Physical Therapists’ Nonverbal Communication Predicts Geriatric Patients’ Health Outcomes Nalini Ambady and Jasook Koo Harvard UniversityRobert… [613930]

Physical Therapists’ Nonverbal Communication Predicts
Geriatric Patients’ Health Outcomes
Nalini Ambady and Jasook Koo
Harvard UniversityRobert Rosenthal
University of California, Riverside
Carol H. Winograd
Stanford University
Two studies explored the link between health care providers’ patterns of nonverbal communication and
therapeutic efficacy. In Study 1, physical therapists were videotaped during a session with a client. Briefsamples of therapists’ nonverbal behavior were rated by naive judges. Judges’ ratings were thencorrelatedwithclients’physical,cognitive,andpsychologicalfunctioningatadmission,atdischarge,andat 3 months following discharge. Therapists’ distancing behavior was strongly correlated with short- andlong-term decreases in their clients’ physical and cognitive functioning. Distancing was expressedthrough a pattern of not smiling and looking away from the client. In contrast, facial expressiveness, asrevealed through smiling, nodding, and frowning, was associated with short- and long-term improve-ments in functioning. In Study 2, elderly subjects perceived distancing behaviors of therapists morenegatively than positive behaviors.
It is now widely accepted within the medical profession that
treatment regimen alone cannot fully account for patient outcome.Indeed, the notion that interpersonal communication between thepatientandthephysicianplaysamajorroleinpatientoutcomehasrecently received a great deal of attention, including an abundanceof research focusing on ways to improve physicians’ interpersonalcommunication skills (DiMatteo & Friedman, 1982; Friedman &DiMatteo, 1982; Maguire, Fairburn, & Fletcher, 1986; Robbins &Woolf, 1989). This research has established an empirical linkbetween patients’ satisfaction with their physicians’ communica-tion style and their adherence to prescribed treatment, essential totheir recovery (Greenfield, Kaplan, & Ware, 1985; Greenfield,Kaplan,Ware,Yano,&Frank,1988;Kaplan,Greenfield,&Ware,1989). Effective physician–patient communication is associatedwith both increased psychological well-being (Devine & Cook,1985; Mumford, Schlesinger, & Glass, 1982) and better biomed-ical outcomes (Greenfield, Kaplan, & Ware, 1985; Greenfield etal., 1988; Kaplan et al., 1989) for the patient. Poor physician–patientcommunication,ontheotherhand,iscostlyandcanleadto
negativeconsequencessuchaspatientdissatisfaction,doctorshop-ping, poor adherence to medical directions, and malpractice liti-gation (Lepper, Martin, & DiMatteo, 1995; White, Levinson, &Roter, 1994; Woolley, Kane, Hughes, & Wright, 1978).
Effective physician–patient communication is especially impor-
tant when the patient is an older adult, due to physical, cognitive,andpsychologicalfactorsuniquetotheagingpatient.Forexample,elderly patients often present with more complicated medicalconditions that require multiple prescriptions, necessitating a morethorough explanation of the treatment regimen. In this case, effec-tive physician–patient communication is crucial in avoiding poorpatient recall of information (Levinson, 1994). The physical signsof aging, including hearing, visual, and cognitive impairments,may act as a barrier to effective physician–patient communicationand thus heighten the need for careful detailed explanations byphysicians.Psychologicalintergenerationaldifferencescomplicatethephysician–patientinteractionevenfurther.Forinstance,elderlyclients tend to be less assertive and more passive in their interac-tions with physicians (Beisecker & Beisecker, 1990), perhapsbecause of fear of being perceived as disrespectful. This presentsa problem when a medical explanation requires further clarifica-tion and the patient is reluctant to ask for it. Finally, elderly clientsareoftenunwillingtobroachpersonaltopicsthatmightberelevanttotheirheathcarestatus(Germanetal.,1987).Thus,investigationinto the factors involved in successful interactions between healthcare provider and elderly clients is clearly warranted.
Physician Communication Style
Unfortunately, much of the research on doctor–patient commu-
nicationindicatesthatphysicians’speechtoelderlyclientsisoftencharacterized by a dismissive patronizing communication style.Nalini Ambady and Jasook Koo, Department of Psychology, Harvard
University; Robert Rosenthal, Department of Psychology, University ofCalifornia, Riverside; Carol H. Winograd, School of Medicine, StanfordUniversity.
Thanks to Stephanie Levin, Gauri Desai, Heather Gray, Elizabeth John-
son, and Mark Hallahan for their assistance and support. This research wassupported by a grant from the John A. Hartford Foundation to Carol H.Winograd and a Presidential Early Career Award for Scientists and Engi-neers award to Nalini Ambady from the National Science Foundation,Grant BCS 9733706.
Correspondence concerning this article should be addressed to Nalini
Ambady, Department of Psychology, 33 Kirkland Street, Harvard Univer-sity, Cambridge, Massachusetts 02138. E-mail: na@wjh.harvard.eduPsychology and Aging Copyright 2002 by the American Psychological Association, Inc.
2002, Vol. 17, No. 3, 443–452 0882-7974/02/$5.00 DOI: 10.1037//0882-7974.17.3.443
443

Greene, Adelman, Charon, and Hoffman (1986), for instance,
foundthatphysiciansarelessrespectful,patient,andsupportiveoftheir older patients relative to their younger patients. Along thesame lines, Adelman, Greene, Charon, and Friedmann (1992)reportedthatphysiciansinitiatethemajorityofconversationtopicswhen speaking to elderly patients and that physicians are lessresponsive to the topics initiated by elderly patients. In examiningthe particular communicative behaviors of physicians, researchershave found that speech to the elderly is often perceived as overlysimplistic and patronizing (Adelman et al., 1992; Caporael, 1981;Caporael & Culbertson, 1986; Coupland, Coupland, & Giles,1984). When speaking to the elderly, heath care providers oftenmodify their speech patterns in accordance with stereotypes of theelderly as less competent and more dependent (Kite & Johnson,1988;Kogan,1979;Levin,&Levin,1980;Rubin&Brown,1975).An extreme form of this patronizing speech pattern is “secondary
baby talk”associated with infantilization of the elderly (Caporael,
Lukaszewski,&Culbertson,1983),characterizedbythehighpitchand exaggerated intonation usually reserved for speech to infants.Caporael (1981) found that the relative frequency of the use ofbaby talk to the elderly is as high as 20%. As part of the sameinvestigation, college students were unable to distinguish betweencontent-filtered speech samples of primary baby talk (to toddlers)and secondary baby talk (to the elderly). It is not surprising, then,that in a recent study, elderly participants named the doctor ’s
office as one of the situations in which they feel patronized mostoften (Hummert & Mazloff, 1993).
Provider Communication Style and
Elderly Patient Outcome
Despite the findings reviewed above indicating that poor com-
munication by health care providers is often associated with de-creased patient satisfaction with the health care encounter, littleattention has been paid to the effects of providers ’communication
on actual health outcomes for elderly patients. No studies, to ourknowledge, have delineated the particular caregiver communica-tivebehaviorsassociatedwithbetterorworseoutcomesforelderlyclients. The first goal of this article, then, is to examine moredirectly the relationship between health care providers ’communi-
cation and health outcomes of elderly clients. In an effort to meetthis goal, direct observations of provider communicative behaviorwere essential.
Thin-Slice Judgments of Nonverbal Behaviors
Considerable evidence suggests that judgments based on brief
excerpts or thin slices of behavior extracted from the ongoingbehavioral stream can be quite reliable and accurate. Thin slicesare samples of expressive behavior, which is chronic, reliable,stylistic, and often not subject to conscious control and monitoring(DePaulo, 1992; Ekman & Friesen, 1969, 1974; Rime & Schiara-tura, 1991). A meta-analysis of a number of studies that used thin-slice judgments revealed that the overall effect sizes associatedwiththin-slicejudgments( r/H11005.39)donotdiffersignificantlyfrom
effect sizes obtained from much longer observations (Ambady &Rosenthal, 1992).
