to interaction partners by providing rewards or punishments for certain behaviors. For example, warm smiles in parents of young children incentivize repeating certain positive behaviors, and laughter has been shown to increase cooperation among individuals [55, 56]. Similarly, it is likely that a providers’ warm smile would incentivize repeating certain desired behaviors, such as medication compliance or engaging in healthy dietary or activity choices. In sum, facial affective behavior can increase perceptions of empathy by patients via affective matching and affective communication.

Autonomic Nervous System

The human nervous system is divided into the central nervous system (i.e., brain and spinal cord) and peripheral nervous system (i.e., all other nerves throughout the body). The peripheral nervous system is further divided into the somatic nervous system (i.e., the portion that controls voluntary motor movements) and the autonomic nervous system (ANS). The ANS is the division of the peripheral nervous system that is responsible for the control of mostly unconscious functions, including heart rate, respiration rate, pupillary response, digestion, urination, sexual arousal, and more. The ANS is controlled by the hypothalamus, which allows for connection to the limbic system. The ANS is subdivided into the sympathetic and parasympathetic nervous system. The sympathetic nervous system (SNS) is well-known to underlie the “fight or flight” response, as well as many “approach and avoidance” behaviors. In contrast, the parasympathetic system is well-known to underlie restorative processes and the maintenance of homeostatic functioning. Emotion reactivity and regulation, and relatedly empathy, have all been associated with changes in ANS functioning [57]. Psychophysiological measurements via electrocardiogram, impedance cardiography, and electrodermography allow for peripheral indexing of autonomic nervous system functioning. Below we examine indices derived from each of these psychophysiological measures, as well as some of the literature linking these indices to empathy.

Respiratory Sinus Arrhythmia (RSA)

Electrocardiogram data can be reliably and validly used to derive RSA, a known index of parasympathetic activity. Biologically, RSA is related to the parasympathetic control of the heart through efferent vagus nerve activity, as empirically demonstrated by pharmacological blockade studies [58, 59]. A preponderance of prior empirical work demonstrates that, in specific contexts, RSA withdrawal is positively associated with emotion regulation and empathetic responding in emotional situations [58, 60,61,62,63]. Further, RSA withdrawal has also been empirically associated with affiliation and related social behaviors, which are believed to be related to empathy [62]. Empathetic responding to both positive and negative emotional cues from others has been linked to RSA withdrawal (i.e., decreased heart rate variability) [64,65,66,67,68,69].

Cardiac Pre-ejection Period (PEP)

Impedance cardiography can be utilized to derive cardiac PEP, an index of SNS activity [70]. PEP is a commonly utilized index of beta-adrenergic influence over the heart and is characterized by the time between depolarization of the left ventricle and the onset of ejection of blood into the aorta [58, 60]. PEP has been associated with a variety of sympathetically mediated functions, including emotional reactivity, mental effort, reward sensitivity, and in some contexts, approach behaviors, including anger [58, 60, 71]. Interval shortening of PEP, in response to emotionally evocative contexts, generally indexes greater sympathetic control of the heart (and greater cardiac output), which is associated with emotion-laden approach behaviors, including anger, as well as reduced empathetic responding [58].

Electrodermal Activity (EDA)

EDA [72] or the measurement of the activity of the eccrine sweat glands [73], has also been utilized to index SNS activity. Cholinergic fibers that directly affect the activity of the eccrine sweat glands have been associated with SNS activity [58, 72, 74, 75]. Specifically, EDA has been positively correlated with levels of emotional arousal [76], and negative, avoidance-based emotions, in particular (e.g., sadness, nervousness, and/or stress) [77]. With respect to empathetic responding, specifically, EDA has been shown to positively correlate with patient ratings of perceived therapists’ empathy in 20 patient–therapist dyads, such that higher levels of EDA are associated with greater ratings of therapist empathy. Further, during the periods of high concordance in electrodermal activity, the patient and therapists showed greater positive social-emotional behavior [78, 79], suggesting an essential role of affective matching in empathetic responding. A further example of the importance of concordance of electrodermal responding to empathy is in the context of pain. Specifically, the higher the concordance in electrodermal responding between the observation of pain in others and self-experienced pain, the more likely the individual will be to engage in the helping of others [79, 80].

