Abstract Mary Lavelle 6 December 2012
Case for support
A debilitating feature of schizophrenia is patients’ difficulty interacting with others. Successful interaction relies on the exchange and coordination of nonverbal behaviour between partners. Motion-capture analysis of patients’ interactions with unfamiliar others revealed that patients difficulty coordinating their movements with others and increased hand movements when speaking, this was influenced by patients’ symptoms and associated with others’ experiencing poorer rapport with them. The current study aims to: (1) investigate if patients’ reduced nonverbal coordination persists in their clinical interactions and explore its impact on therapeutic relationship, (2) investigate the communicative meaning of patients’ hand movements (3) investigate patients’ responsiveness to the nonverbal behaviour of others.
Background & Rationale
Schizophrenia is a severe psychiatric disorder, which affects 1% of people Worldwide. One of the most debilitating features of schizophrenia is patients’ difficulty interacting socially with others, which has a profound impact on patients’ lives. Compared to healthy people or other psychiatric patient groups, schizophrenia patients have smaller and less satisfactory social networks, are less likely to have a significant long-term relationship and are more likely to be unemployed.1-3 Indeed, patients social deficits have such a detrimental§ impact on their lives that patients prioritise functioning in their community as a treatment outcome over relief of other, frequently disturbing, symptoms such as sensory hallucinations.4 Patients’ social deficits are of clinical relevance as they present prior to the onset of positive symptoms,5 remain stable over time and are thought to be a good predictor of patient prognosis.6 Thus, patients’ social deficits are an important treatment target both for patients and clinicians. However, the nature of these deficits remains unknown. As a result, treatments that successfully improve patients’ social difficulties are limited.7 Social skills training remains the most commonly used, typically addressing a broad range of social skills. Perhaps its modest success and its poor generalisability are related to its non-specificity.8 9
An obstacle in developing new treatments is the difficulty accurately measuring patients’ social deficits. Currently patients’ deficits are assessed indirectly through ‘off-line’ pen and paper social cognitive tests, designed to investigate the mental operations underlying social interactions such as perceiving, and interpreting social information.10 Such tests require participants to watch vignettes of actors interacting and make judgements about the thoughts or feelings of the actors. Patients have consistently poor performance on these tests. However, such tasks are far removed from ‘online’ social interaction and it is unclear if patients’ test performance is representative of the social deficit present in their real world interactions.
Few studies have investigated what actually happens during patients’ interactions with others. Social interaction is a highly coordinated, reciprocal process, with the majority of communication being conveyed nonverbally through; facial expressions, head and body movement and hand gestures.11 Nonverbal behaviours have specific meanings depending on when and how they are produced during an interaction (e.g. a listener nodding their head towards a speaker, informs the speaker that they have understood what they are saying). Such nonverbal behaviours convey critical information about the dynamics of the interaction, such as; when a speaker will start and end their turn, the role of each partner in the conversation (e.g. as speaker or listener) and the level of engagement, shared understanding and affiliation between partners. The success of an interaction relies on partners’ coordinating their nonverbal behaviours allowing conversational processes, such as speaker exchange, to be regulated nonverbally without the need to vocalize when and how they should occur.12 13 Nonverbal coordination is also associated with more positive interpersonal relationships between partners such as better rapport and, in clinical settings, better therapeutic relationship. If patients have difficulty perceiving and interpreting others’ nonverbal behaviours, this should be evident in the nonverbal behaviour of patients and their partners during interaction.
Previous research: As part of my doctoral research I investigated nonverbal behaviour during patients’ interactions and it’s impact on interpersonal rapport. Out-patients with mild to moderate symptoms, who were not displaying any overt symptoms at the time of study, interacted with unfamiliar partners who were unaware of their diagnosis. Participants’ precise movements were recorded using 3-D motion capture techniques and compared with control interactions comparisons. Given that the body moves in 3D, this method offered a significant advance on previous studies relying on observer coding of nonverbal behaviour from 2D video recordings. Patients displayed increased hand movements when speaking, reduced head nodding when listening and had difficulty coordinating subtle nonverbal behaviours with others. Patients’ partners adopted a similar pattern of behaviour. Patients’ atypical hand and head movements and impaired coordination were intensified by their symptoms and were associated with others experiencing poorer rapport with them. This was seen even though patients’ symptoms were mild and their partners were unaware a patient was present.