A number of studies that used thin-slice judgments have shown
that such judgments are predictive of outcomes in health caresettings (Ambady, Bernieri, & Richeson, 2000; Ambady &
Rosenthal, 1992). For example, ratings of anxiety from thin slicesof physicians ’voices predict their success in referring clients
(Milmoe, Rosenthal, Blane, Chafetz, & Wolf, 1967). Other studieshave shown that thin-slice ratings of physicians ’behavior predict
patient satisfaction (Hall, Roter, & Rand, 1981) and providers ’
expectations regarding clients (Blanck, Rosenthal, & Vannicelli,1986).
Practitioner effectiveness can also be judged from thin slices
(Rosenblum et al., 1994; Tickle-Degnen, 1998). Thus, for exam-ple,Rosenblumetal.(1994)foundthatratingsofsix15-sslicesofmedical students in a pediatric clerkship videotaped interviewingadult patients, predicted the grades assigned by their clinical su-pervisors. In another study, thin-slice judgments of 15-s clips ofoccupational therapy students predicted their clinical performance(Tickle-Degnen, 1998; Tickle-Degnen & Puccinelli, 1999). More-over, these thin-slice judgments proved sensitive enough to distin-guish between specific therapist attributes uniquely suited to spe-cific clinical contexts. Specifically, students who were judged asless nonverbally responsive and more dominant were more effec-tive in a pediatric rehabilitation setting, whereas less friendlystudents were more effective in a physical rehabilitation context.On the basis of these findings, suggesting the usefulness of thin-slice judgments in predicting outcomes related to health care, weinvestigated whether thin-slice ratings of physical therapists ’be-
haviorsduringtheirinteractionswithelderlyclientswererelatedtophysical and cognitive outcomes of the clients.
Providers ’specific nonverbal behaviors have been found to
predictclients ’satisfactionandimpressionofthephysician(Roter,
Hall, & Katz, 1987). Such behaviors may contribute to the devel-opment of trust and rapport and to the establishment and mainte-nance of interpersonal relationships with clients (Ambady &Rosenthal, 1992; Hall, Harrigan, & Rosenthal, 1995). Meta-analytic work suggests that greater client satisfaction is associatedwith more nonverbal immediacy (as indexed by forward leans,direct eye contact, direct body orientation, and less interpersonaldistance) and attention from physicians (Hall & Dornan, 1988).Satisfaction has also been related to nonverbal behaviors thoughttoconveyencouragementandinterestsuchasheadnods,openarmposition, and forward leans (Harrigan & Rosenthal, 1983; Larsen& Smith, 1981; Weinberger, Greene, & Mamlin, 1981). Othernonverbal behaviors, including eye contact, gestures, and posture,have also been implicated in the therapeutic process. Specificbehaviors have been associated with perceptions and ratings ofproviders. Eye contact, for example, has been related to higherratingsofcounselorrespectandgenuineness(Kelly&True,1980),empathic qualities (Hasse & Tepper, 1972; Seay & Altekruse,1979; Tepper & Hasse, 1978; Timpton & Rymer, 1978), andoverall ratings of positivity (Harrigan, Oxman, & Rosenthal,1981); therapist nodding appears to be associated with clients ’
feelings of support and accomplishment (Hill & Stephany, 1990)and other positive consequences (D ’Augelli, 1974; Harrigan &
Rosenthal, 1983; LaCrosse, 1975); and body position has beenrelated to more favorable ratings of counselors (Fretz, Corn,Tuemmler, & Bellet, 1979; Harrigan & Rosenthal, 1983; Harriganet al., 1985; Hasse & Tepper, 1972; Hermansson, Webster, &McFarland, 1988; Tepper & Hasse, 1978) and to counselors ’
warmth and empathy ratings (Smith-Hanen, 1977). Given theimportance of these provider behaviors to clients ’perceptions and444 AMBADY, KOO, ROSENTHAL, AND WINOGRAD

satisfaction, it seems important to further investigate them in
relation to elderly patients. Again, although perceptions and satis-faction associated with such behaviors have been investigated,there has been a paucity of work relating such behaviors to actualhealth care outcomes. Thus, a second goal of the present work istoinvestigatetherelationshipbetweenphysicaltherapists ’specific
nonverbal behaviors such as smiling and frowning and the healthoutcomes of geriatric clients.
In sum, this study seeks to expand the research on provider –
client communication by examining (a) the relationship betweenhealth care providers ’(physical therapists) communicative behav-
iors in actual interactions with their clients and elderly clients ’
health care outcomes, and (b) the relationship between specificnonverbal behaviors of providers as rated from actual interactionswith their clients and elderly clients ’health care outcomes.
Study 1: Physical Therapists ’Behaviors
and Clients ’Outcomes
Method
Overview
In this study, physical therapists and their clients were videotaped
interacting during a therapy session. From these videotapes, thin slices(three 20-s clips) of therapists ’behavior were extracted and then evaluated
by naive judges. We examined correlations between judges ’ratings of the
physical therapists ’communicative and specific nonverbal behaviors with
several measures of clients ’physical, cognitive, and psychological func-
tioning taken at admission, discharge, and 3 months following discharge.
Phase 1: Creating Stimuli
Participants (targets). Interactions between 48 clients (28 female, 20
male)and11physicaltherapists(8female,3male)wereratedinthisstudy.Clients were all 75 years old or over, had ambulated independently with orwithout aids 2 weeks prior to admission to Stanford University Hospital,but had demonstrated recent decline in mobility and were unable to walk300 feet or more without assistance. Clients began physical therapywithin 48 hr of admission and stayed in hospital an average of 9.3 days.The first or last therapy session was videotaped, and the camera was in theroom and was focused on the therapist. Both the therapists and the clientsknew that the sessions were being recorded. Informed consent was ob-tained from the clients.
Outcome measures. Outcome measures evaluated patients ’physical,
cognitive, and psychological functioning. Physical and cognitive measureswere administered at admission, discharge, and 3 months following dis-charge. These included two self-report measures (to evaluate mobility andthe ability to carry out activities of daily living) and one interview measure(confusion assessment) described below. Psychological functioning mea-sures were taken only at discharge (due to logistical issues, these measurescould not be completed at admission); physical and cognitive measureswere repeated across 3 time periods. By computing the proportion ofchange from admission to discharge and from admission to 3 months afterdischarge using the admission score as a baseline, were able to derive anindex of improvement for each patient. Thus, the improvement score atdischargewouldbethedifferencebetweentheadmissionandthedischargescore divided by the admission score.
Physical Functioning
Mobility assessment. A self-report measure assessed physical func-
tioningbyusing10itemsthatevaluatedifficultiesinperformingarangeofphysical activities, such as walking across a room, getting out of a chair,
and sitting up in bed (Stewart & Kamberg, 1989). The reliability of theMobility Assessment Scale is satisfactory (
/H9251/H110050.92).
Activities of daily living. The Physical Self-Maintenance Scale (Law-
ton & Brody, 1982) was used to evaluate the ability to perform activitiesnecessary for daily life, such as toileting, feeding, dressing, grooming,ambulating, and bathing. The Physical Self-Maintenance Scale focuses onindependence rather than difficulty or ability and has an internal consis-tency reliability of .83 (Lawton et al., 1982).