3.3 Nonverbal Behaviors That Express Empathy in Clinical Settings

Amount of Time Spent with the Patient

As the time spent by the health-care providers documenting in electronic health record (EHR) increased, the time spent making eye contact and speaking with the patients decreased [81]. Nurses feel that the time spent using the EHR leaves them less time to care for patients, even when they bring the computer in the hospitalized patients’ room. Although the nurse is physically present in the patient’s proximity, the computer makes it difficult to look at the patient and not at the screen during the patient interactions. The EHR “checkbox” model of patient assessment allows little room for describing details about the patient’s medical condition. The patients feel that they are answering questions to a computer. Overall nurses feel that the EHR improves patient safety, but it lowers quality of care [82]. In the case of physicians, the amount of time spent with patients significantly predicts patient satisfaction, with patients who spend more than 10 min with their doctor being most satisfied [83].

Theaffective tone of the physician (warmth, tone, and responsiveness) is influenced by patient–physician racial dyad pairing, with South Asian physicians being more proficient at decoding the facial expressions and vocal tone of South Asian patients and similar findings in African American concordant dyads [8]. Race and culture influence empathy in cross-cultural care. Physician’s nonverbal expression of concern is the best predictor of patient satisfaction (p < 0.001) and of positive recommendation of the physician by patients (p = 0.001) [8].

Touch is regarded as a form of human connection beyond words which can represent caring even when verbal communication is limited or inadequate [84]. Nursing research distinguishes functional touch to perform necessary patient-care tasks from touch as a “nonverbal expression of care, comfort, and empathy” [85, p. 201]. A metaethnography of touch across health professions [84] and it identified its important characteristics. Touch communicates caring. Touch is important in Swedish nurses’ cross-cultural communication, and it is important in Filipino patients developing trust in their nurses. Supportive touch is an important tool (along with eye contact, smile, vocal warmth, and respectful silence) in the delivery of bad news to patients [8]. Touch in geriatric nursing is seen as mothering, and it is perceived as being caring. Touch can also represent power and status. Touch can be regarded as risky in the case of male nurses and family physicians due to the risk of sexualization or crossing professional boundaries, whereas it is seen as acceptable, natural, and maternal when delivered by a woman although age and cultural context intervene in this context as well [85]. While it is widely accepted in professions like physical therapy and osteopathy, touch is avoided in psychotherapy, where physical contact is often associated with a boundary violation [85]. The experience of touch is bidirectional, and it connects the provider and the patient in the process of health care. Touch can be perceived as empathic and caring, or it can be perceived negatively, depending on the provider’s and patient’s gender, age, space, and boundaries within which it is performed, as well as personal and professional experience [84].

Listening could be one of the most useful means of caring for people. Listening well is described by hospital chaplains as an intercorporeal phenomenon [86] which includes eye level, eye contact, emotions as embodied narrative plots, being still, and distancing self from religion. Placing self at the same eye level with the person by sitting down, invites dialog through a communicative body, enhances empathic ability, and minimizes power imbalance [86].

Eye contact is important in nonverbal behavior, particularly since the brain responds even to another person’s small nonverbal signals, such as gaze shifts and eye blinks, with stronger response in subjects who are more empathetic [16]. Although positive in many cultures, there are differences in how eye contact is received by the subject of empathy. Eye contact is important in Hispanic women’s interaction with physicians, along with simple signs of professionalism and warmth on the part of the health-care provider, while in other cultures (Tobago), it is considered disrespectful to look an elder in the eyes [8]. In a multinational qualitative study, keeping eye contact with patients, listening without interruptions, empathy, and avoiding disruptions due to computer and phone were among the tips given by patients to make the medical consultation more successful [87]. Eye contact is paramount in nurses’ interactions with nonverbal patients in the intensive care unit, contributing to positive communication when combined with asking open-ended questions, greeting by name or touch, and the use of gesture or pointing in assisting patients [88]. Further, eye contact is important in recognizing the unspoken emotions like anxiety or shame. Taking in people’s embodied performance of emotional life through listening and eye contact, for example, listening to someone crying, is an important part of chaplains’ work with hospitalized patients [89].

Gestures and Body Posture

Body movement and posture correlate with emotional states [79]. Counselors’ arm and leg positions significantly influence how people appreciate counselors’ warmth and empathy. The arms crossed position and the leg crossed over the other leg (such that the ankle of the crossed leg rests on the knee of the other leg) are considered as the coldest and the least empathic positions [85]. Speakers with higher empathy towards the listener produce more salient gestures. In turn, the person spoken has a higher chance to understand the information that is transmitted [90]. Further, speakers take into account the knowledge and shared experiences of the listener and adapt the quantity and form of their gestures accordingly [91].

A specialized type of body interaction takes place in habilitation (i.e., services like occupational therapy, speech-language pathology, and others that help people with disabilities learn daily living skills). Here, the therapist applies body empathy to understand the children’s experience of limitations in body function [88]. Being together with a child with significant motor limitations involves understanding and communicating about the limitations of the child and further, adapting the therapist’s actions to the unique individual they are supporting at the time. Among the body experiences described by therapists, affection, and closeness are significant and closely related. The therapists report an enhanced experience of their own body on the background of the relationship with the child [88]. Finally, being still when listening to a patient is important because it invites unspoken questions about meaning and fears, and it invites the other person to share in the listener’s calmness and share their story [86].