Proposed Research: The doctoral research demonstrates that nonverbal behaviour is anomalous in patients’ interactions. Patients’ partners appear to be detecting and responding to anomalies in patients' nonverbal behaviour, which influences their experience of rapport with them. Specifically, after adjusting for symptoms, patients’ reduced nonverbal coordination and their increased hand movement when speaking appear to be the best predictors of others’ poorer experience of rapport with them. Thus, highlighting these behaviours as potential markers of patients’ social deficits that require further investigation. The proposed research plans to do this in three ways. Firstly, the majority of patients’ real world interactions will involve others who are aware of their diagnosis. It is unknown if patients’ reduced coordination persists in such interactions. When aware of the patients’ diagnosis, others may compensate, or accommodate, for their behaviour, which may impact nonverbal coordination and their experience of rapport with the patient. This is of particular importance in clinical interactions, where studies of healthy participant samples have shown a relationship between increased nonverbal coordination and better therapeutic relationship. In schizophrenia specifically, clinicians’ experience of therapeutic relationship with their patient has been shown to predict patients’ longer-term outcomes. Thus, reduced coordination in patients’ clinical interactions may be relevant for their therapeutic relationship and in turn, patients’ longer term prognosis. The proposed research will investigate nonverbal coordination in patients’ clinical interactions and explore its links with the clinicians’ experience of the therapeutic relationship with the patient. Secondly, the communicative meaning of patients’ speaking hand movements is not fully understood. Speaking hand movements are thought to be indicative of communicative gestures, which are highly coordinated with and complement the speakers’ speech. In ethological studies, communicative gestures are seen as a positive signal of engagement and involvement. However, in the doctoral research patients’ speaking hand movement were associated with others’ experiencing poorer rapport with them. Speakers’ gestures are highly coordinated with the verbal message, indeed experimental studies have shown that even subtle deviations in coordination between and individuals speech and nonverbal behaviour can impair communication. Perhaps schizophrenia patients display reduced coordination on an individual level, with reduced coordination between the timing of their speech and communicative gestures. This hypothesis will be tested in the proposed study. Thirdly, schizophrenia patients have difficulty perceiving and interpreting nonverbal cues when assessed using social cognitive tests. However, is unclear if this difficulty persists in patients’ actual interactions with others. This study will experimentally investigate patients’ responsiveness to the nonverbal behaviour of others’ during live social interaction.
Overall, the aim of the proposed study is to investigate social deficits in patients with a diagnosis of schizophrenia as they manifest in patients’ live interactions. Specifically investigating: (1) nonverbal interpersonal coordination in patients’ clinical interactions and its impact on therapeutic relationship, (2) patients’ individual level coordination between their speech and communicative gestures and (3) patients’ responsiveness to the nonverbal behaviour of others.
- Erickson DH, Beiser M, Iacono WG, Fleming JA, Lin TY. The role of social relationships in the course of first episode schizophrenia and affective psychosis. American Journal of Psychiatry 1989;146:1456-61.
- Mental Health and Social Exclusion: A Social Exclusion Unit Report. London: Office of the Deputy Prime Minister, 2004.
- Perkins R, Rinaldi M. Unemployment rates among patients with long-term mental health problems: A decade of rising unemployment. Psychiatric Bulletin 2002;26(8):295-98.
- San L, Ciudad A, Alvarez E, Bobes J, Gilaberte I. Symptomatic remission and social/vocational functioning in outpatients with schizophrenia: Prevalence and associations in a cross-sectional study. European Psychiatry 2007;22(8):490-98.
- Addington J, Penn D, Woods SW, Addington D, Perkins DO. Social functioning in individuals at clinical high risk for psychosis. Schizophrenia Research 2008;99(1-3):119-24.
- Monte RC, Goulding SM, Compton MT. Premorbid functioning of patients with first-episode nonaffective psychosis: A comparison of deterioration in academic and social performance, and clinical correlates of Premorbid Adjustment Scale scores. Schizophrenia Research 2008;104(1-3):206-13.
- Marder SR. Neurocognition as a Treatment Target in Schizophrenia. Focus 2008;6(2):180-83.
- Pilling S, Bebbington P, Kuipers E, Garety P, Geddes J, Martindale B, et al. Psychological treatments in schizophrenia: II. Meta-analyses of randomized controlled trials of social skills training and cognitive remediation. Psychological Medicine: A Journal of Research in Psychiatry and the Allied Sciences 2002;32(5):783-91.
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- Burgoon JK, Buller DB, Woodall WG. Nonverbal Communication: The Unspoken Dialogue. New York: Harper & Row Publishers Inc., 1989.
- Bavelas JB, Gerwing J. Conversational hand gestures and facial displays in face-to-face dialogue. In: Fiedler K, editor. Social Communication. New York: Psychology Press, 2007.
- Kendon A. Movement coordination in social interaction: Some examples described. Acta Psychologica 1970;32:101-25.
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