Cognitive Functioning: Confusion Assessment
Confusion Assessment is a 3-item scale and was filled out by an
interviewer blind to the hypotheses, evaluating difficulty in focusing at-tention, disorganized or incoherent speech, and the level of consciousness.
Psychological Functioning
The following measures were used to assess patients ’psychological
functioning.
Geriatric Depression Scale. The Geriatric Depression Scale is a 15-
item scale that measures aspects of mood, such as satisfaction with life,motivation, helplessness, memory problems, and feelings of worth. Thisscale provides a valid, reliable, and internally consistent measure of de-pression in elderly patients (Brink et al., 1982; Koenig, Meador, Cohen, &Blazer, 1988; Yesavage, Brink, Rose, & Adey, 1983; Yesavage, Brink,Rose, & Lum, 1983).
Will to Function. We included a 7-item scale (Hays, Sherbourne &
Mazel, 1993), evaluating aspects of the will to function, such as helpseeking.
Self-Esteem Scale. The 10-item Rosenberg Self-Esteem Scale was
used to measure self-esteem (Rosenberg, 1965) and is considered appro-priate for elderly subjects (Crandall, 1973). This scale has high levels ofreliability and validity (Crandall, 1973; Silber & Tippett, 1965).
Three video clips were extracted from each of 57 dyadic interactions
between therapists and geriatric clients by a research assistant. The 57sessions were comprised of interactions among 11 physical therapistsinteracting with 44 patients (there were 57 dyads because some therapistsinteracted with more than 1 patient; the next section on the unit of analysisdiscussesthisissuefurther).Theresearchassistantwasinstructedtoextractthevideoclipsatrandom,withthestipulationthatthecamerashouldfocusonthetherapistwiththepatient ’sbacktowardthecamera.Three20-sclips
were extracted from each videotaped interaction. One clip was taken byrandomly stopping the tape within the first 10 min of the session, one clipwastakensimilarlyfromthemiddle10minofthesession,andthelastclipwas taken from the last 10 min of the session. The order of the clips wasrandomized in a Latin square-like design. The 171 clips (3 clips each of 57interactions) were recorded onto a master tape. To control for any biasingeffects due to the order of presentation, we made another master tape byreversing the order of the 171 clips.
Phase 2: Evaluating Nonverbal Behavior
Participants (judges). Clips were judged by 12 undergraduate students
who rated silent video clips in three ratings sessions. Judges were told thatthey would see short segments of physical therapy sessions and would beasked to rate therapists ’nonverbal behavior on a variety of dimensions.
Therapists ’behavior in each clip was rated on 17 interpersonal affective
dimensions on a 9-point scale, ranging from 1 ( not at all)t o9(very). The
dimensionsratedwereselectedfromthoseusedinpreviousresearch,usingthin slices to examine health care interactions (Blanck, Rosenthal, Vanni-celli, & Lee, 1986; Learman, Avorn, Everitt, & Rosenthal, 1990). Dimen-sionsratedincludedhowaccepting,aloof,attentive,competent,concerned,confident, dominant, empathic, enthusiastic, honest, infantilizing, likable,445 PHYSICAL THERAPISTS AND ELDERLY CLIENTS

nervous, optimistic, professional, supportive, and warm the therapist ap-
peared to be. These dimensions are referred to as molar behaviors in therest of this article. Six judges (3 male, 3 female) rated the original mastertape, and 6 judges rated the clips in the reverse order. If requested, a clipwas shown twice. Judges were not given any training and were told to relyon their intuition, as is customary in most research that uses thin-slicejudgments (Ambady et al., 2000). In an effort to ensure that judges ratedtherapist behavior independent of the patient, the back of the patient wasfacing the camera in all clips so that patients ’facial expressions could not
influence the judges ’ratings.
Coding specific nonverbal behaviors. Two undergraduates coded a
number of potentially relevant nonverbal behaviors from the thin-sliceclips. The frequencies of these behaviors were coded for each 20-s clip.Thesebehaviorsincludedthefollowing:smiles,laughs,frowns,headnods,head shakes, shrugs, gesturing, fidgeting, pointing, leaning toward theclient, and sitting versus standing. Some of these behaviors (i.e., fidgeting,pointing, and gesturing) occurred only rarely and were dropped fromfurther analysis. The final set of variables included smiles, frowns, nods,head shakes, shrugs, forward leans, looks away, and sitting.
Results and Discussion
Data Reduction: Principal-Components Analysis
To reduce the 17 molar variables and form composite variables,
we conducted a principal-components analysis. The mean of thejudges’ratings for each of the 17 variables was computed for each
dyad and was subjected to a principal-components analysis. Theprincipal-components analysis yielded four interpretable compo-nents or composite variables. The composite variable “positive
affect”was comprised of the average of the mean ratings of 11
variables (warm, likable, optimistic, empathic, enthusiastic, sup-portive,accepting,concerned,honest,attentive,andnotaloof),andthe composite variable “professional ”was comprised of the aver-
age of the mean ratings of 4 variables (confident, competent,dominant,andprofessional).Twovariables, “nervous”and“infan-
talizing,”loaded onto separate composites and were therefore
considered as separate variables. Intercorrelations of the variableswithin each new composite variable and between the new com-posite variables provided strong support for the four-compositesolution.
Reliability of Judges’ Ratings
ReliabilitiesforeachcompositevariablearereportedinTable1.
Effective reliabilities (Cronbach ’s alpha) ranged from .75 to .89,
with a mean of .84, indicating that there was a high degree ofconsensus among judges. These reliabilities are displayed in thefirstcolumnofTable1.ThesecondcolumnofTable1displaysthereliability of a single judge.Behaviors Associated With Molar Judgments
To understand the nature of the composites, we examined the
specific nonverbal behaviors that were related to each compositevariable. Table 2 displays the correlations between molecularnonverbal behaviors and the molar composite variables. The judg-ment of infantilization was associated with a clear pattern ofbehaviorsinvolvingalackofsmiling( r/H11005/H11002.28,p/H11021.05),looking
away (r/H11005/H11002.33,p/H11021.01), and sitting ( r/H11005.30,p/H11021.05). This
suggests that judges interpreted infantilizing in the video channelto mean distancing or a lack of interest in the client. Thus,infantilization seems to be interpreted somewhat differentlythrough the visual as compared with the vocal channel. In thevisual channel, infantilization was associated with not smiling,remaining seated, and not looking at the client, behaviors whichwould seem to communicate a distancing message to the client, incontrast to the association of infantilization with patronizing be-haviorinpreviousresearchexaminingthevocalchannel(Caporaelet al., 1983; O ’Connor & Rigby, 1996). A possible line of future
research is the careful delineation of the nonverbal vocal andvisual correlates of infantilization. Unfortunately, because of thepoor sound quality of the tapes, we were not successful in obtain-ing ratings of the vocal channels in the present research. For easeof interpretability, and to distinguish infantilization from its asso-ciation with patronizing behavior and babytalk in the vocal chan-nel, we shall refer to this variable as distancing in the rest of this
article.
Positiveaffectwasassociatedwithfewershrugs( r/H11005/H11002.29,p/H11021
.05), professionalism with fewer nods ( r/H11005/H11002.28,p/H11021.05), and
nervousness with fewer head shakes ( r/H11005/H11002.26,p/H11021.05).