3.4 The Impact of Nonverbal Empathy on the Patient and the Health-Care Provider

Patients’ Perception of Nonverbal Empathy

Since nonverbal empathy accounts for 45% of the variability in empathy perception by the object of communication [6], it plays a role in patients’ perception of health-care providers’ empathy. A relaxed body language of the doctor with respect to hand movements, with low reading and writing activity, were associated with patient empowerment in a study of primary care. Other features of socioemotional interchange (agreements, approvals, laughter, and legitimization) were associated with the extent to which a patient feels empowered after a medical consultation, in terms of being able to cope with, understand, and manage their illness, defined as patient “enablement.” These features, together with task-related behavior, explain up to 33% of the variance of enablement [92]. Physicians (oncologists) who lowered the pitch of their voice when giving bad news, in addition to delivering empathic verbal content were perceived as more caring and sympathetic by listeners [93]. Clients of counselors with better ability to decode nonverbal communication have higher improvement of symptoms of depression and anxiety [94]. Infrequent speaking, closeness to the patient, head nods, concerned understanding, listening, and mutualism, as well as increased experience and age are important characteristics of empathic nurses [95]. In a study of surgeon’s interactions with their patients, blinded raters coded the following characteristics of surgeons based on audiotapes: warm, anxious/concerned, interested, hostile, sympathetic, professional, competent, dominant, satisfied, and genuine. The raters accessed the audiotapes after they were filtered for conversation content, leaving only intonation, speed, pitch, and rhythm of the interaction to be coded. Based on these variables, surgeons who were judged to be more dominant (OR 2.74, P = 0.02, 95% CI 1.16 to 6.43) and less concerned/anxious based on their tone of voice (OR 0.46, P = 0.05, 95% CI 0.21 to 1.01) were more likely to have been subject to malpractice claims than surgeons who were judged to be less dominant and more concerned/anxious [96] (with the limitation that there were no data about the history of unfavorable surgical outcomes for the participant surgeons) [97]. Physicians who display empathy through nonverbal behavior are perceived as more empathetic, warm and competent than physicians who display non-empathetic nonverbal behavior [98]. In a study where medical residents were impersonated by actors, patient-centered gaze and body orientation had a positive effect on perceived empathy as rated by members of the general population. In this study, the effect of the gaze was stronger than the effect of body orientation, and it was particularly pronounced in the case of male actors [99]. In a study of final year medical students who each interviewed standardized patients, there was a significant correlation of empathy with nonverbal communication (i.e., gaze and body orientation), but not with verbal communication, as appreciated by two independent raters. This supports the idea that both verbal and nonverbal communication of empathy must be addressed equally with training and feedback in medical student education [100]. In summary, although the research into the effect of nonverbal empathy on patient satisfaction and health-care outcomes is scarce, evidence points to its prominent role in patient–clinician communication.

The Patients and Health-Care Providers Show Consistent Physiological Changes in Situations That Trigger Empathy

Empathy comes at a cost in terms of personal distress, concern, compassion, and sympathy experienced by the health-care providers in the process of health-care delivery. Rollings [67] measured heart rate and respiratory sinus arrhythmia in people who viewed video clips that represented happy, sad, and physical pain affect conditions. High Personal Distress and Empathic Concern subscale scores on the Interpersonal Reactivity Index (IRI) [97] independently predicted a change in heart rate in each of the affective conditions. Further, in this study, individuals with high Personal Distress scores had an unhealthy cardiovascular response to the affective stimuli. The higher the autonomic response displayed by subjects when receiving painful stimulation and when observing pain being inflicted on another person, the greater the likelihood that they would decide to prevent the infliction of pain on others by choosing to endure the pain themselves [80]. This finding shows that the strength of one’s autonomic response to pain motivates the prosocial behavior of avoiding pain in others. Decety [101] demonstrated that physicians conditionally downregulate the sensory processing necessary to perceive pain in others when compared to matched controls. This downregulation dampens the personal distress component of empathy and frees up cognitive resources to assist others who experience pain, without becoming emotionally overinvolved in a way that can hinder patient care [101]. Research demonstrates that emotional responses are attenuated by concurrent cognitive processes [102]. Collectively, these results demonstrate that clinicians show a notable physiological response to patients’ emotions, and that, depending on complex factors, this response can lead to clinicians’ personal distress or can be adapted to facilitate clinical performance.