Unit of Analysis
All further analyses used the dyad as the unit of analysis rather
than the therapist or the patient. Recall that although only 11therapists participated in the study, a total of 57 dyads comprisedthe data set. Because the therapist –client relationship (to which
certainly client characteristics may contribute) is unique to eachdyad, the dyad was chosen as the unit of analysis. Although someclients interacted with multiple therapists and appeared in multipledyads, clients ’backs were to the camera in all the clips. For each
of the 6 therapists who interacted with multiple patients ( M/H110053.5
patient per therapist), an intraclass correlation was computed toexamine the consistency of judgments of individual therapists foreach of the composite variables. The low correlations suggest thatthere were no large therapist effects and that there was consider-able variability in the behavior of each therapist across the clips inwhich that therapist was present differentially across clients (theaverage intraclass rs were,r/H11005.17 for positive affect, r/H11005.02 for
professionalism, r/H11005.03 for nervousness, r/H11005.10 for distancing).
In the following section, we present results examining compos-
ite variables as predictors of client physical, cognitive, and psy-chological outcomes. In measuring the relationship between ther-apists’behaviors and clients ’physical and cognitive outcomes, we
used a difference score as a measure of clients ’improvement from
admission to discharge and from admission to 3 months afterdischarge, and divided the change by the clients ’level of func-
tioning at admission to control for clients ’functioning at admis-
sion. Because of logistical issues, we were not able to obtainTable 1
Reliabilities of Composite Variables
Variable R(12 judges) r
Infantilizing –distancing .88 .38
Nervousness .84 .30Positive affect .89 .40Professionalism .75 .20
M .84 .32446 AMBADY, KOO, ROSENTHAL, AND WINOGRAD

measures of psychological status at admission. Thus, we report
only the relationship between physical therapists ’behaviors and
psychological outcomes at discharge.
Clients’State at Admission and Physical Therapists ’
Behavior
Did physical therapists ’behavior vary, depending on the phys-
ical and cognitive state of the client at admission? There were nosignificant relationships between physical therapists ’behavior and
clients’physical functioning at admission. However, therapists
showed more positive affect toward clients who were more con-fused at admission ( r/H11005.27,p/H11021.05).
Physical Therapists ’Molar Behaviors as Predictors of
Clients’Physical Improvement
Recall that to control for the state of the client at admission, all
the following analyses indexed improvement in the client ’s func-
tioning by subtracting the clients ’scores at admission from their
scores at discharge or at 3 months following discharge and divid-ing the difference by their scores at admission. Thus, we indexedthe improvement of each client relative to his or her baselinefunctioning at admission.
Improvement from admission to discharge. As Table 3 indi-
cates, therapists ’distancing behavior significantly predicted a de-
crease in clients ’activities of daily living from admission to
discharge ( r/H11005/H11002.34,p/H11021.01).
Improvement from admission to 3 months following discharge.
As displayed in Table 3, physical therapists ’distancing behavior
predicted a decrease in activities of daily living from admission to3 months following discharge ( r/H11005/H11002.35,p/H11021.05). In addition,
therapists ’professional and nervous behaviors were associated
with a decrease in mobility ( r/H11005/H11002.51 andr/H11005/H11002.52,p/H11021.0005,
respectively).
Physical Therapists ’Molar Behaviors as Predictors of
Clients’Cognitive Improvement
Improvement from admission to discharge. Correlations be-
tween physical therapists ’molar behaviors and client cognitive
outcomes are displayed in Table 4. Judgments of physical thera-pists’distancing behavior was associated with an increase inclients’cognitiveconfusion( r/H11005.29,p/H11021.05).Incontrast,positive
affect displayed by therapists was associated with a decrease inconfusion ( r/H11005/H11002.27,p/H11005.06).
Improvement from admission to 3 months following discharge.
Therewerenosignificantcorrelationsbetweenjudgmentsofphys-ical therapists ’molar behaviors and clients ’cognitive differences
from admission to 3 months following discharge.
Physical Therapists ’Molar Nonverbal Behavior as
Predictors of Clients ’Psychological Outcomes at
Discharge
As revealed by Table 5, therapists ’distancing behavior during
physical therapy sessions was negatively correlated with degree ofdepression ( r/H11005/H11002.27,p/H11021.05), as was therapists ’professional
behavior ( r/H11005/H11002.35,p/H11021.01). In contrast, therapists ’nervousness
was positively related to the will to function ( r/H11005.29,p/H11021.05).
In sum, distancing or uninvolved behavior on the part of phys-
ical therapists was associated with both short- and long-termdecreasesinactivitiesofdailylivingandwithshort-termincreasesin confusion. Physical therapists ’distancing behavior was also
associated with clients ’level of depression at discharge. PositiveTable 2
Physical Therapists ’Molecular Nonverbal Behaviors as
Predictors of Molar Variables
Behavior Positive affect Professional Nervous Distancing
Smile .01 .01 /H11002.01 /H11002.28*
Frown /H11002.19 /H11002.16 .04 /H11002.09
Nod /H11002.21 /H11002.28* /H11002.06 .06
Head shake /H11002.07 /H11002.14 /H11002.26* /H11002.14
Shrug /H11002.29* /H11002.13 .19 .16
Forward lean /H11002.03 /H11002.03 .09 .08
Look at /H11002.04 .10 .12 /H11002.33**
Sit .06 /H11002.12 /H11002.18 .30*
Note.The correlations reported are Pearson rs.n/H1100557.
*p/H11021.05. **p/H11021.01.Table 3
Change in Clients ’Physical Functioning in Relation to Physical
Therapists ’Molar Behavior
MeasureMolar composites
Positive affect Professional Nervous Distancing
Change from admission to discharge ( n/H1100551)
Mobility /H11002.13 /H11002.09 .09 .02
Activities of
daily living /H11002.21 /H11002.17 /H11002.09 /H11002.34**
Change from admission to 3 months from discharge ( n/H1100543)
Mobility .22 /H11002.51**** /H11002.52**** /H11002.08
Activities of
daily living /H11002.24 /H11002.16 /H11002.09 /H11002.35*
Note.The correlations reported are Pearson rs.
*p/H11021.05. **p/H11021.01. **** p/H11021.0005.
Table 4
Change in Clients ’Cognitive Functioning in Relation to
Physical Therapists ’Molar Behavior
MeasureMolar composites
Positive affect Professional Nervous Distancing
Change from admission to discharge ( n/H1100551)
Confusion /H11002.27 /H11002.02 .06 .29*
Change from admission to 3 months from discharge ( n/H1100543)
Confusion /H11002.01 /H11002.20 .25 .10
Note.The correlations reported are Pearson rs.
*p/H11021.05.447 PHYSICAL THERAPISTS AND ELDERLY CLIENTS

affect displays by physical therapists predicted short-term de-
creases in confusion, and therapists ’professionalism and nervous-
ness predicted long-term decreases in mobility.
Physical Therapists ’Molecular Nonverbal Behavior as
Predictors of Clients ’Improvement
Finally, we examined the relationship between physical thera-
pists’specific behaviors and outcome variables for the elderly
clients,reflectedinimprovementfromthetimeofadmissiontothetime of discharge and from the time of admissions to 3 monthsfollowing discharge. Table 6 displays these findings. One clearfinding in this area is the positive effect of frowning ( r/H11005.59,p/H11021
.0001) and nodding ( r/H11005.36,p/H11021.01) on activities of daily living
from admission to discharge. This effect held true for the long-term period (admission to 3 months after discharge) for bothfrowning ( r/H11005.60.p/H11021.0001) and for nodding ( r/H11005.33,p/H11021.05).
Other positive effects of frowning and nodding were illustrated
by the decrease in confusion between admission and discharge(r/H11005/H11002.35,p/H11021.01, for nods; r/H11005/H11002.26,p/H11021.08, for frowns).
Smilingpredictedanimprovementinmobilityfromadmissionto3months after discharge ( r/H11005.26,p/H11021.05). Finally, shrugging was
associatedwithadecreaseinmobilityfromadmissiontodischarge(r/H11005/H11002.44,p/H11021.0001), and head shaking was associated with a
decrease in confusion from admission to 3 months after discharge(r/H11005/H11002.31,p/H11021.05).Nomolecularbehaviorswereassociatedwith
clients’psychological functioning at discharge.
On the basis of these findings, the three molecular behaviors
associated with positive client outcome (frowning, nodding, andsmiling) were Zscored and combined to form a composite non-
verbalbehavior, “facialexpressiveness. ”Furtheranalysesrevealed
that facial expressiveness was associated with a substantial im-provementinactivitiesofdailylivingfromadmissiontodischarge(r/H11005.60) and with a decrease in confusion from admission to
discharge ( r/H11005/H11002.41).
Thus, the findings in regard to therapists ’distancing behavior
were quite striking. The clients of physical therapists who werejudged by naive raters to display a high degree of distancingbehavior showed decreases in both physical and cognitive func-tioning from admission to discharge, and the decrease in physicalfunctioning held stable for the 3 months following discharge. Notethat distancing was the only variable associated with both short-and long-term health outcomes.
The findings in regard to facial expressiveness molecular com-
posite are also noteworthy. Physical therapists ’facial expressive-
ness—smiling, nodding, and frowning —was associated with
short- and long-term improvements in physical and cognitivefunctioning of the clients ’, after controlling for the physical and
cognitive state of the client at admissions. One possible explana-tion for these findings is that facial expressiveness communicatesempathy and concern for the client thus promoting patient satis-faction and health improvements. This speculation falls in linewith previous research indicating that combination of caring andconcern results in the highest levels of patient satisfaction (Hall etal., 1981). The results of this study suggest that such behaviorsmay also be related to improvements in clients ’physical and
cognitive functioning. This also falls in line with Carl Rogers ’s
(1975) contention that empathy is a powerful therapeutic interven-tion. Empathy, however, is a vague concept and is difficult toteach. This study suggests that certain specific behaviors of pro-vidersareassociatedwiththecommunicationofempathy.Anotherpossibility is that providers were able to assess the prognosis oftheir clients and communicated these expectations through theirnonverbal behaviors. Thus, providers might have behaved moreTable 5
Clients’Psychological Functioning at Discharge in Relation to
Physical Therapists ’Molar Behavior
Variable DepressionWill to
function Self-esteem
Positive affect /H11002.06 /H11002.17 .02
Professional /H11002.35** /H11002.02 /H11002.25
Nervous /H11002.21 .29* /H11002.19
Distancing /H11002.27* .01 /H11002.16
Note.The correlations reported are Pearson rs.n/H1100548.
*p/H11021.05. **p/H11021.01.
Table 6
Physical Therapists ’Nonverbal Behaviors as Predictors of Clients ’Outcomes
BehaviorAdmission to dischargeAdmission to 3 months
after discharge At discharge
Mobility ADL Confusion Mobility ADL Confusion Depression WTF Self-esteem
n 51 51 50 43 43 41 48 48 48
Smile .14 .24 /H11002.19 .26* .26* .04 .08 .02 .03
Frown .09 .59*** /H11002.35** .07 .60*** .02 .03 /H11002.20 /H11002.05
Nod /H11002.03 .36** /H11002.26 .04 .33** .17 .18 .07 .14
Head shake /H11002.09 /H11002.08 .06 .09 /H11002.08 /H11002.31* .03 /H11002.13 /H11002.01
Shrug /H11002.44*** .02 .00 /H11002.15 /H11002.06 /H11002.09 .16 .24 .17
Forward lean .14 /H11002.17 .00 .02 /H11002.20 .15 .26 .10 .14
Look at .13 /H11002.04 /H11002.18 /H11002.13 /H11002.05 .23 /H11002.08 /H11002.02 /H11002.16
Sit /H11002.04 /H11002.21 .10 .05 /H11002.23 /H11002.07 /H11002.06 /H11002.09 /H11002.02
Facial affect composite .08 .60*** /H11002.41** .18 .58*** .14 .17 /H11002.02 .16
Note.The correlations reported are Pearson rs. ADL /H11005Activities of Daily Living Scale; WTF /H11005Will to Function Scale.
*p/H11021.05. **p/H11021.01. *** p/H11021.001.448 AMBADY, KOO, ROSENTHAL, AND WINOGRAD

expressively toward clients for whom they had more positive
expectations. Interpersonal expectations are often subtly and non-consciously communicated through nonverbal behavior (Rosen-thal, 1987; Rosenthal & Rubin, 1978).
Given these results regarding the relationship between physical
therapists ’behavior, especially distancing behavior, and elderly
clients’healthoutcome,webecameinterestedinfurtherexamining
onepotentialmechanismunderlyingtherelationshipbetweenther-apist behaviors and client health outcome: client perception. Doclients perceive the distancing molecular nonverbal behaviors as-sociated with distancing as indifference to their well-being? Suchperceptions might result in poor health outcomes. For example, ifdistancing behavior is perceived negatively, then elderly clientrecipients of such behavior might be prone to withdraw from therelationship, and such a withdrawal could certainly cause futurehealth problems due to the client ’s reluctance to broach health
concerns or even to keep medical appointments. Thus, in Study 2,we explored elderly participants ’perceptions of different provider
behaviors.
Study 2: Perceptions of Physical Therapists ’Behaviors
This study examined elderly participants ’perceptions of phys-
ical therapists ’communicative behavior patterns. The goal was to
investigate how elderly adults perceived the interpersonal charac-teristics of providers displaying the nonverbal behavior patternsassociated in Study 1 with clients ’health care outcomes. Elderly
participants ’reactions to three specific behavioral patterns were of
interest. One nonverbal behavior pattern of interest was facial
expressiveness , the composite of smiling, nodding, and frowning.
RecallthatthispatternwasassociatedwithclientimprovementsinStudy 1. In addition, we were interested in the composite oflooking away from the patient and not smiling, linked to percep-tions of distancing and poor patient outcomes in the previousstudy.
Adults over the age of 60 viewed examples of these three
behavioral patterns spontaneously produced by the physical ther-apists in Study 1 and rated the physical therapists on severaldimensions.
Method
Phase 1: Creating Stimulus Tapes
Of the 171 clips created for Study 1, 24 were extracted to be viewed by
older adult participants in Study 2. Eight clips deemed most representativeof each of the three behavior patterns, based on the ratings obtained inStudy 1, were used. These categories were facial expressiveness (thecombination of smiling, frowning and nodding), positive affect (the com-bination of smiling and nodding), and withdrawal (the combination of notsmiling and looking away). Clips that had the highest mean ratings in eachof the three categories and that did not overlap with other categories wereselected for this study.
Phase 2: Evaluating Nonverbal Behavior
Participants (judges). Clips were judged by 14 participants, ranging in
age from 63 to 81 years. Judges included 12 women and 2 men. Judgeswere recruited from the Boston area by using a database of elderlyparticipants made available by researchers from a nearby laboratory.Judges were paid $20 plus the cost of transportation for their participation.Procedure. Judges were run individually by a research assistant. On
arrivaltothelaboratory,theywereescortedtoasmallroomandweregiveninstructions on rating the video clips. Judges were told that they would seeshort silent video segments of physical therapy sessions and would beasked to rate physical therapists on a variety of dimensions. Judges wereinstructed to rate each physical therapist immediately after viewing eachvideo clip, and they were directed to push the stop button on the VCR togive themselves plenty of time to make their ratings. In an effort to ensurethat participants understood the directions and were comfortable with theprocedures, all participants completed 2 –4 practice sessions in which they
viewed 10-s silent video clips used in an unrelated study and used therating scales designed for the present study.