4 Nonverbal Empathy in Health-Care Education: How and When to Train?

Empathy training in health care utilizes written patient narratives, experiential learning through patient shadowing, communication skill workshops with role play, wellness programs, as well as visual art, music, and literature [103,104,105,106,107]. Some of these empathy training methods include role play and/or videotaping of an encounter with a colleague, actor or patient, followed by encounter feedback from peers or supervisors [108, 109]. However, if these methods of deliberate practice and feedback if these methods do not address nonverbal elements of communication and experience, they will be incomplete by not addressing the contribution of providers’ nonverbal empathy to the patients’ experience of health care. To be complete, all modalities to teach empathy must equally address verbal and nonverbal modalities to communicate empathy. In addition to the trainee’s verbal communication and global perception of empathy, detailed reference must be made to aspects of nonverbal empathy like affective tone, gestures and body posture, eye contact, and facial affective behavior [110]. To date, few educational interventions focus on nonverbal communication.

The most common type of intervention addressing nonverbal communication skills is the feedback given to medical, nursing and other health-care professions’ trainees on standardized patient (SP) checklists, following SP encounters. In addition to content items related to the patient’s clinical issue, such lists contain feedback on trainee’s gestures, body posture, proxemics, smile, and overall appearance [111]. Generally, this feedback is qualitative and subjectively related to the preferences and life experiences of the SP filling out the checklist, which is in itself a strength since the behavior exhibited should be attuned to the particular patient.

Walter and Shenaar-Golan [110] created an experiential teaching intervention in the group setting for social workers, combining sensory language play activities with the learning of Gendlin’s focusing-oriented psychotherapy [112]. The authors supported, lifted, and carried others in order to understand the movement of different body parts, body size, strength, and develop a physical relationship with a partner and a group. Through touch, participants explored themes like bonding, attachments, relationships, personal body image, body awareness, and feelings. Participants felt that the experience increased their self-awareness, empathy, ability to prioritize between the needs of oneself and others, and professional self-confidence [110].

The awareness and recognition of patient affect often represent an elusive and intimidating challenge for students. Micro Expression Training Tool and the Subtle Expression Training Tool [113] were successfully used to train medical students’ nonverbal communication skills and resulted in 29.3% improvement in students’ ability to detect short facial expressions, and 36.2% improvement recognizing small movements of face that occur when a person is trying to deliberately or unconsciously control a strong emotion post-training [113]. In addition, physicians who receive this empathy training elicit higher patient ratings of empathy and higher ability to decode facial expressions of emotion in their patients, compared to a control group of physicians [114].

Grace [115] taught counseling students the basic concepts of nonverbal attentiveness by role-playing and sharing the salient observations with the peer and the group. The students responded to the client (impersonated by another trainee) based on a specific nonverbal behavior of the client, with one of the peers counseling the student on ways to convey the information to the client. Finally, the students had to practice using their awareness of patients’ nonverbal behavior to make empathic statements. In this study, brief training, attending and responding to nonverbal behavior resulted in more trainee responses to client nonverbal behavior, and these responses seemed to lead to higher client ratings of working alliance [115]. In sum, although empathy is taught extensively throughout health professions, only few didactic methods include focus on nonverbal aspects of empathy, leaving a large educational gap to be addressed.

5 Conclusions and Future Directions

Understanding how to engage emotionally during patient–clinician interactions is a guiding principle in building empathetic cooperation, patient confidence, and rapport [115]. Such attentiveness will lead to a subtle appreciation for the patient and their concerns, ultimately leading to an increase in health-care quality and patient’s sense of empowerment and appreciation for the clinician [116]. To perform these tasks, clinicians need to attend to the patients and their own eye contact, facial expression, gestures, proxemics, and touch. They must understand the importance of spending time with the patient unimpeded from the work on the computer and the importance of listening. Nonverbal empathy is neglected in many educational interventions despite the fact that it strongly underlies the patient’s perception of clinician’s empathy and competency. To address this gap, we propose a multimodal, multistep approach to teaching empathy. Firstly, attention must be paid to components of nonverbal empathy in the didactic and experiential teaching of empathic communication and must be reinforced throughout clinical training and later, throughout professional practice. Second, nonverbal empathy must be included in formative and summative evaluations along with feedback and suggestions for improvement given to the health-care trainee or clinician. Finally, research on empathy interventions should include objective physiological measurement of nonverbal empathy to further inform areas of interest for interventions. Research points to the connection between clinicians’ personal distress (i.e., feelings of discomfort and anxiety) and physiological arousal in the process of communicating with patients. Further research into this area may uncover modalities to address clinician’s well-being and emotional response to patients.