Codingmolarvariables. Therapists ’behaviorineachclipwasratedon
six interpersonal affective dimensions on a 7-point scale, ranging from 1(not at all )t o7(very). The molar variables rated included the follow-
ing: warm, caring, concerned, empathic, indifferent, and distancing/infantilizing.
Results and Discussion
Data Reduction
To reduce the data and increase the stability of the interpersonal
affective dimensions, we conducted principal-components analy-ses. First, the mean of the judges ’ratings of each of the 6 dimen-
sions was computed across the 24 clips. These means were sub-jectedtoprincipal-componentsanalysiswithvarimaxrotation.Thetwo-factor solution with varimax rotation provided the clearestsolution, indicating the presence of two composites. On the basisof these results, 4 variables (warm, concerned, caring, and em-pathic) were summed to create the composite variable “positivity ”
and2variables(indifferent,distancing)weresummedtocreatethecomposite variable “negativity. ”The standard deviations of the
variablesweresimilarenoughsothattransformationsintostandardscores were not needed before combining the variables. Correla-tional analyses revealed that the variables within each compositecorrelatedmuchmorehighlywitheachotherthantheydidwiththevariables comprising the other composites. Thus, the averageintercorrelation among the variables comprising the composite“positivity ”wasr/H11005.96. The average intercorrelation among the
variables comprising the “negativity ”composite was also high
(r/H11005.45).
Positivity
A one-way analysis of variance (ANOVA) revealed a signifi-
cant main effect for molecular behavior pattern on mean positivityratings,F(2, 21)/H1100515.20,p/H11021.00001. Two patterns of molecular
behavior, facial expressiveness and positive affect, were ratedmore positively ( M/H110055.45 and 5.74, respectively) than the “with-
drawn”pattern (M/H110054.10).
Negativity
Fornegativityratings,aone-wayANOVArevealedasignificant
main effect for molecular behaviors, F(2, 21) /H1100520.28,p/H11021
.00001. The withdrawn pattern was rated more negatively(M/H110053.40) than both the facially expressive pattern ( M/H110052.33)
and the positive-affect pattern ( M/H110052.26).
These findings support those of the previous study by demon-
strating that naive older adult participants responded differently to449 PHYSICAL THERAPISTS AND ELDERLY CLIENTS

specific combinations of nonverbal behaviors of health care pro-
viders. Older participants ’ratings of physical therapists along
several interpersonal, affective dimensions differed as a functionof the nonverbal behavior patterns of therapists. Specifically, thecomposite behavioral patterns of smiling, nodding, and frowning,andsmilingandnoddingwereratedmostpositively(asdefinedthevariables warmth, caring, concerned, and empathic) and leastnegatively (as defined by the variables indifferent and distancing).It is interesting to note that the combination of not smiling andlooking away was associated with the perception of both indiffer-ence and distancing/infantilization. In general, these results sug-gest that clients ’perceptions of these nonverbal behaviors might
be related to their improvement and outcomes.
General Discussion
These studies reveal that the nonverbal behavior of health care
providers is associated with both the perceptions and therapeuticoutcomesoftheirclients.AlthoughStudy1suggestedthepotentialbeneficial effects of facial expressiveness (as revealed by thecombination smiling, nodding, and frowning) and the negativeconsequences of distancing and indifference (as revealed by notsmiling and looking away), Study 2 indicated that these behaviorsare differentially perceived by the elderly as positive or negative.
The facial expressiveness (i.e., smiling, nodding, furrowed
brows) of physical therapists was associated with an improvementin elderly clients ’activities of daily living from admission to
discharge and with a decrease in confusion from admission todischarge. It was speculated following Study 1 that facial expres-siveness communicates engagement and concern for the client,thereby promoting patient satisfaction and health improvements.Results of Study 2 confirmed this prediction: Here, therapists whoexhibited facial expressiveness and positive affect were perceivedasmorewarm,caring,concerned,andempathic.Atthesametime,they were perceived as less indifferent and distancing.
These results highlight the importance of health care providers ’
nonverbal behavior in the therapeutic exchange in a dyad. This isespecially true in regard to distancing behavior by the physicaltherapists that was associated with a paradoxical outcome in theclients. Recall that distancing was associated with long-term neg-ative consequences for cognitive and physical functioning. Theresults of Study 2, which used relatively independent elderlyindividuals as participants, suggest that distancing is perceivednegatively by this population.
One plausible explanation for the results showing that physical
therapists ’behaviorswaslinkedtoclients ’outcomesmightbethat
the physical therapists ’behavior revealed their expectations for
client’s outcomes.
1Perhaps providers are able to gauge the poten –
tial improvement of patients, and their behavior reflects and com-municates these expectations. A great deal of research has shownthat interpersonal expectations are often communicated quite sub-tly through nonverbal behavior (Ambady et al., 2000). It is con-ceivablethatclientssensedtheseexpectationsandconfirmedthem(Rosenthal & Rubin, 1978). Further work is needed to examinethis possibility.
Itisnotsurprisingthatthesestudiessupporttheideathatpatient
perceptions might moderate the effects of providers ’nonverbal
behavior patterns on therapeutic outcome. Previous work on el-derspeak (Caporael, Lukaszewski, & Culbertson, 1983; O ’Connor& Rigby, 1996) has found that secondary baby talk is perceived
differentially as a function of patient characteristics. These studieshave found that patient functioning prior to treatment plays animportant role in the perception of secondary baby talk as warmand nurturing or demeaning and disrespectful. For example, in thestudy by Caporael et al. (1983), lower functioning residents of anursing home tended to prefer baby talk, perhaps because theydesired more nurturance. In contrast, the negative perceptions ofdistancing behavior in the present study may have been driven bythe relative independence of the elderly participants. Thus, itseems that as dependence on caregivers increases, so does thepreferenceforapatternofnonverbalbehaviorthatsignalsalackofrespect and patronization.
Afewimportantlimitationsofthisworkshouldbekeptinmind.
The major limitation of the first study is that it was correlational.We focused on the nonverbal behavior patterns of only one half ofthe patient –therapist interaction: the therapist, but the unit of the
analysis was the dyad. The angle of the camera prevented us frombeing able to examine the clients ’behavior. But the patient –
therapist interaction is a dynamic one in which the thoughts andbehavior of one interactant are constantly responding to and influ-encing those of the other interactant. Additional studies separatelyexamining therapist behavior, client behavior, as well as the inter-action, would further our understanding of the dynamics ofpatient–physician communication. We hope that in the future,
randomized experimental studies with physicians and elderly pa-tients will examine these phenomena more systematically. More-over, this study examined reactions and perceptions to nonverbalbehavior as displayed mostly through facial expression and ges-tures. Additional channels, such as speech and vocal tone, shouldbe examined to expand on the present findings. These channelsmay provide particular insights as to evaluative perceptions ofdistancingandanxiouscaregiverbehavior.Forinstance,anxietyasjudged from the vocal channel may communicate concern in amannersimilartothefacialexpressivenesscompositeexaminedinthis article (Milmoe et al., 1967).
In sum, these studies suggest that providers ’nonverbal commu-
nication, particularly facial cues and gestures, are associated withelderlyclients ’improvementaswellaselderlyclients ’perceptions
of caregivers in medical interactions. They, thus, add to the bur-geoning evidence linking physician –patient communication to im-
portant outcomes, such as patient dissatisfaction and poor healthoutcomes (Bensing, 1991; Ben-Sira, 1980; DiMatteo, Prince, &Hays, 1980; Hall et. al., 1981; Lepper et al., 1995; White et al.,1994; Woolley et al., 1978). These studies also suggest that thephysician communicates a wealth of information by means ofminimalcuesthatcanhaveimportantconsequences.Theyindicatethat in the complex interaction between health care providers andtheir elderly clients, how a message is conveyed might be asimportant as what a message conveys.
1We thank an anonymous reviewer for this suggestion.
References
Adelman, R. D., Greene, M. G., Charon, R., & Friedmann, E. (1992). The
content of physician and elderly patient interaction in the medicalprimary care encounter. Communication Research, 19, 370–380.450 AMBADY, KOO, ROSENTHAL, AND WINOGRAD

Ambady, N., Bernieri, F., & Richeson, J. (2000). Towards a histology of
social behavior: Judgmental accuracy from thin slices of behavior. InM. P. Zanna (Ed.), Advances in experimental social psychology, 32,
201–272.
Ambady, N., & Rosenthal, R. (1992). Thin slices of behavior as predictors
of interpersonal consequences: A meta-analysis. Psychological Bulle-
tin, 2,256–274.
Beisecker, A. E., & Beisecker, T. D. (1990). Patient information seeking
behaviors when communicating with doctors. Medical Care, 28, 19–28.
Bensing, J. (1991). Doctor –patient communication and the quality of care.
Social Science and Medicine, 32, 1301–1310.
Ben-Sira, Z. (1980). Affective and instrumental components in the
physician –patient relationship: An additional dimension of interaction
theory.Journal of Health and Social Behavior, 21, 170–180.
Blanck,P.D.,Rosenthal,R.,&Vannicelli,M.(1986).Talkingtoandabout
patients: The therapist ’s tone of voice. In P. D. Blanck, R. Buck, & R.
Rosenthal (Eds.), Nonverbal communication in the clinical context.
University Park, PA: Penn State University Press.
Blanck, P. D., Rosenthal, R., Vannicelli, M., & Lee, T. D. (1986). Ther-
apist’s tone of voice: Descriptive, psychometric, interactional, and com-
petence analyses. Journal of Social and Clinical Psychology, 4, 154–
178.
Brink, T. L., Yesavage, J., Lum, O., Heersema, Adey, M., & Rose, T. L.
(1982). Screening tests for geriatric depression. Clinical Gerontolo-
gist, 1,37–44.
Caporael, L. R. (1981). The paralanguage of caregiving: Baby talk to the
institutionalizedaged. JournalofPersonalityandSocialPsychology,40,
876–884.
Caporael, L. R., & Culbertson, G. H. (1986). Verbal response modes of
baby talk and other speech at institutions for the aged. Language and
Communication, 6, 99–112.
Caporael, L. R., Lukaszewski, M. P., & Culbertson, G. H. (1983). Sec-
ondary baby talk: Judgments by institutionalized elderly and their ther-apists.Journal of Personality and Social Psychology, 44, 746–754.
Coupland, N., Coupland, J., & Giles, H. (1991). Language, society and the
elderly: Discourse, identity, and ageing. Oxford, England: Basil
Blackwell.
Crandall, R. (1973). The measurement of self-esteem and related con-
structs. In J. R. Robinson & P. R. Shaver (Eds.), Measures of social
psychologicalattitudes (pp.45–167).AnnArbor,MI:InstituteforSocial
Research.
D’Augelli, A. R. (1974). Nonverbal behavior of helpers in initial helping
interactions. Journal of Counseling Psychology, 21, 360–363.
DePaulo, B. M. (1992). Nonverbal behavior and self-presentation. Psycho-
logical Bulletin, 11, 203–243.
Devine, E. C., & Cook, T. D. (1985). A meta-analytic analysis of the
effects of psychoeducational interventions on length of post-surgicalhospital stay. Nursing Research, 32, 267–274.
DiMatteo, M. R., & Friedman, H. S. (1982). Social psychology and
medicine. Cambridge, MA: Oelgeschlager, Gunn, & Hain.
DiMatteo, M. R., Prince, L. M., & Hays, R. (1980). Nonverbal communi-
cation in the medical context: The physician –patient relationship. In
P. D. Blanck, R. Buck, & R. Rosenthal (Eds.), Nonverbal communica-
tion in the clinical context (pp. 74–98). University Park, PA: Penn State
University Press.
Ekman, P., & Friesen, W. V. (1969). Nonverbal leakage and clues to
deception. Psychiatry, 32, 88–105.
Ekman, P., & Friesen, W. V. (1974). Nonverbal behavior and psychopa-
thology. In R. J. Friedman & M. M. Katz (Eds.), The psychology of
depression: Contemporary theory and research. Washington, DC: Win-
ston and Sons.
Fretz, B. R., Corn, R., Tuemmler, J. M., & Bellet, W. (1979). Counselor
nonverbal behaviors and client evaluations. Journal of Counseling Psy-
chology, 26, 304–311.Friedman, H. S., & DiMatteo, M. R. (Eds.). (1982). Interpersonal issues in
health care. New York: Academic Press.
German, P. S., Shapiro, S., Skinner, E. A., Von Korff, M., Klein, L. E.,
Turner,R.W.,etal.(1987).Detectionandmanagementofmentalhealthproblems of older patients by primary care providers. Journal of the
American Medical Association, 257, 489–493.
Greene, M. G., Adelman, R., Charon, R., & Hoffman, S. (1986). Ageism
in the medical encounter: An exploratory study of the doctor –elderly
patient relationship. Language & Communication, 6, 113–124.
Greenfield, S., Kaplan, S. H., & Ware, J. E., Jr. (1985). Expanding patient
involvement in care: Effects on patient outcomes. Annals of Internal
Medicine, 102, 520–528.
Greenfield, S., Kalpan, S. H., Ware, J. E., Jr., Yano, E. M., & Frank, J. H.
(1988). Patients ’participation in medical care: Effects on blood sugar
control and quality of life in diabetes. Journal of General Internal
Medicine, 3, 448–457.
Hall,J.A.,&Dornan,M.C.(1988).Whatpatientslikeabouttheirmedical
care and how often they are asked: A meta-analysis of the satisfactionliterature. Social Science and Medicine, 27, 935–939.
Hall, J. A., Harrigan, J. A., & Rosenthal, F. (1995). Nonverbal behavior in
clinician–patient interaction. Applied and Preventive Psychology, 4,
21–37.
Hall, J. A., Roter, D. L., & Rand, C. S. (1981). Communication of affect
between patient and physician. Journal of Health and Social Behav-
ior, 22,18–30.
Harrigan, J. A., Oxman, T. E., & Rosenthal, R. (1985). Rapport expressed
through nonverbal behavior. Journal of Nonverbal Behavior, 9, 95–110.
Harrigan, J. A., & Rosenthal, R. (1983). Physicians ’head and body
positionsasdeterminantsofperceivedrapport. JournalofAppliedSocial
Psychology, 13, 469–509.
Hasse, R. F., & Tepper, D. T. (1972). Nonverbal components of empathic
communication. Journal of Counseling Psychology, 19, 417–424.
Hays, R. D., Sherbourne, C. D., & Mazel, R. E. (1993). The RAND
36-item health survey 1.0. Health Economics, 2, 217–227.
Hermansson, G. L., Webster, A. C., & McFarland, K. (1988). Counselor
deliberate postural lean and communication of facilitative conditions.Journal of Counseling Psychology, 35, 149–153.
Hill,C.E.,&Stephany,A.(1990).Relationofnonverbalbehaviortoclient
reactions. Journal of Counseling Psychology, 37, 22–26.
Hummert, M. L., & Mazloff, D. (1993). Elderly adults ’views of patron-
izing speech: A focus group study. Unpublished manuscript.
Kaplan, S. H., Greenfield, S., & Ware, J. E. (1989). Assessing the effects
of physician –patient interactions on the outcomes of chronic disease.
Medical Care, 27, 110–127.
Kelly, E. W., Jr., & True, J. H. (1980). Eye contact and communication of
facilitative conditions. Perceptual and Motor Skills, 51, 815–820.
Kite, M. E., & Johnson, B. T. (1988). Attitudes toward older and younger
adults: A meta-analysis. Psychology and Aging, 3, 233–244.
Koenig, H. G., Meador, K. G., Cohen, H. J., & Blazer, D. G. (1988).
Depressioninelderlyhospitalizedpatientswithmedicalillness. Archives
of Internal Medicine, 148, 1929–1936.
Kogan, N. (1979). Beliefs, attitudes, and stereotypes about old people.
Research on Aging, 1, 11–36.
LaCrosse, M. B. (1975). Nonverbal behavior and perceived counselor
attractiveness and persuasiveness. Journal of Counseling Psychol-
ogy, 22,563–566.
Larsen, K. M., & Smith, C. K. (1981). Assessment of nonverbal commu-
nication in the patient –physician interview. Journal of Family Prac-
tice, 12,481–488.
Lawton, M. P., & Brody, E. M. (1982). Assessment of older people:
Self-maintaining and instrumental activities of daily living. Gerontolo-
gist, 9,179–186.
Lawton, M. P., Moss, M., Fulcomer, M., & Kleban, M. H. (1982). A451 PHYSICAL THERAPISTS AND ELDERLY CLIENTS

research and service oriented multilevel assessment instrument. Journal
of Gerontology, 37, 91–99.
Learman, L. A., Avorn, J., Everitt, D. E., & Rosenthal, R. (1990). Pyg-
malion in the nursing home: The effects of caregiver expectations onpatient outcome. Journal of the American Geriatric Society, 38, 797–
803.
Lepper, H. S., Martin, L. R., & DiMatteo, M. R. (1995). A model of
nonverbal exchange in physician-patient expectations for patient in-volvement. Journal of Nonverbal Behavior, 19, 207–222.
Levin, J., & Levin, W. C. (1980). Ageism: Prejudice and discrimination
against the elderly. Belmont, CA: Wadsworth.
Levinson,W.(1994).Physician –patientcommunication:Akeytomalprac-
tice prevention. Journal of the American Medical Association, 273,
1619–1620.
Maguire, P., Fairburn, S., & Fletcher, C. (1986). Consultation skills of
young doctors: Benefits of feedback training in interviewing as studentspersist.British Medical Journal, 2992, 1573–1576.
Milmoe, S., Rosenthal, R., Blane, H. T., Chafetz, M. E., & Wolf, I. (1967).
The doctor ’s voice: Postdictor of successful referral of alcoholic pa-
tients.Journal of Abnormal Psychology, 72, 78–84.
Mumford, E., Schlesinger, H., & Glass, G. (1982). The effects of psycho-
logical intervention on recovery from surgery and heart attacks: Ananalysis of the literature. American Journal of Public Health, 72, 141–
151.
O’Connor, B. P., & Rigby, H. (1996). Perceptions of babytalk, frequency
of receiving babytalk, and self-esteem among community and nursinghome residents. Psychology and Aging, 11, 147–154.
Rime, B., & Schiaratura, L. (1991). Gestures and speech. In R. S. Feldman
& B. Rime (Eds.), Fundamentals of nonverbal behavior. New York:
Cambridge University Press.
Robbins, L. S., & Woolf, F. M. (1989). The effect of training on medical
students’response to geriatric patient concerns: Results of a linguistic
analysis. Gerontologist, 29, 341–344.
Rogers, C. R. (1975). The necessary and sufficient conditions of therapeu-
ticpersonalitychange. JournalofConsultingPsychology,21, 995–1103.
Rosenberg, M. (1965). Society and the adolescent self-image. Princeton,
NJ: Princeton University Press.
Rosenblum, N. D., Wetzel, M., Platt, O., Daniels, S., Crawford, J., &
Rosenthal, R. (1994). Predicting medical student success in a clinicalclerkship by rating students ’nonverbal behavior. Archives of Pediatric
Adolescent Medicine, 148, 213–219.
Rosenthal, R. (1987). Pygmalion effects: Existence, magnitude, and social
importance. Educational Researcher, 16, 37–41.
Rosenthal, R., & Rubin, D. B. (1978). Interpersonal expectancy effects:
The first 345 studies. Behavioral and Brain Sciences, 3, 377–415.
Roter, D. L., Hall, J. A., & Katz, N. R. (1987). Relation between physi-
cians’behavior and analogue patients ’satisfaction, recall, and impres-
sions.Medical Care, 25, 437–451.
Rubin, K. H., & Brown, I. D. R. (1975). A life-span look at personperception and its relationship to communicative interaction. Journal of
Gerontology, 30, 461–468.
Seay, T. A., & Altekruse, M. K. (1979). Verbal and nonverbal behavior in
judgments of facilitative conditions. Journal of Counseling Psychol-
ogy, 26,108–119.
Silber, E., & Tippett, J. S. (1965). Self-esteem: Clinical assessment and
measurement validation. Psychological Reports, 16, 1017–1071.
Smith-Hanen,S.S.(1977).Effectsofnonverbalbehaviorsonjudgedlevels
of counselor warmth and empathy. Journal of Counseling Psychol-
ogy, 24,87–91.
Stewart, A. L., & Kamberg, C. (1989). Physical functioning. In A. L.
Stewart & J. E. Ware (Eds.), Measuring functional status and well-
being: The medical outcomes study approach (pp. 86–101). Durham,
NC: Duke University Press.
Tepper, D. T., & Hasse, R. F. (1978). Verbal and nonverbal communica-
tion of facilitative conditions. Journal of Counseling Psychology, 25,
35–44.
Tickle-Degnen, L. (1998). Working well with others: The prediction of
students’clinicalperformance. AmericanJournalofOccupationalTher-
apy, 52,133–142.
Tickle-Degnen, L., & Puccinelli, N. M. (1999). The nonverbal expression
of negative emotions: Peer and supervisor responses to occupationaltherapy students ’emotional attributes. Occupational Therapy Journal of
Research, 19, 1–22.
Timpton, R. M., & Rymer, R. A. (1978). A laboratory study of the effects
of varying levels of counselor eye contact on client-focused andproblem-focused counseling styles. Journal of Counseling Psychol-
ogy, 25,200–204.
Weinberger, M., Greene, J. Y., & Mamlin, J. J. (1981). The impact of
clinical encounter events on patient and physician satisfaction. Social
Science in Medicine, 15, 239–244.
White, J., Levinson, W., & Roter, D. (1994). “O h ,b yt h ew a y… ”The
closing moments of the medical visit. Journal of General Internal
Medicine, 9, 24–28.
Woolley, F. R., Kane, R. L., Hughes, C. C., & Wright, D. D. (1978). The
effects of doctor patient communication on satisfaction and outcome ofcare.Social Science and Medicine, 12, 123–128.
Yesavage, J., Brink, T. L., Rose, T. L., & Adey, M. (1983). The geriatric
depression rating scale: Comparison with other self-report and psychi-atricratingscales.InT.Crock,S.Ferris,&R.Bartus(Eds.), Assessment
in geriatric psychopharmacology (pp. 153–163). New Canaan, CT:
Mark Powley Associates.
Yesavage, J., Brink, T. L., Rose, T. L., & Lum, O. (1983). Development
and validation of a Geriatric Depression Screening Scale: A preliminaryreport.Journal of Psychiatric Research, 17, 37–49.
Received August 16, 2000
Revision received December 10, 2001
Accepted January 9, 2002 /H18546452 AMBADY, KOO, ROSENTHAL, AND WINOGRAD