Non-verbal Behavior in Cross-Cultural InteractionsPosted by Marcia Carteret, M. Ed. in Immigrant and Refugee Health
In previous newsletters, we explored using informed generalizations to learn about cultural differences. This concept certainly applies to learning about non-verbal behaviors. There is no quick and easy-to-use reference guide for culturally-based behaviors and lists of cultural dos and don’ts are ineffective. Even if it were possible to assemble a truly comprehensive list of facts for each culture, memorizing such information and keeping it straight is unrealistic– and people don’t really use lists, anyway. You can’t find them when you need them, and you can’t carry them around with you. Perhaps most important, interactions between people happen within a given context, and relying on lists actually distracts a person from the immediacy of each encounter.
When using dimensions of culture – time control, status, individualism, etc. – we understand that these dimensions point to probabilities about cultures that are worth paying attention to – and the word probability is key. The same is true when we observe non-verbal behavior and attempt to decipher its meaning. We must always allow for the ambiguous nature of communication between people. Observing ourselves and becoming more aware of the assumptions we make about other people’s behaviors helps us be less reactive. We begin to see the individual in each encounter rather than just our interpretation of the situation.
The most important thing to keep in mind about non-verbal behaviors is that they do not translate across cultures easily and can lead to serious misunderstanding. Human behaviors are driven by values, beliefs, and attitudes, and it is helpful to consider how these invisible aspects of culture drive the behaviors we can see.
Eye Contact: Americans typically look directly into each other’s eyes when talking, conveying informality, spontaneity, and equality in their exchange of glances. When eyes shift and avoid meeting those of the other person, Americans may sense disinterest or perhaps even deception. However, a lack of consistent and strong eye contact may be a sign of respect or humility in other cultures. In some Asian cultures, eyes may be downcast or sweeping, and this often disturbs Americans. “He wouldn’t look me in the eye!” In Hispanic culture, direct eye contact is used far less and direct disagreement with a provider is uncommon.
Head Nodding: Nodding of the head may be a sign of acknowledgement rather than agreement in some cultures. The nod may be saying, “Yes, I am listening to you intently” rather than “yes I understand what you are saying and I agree.” The usual response to a decision with which the patient or family disagrees is silence and noncompliance. So, nodding and silence may mean “I am listening…but I am not in agreement.” The only way to know is to ask in a respectful manner if they understand or have any concerns. You may have to ask more than once – even somewhat emphatically! Asking open-ended questions will elicit more thorough answers and reduce deferential head nodding.
Taking Turns in Conversation & Use of Silence: The way conversation gets passed between people varies greatly between cultures, and it is the length of sustained eye contact that cues conversational turn taking. Americans tend to make medium-length eye contact before looking away, and they use a longer direct gaze to cue changing speakers. In other cultures, where a direct gaze may be confrontational, lack of eye contact may make it awkward for Americans to pass conversation back and forth. Being generally uncomfortable with any period of silence in conversation, Americans will tend to rush through pauses and quickly complete sentences that dangle. As a result, people from less direct cultures may struggle to participate equally in conversation with Americans, an obvious hindrance in successful patient-provider exchanges. The solution is to practice allowing silence, which necessitates slowing down conversation and more careful listening as well. Being a task-oriented culture, Americans tend to want conversation to get to the point, where other cultures will use it to build relationship. The use of silence suggests really hearing, considering, and valuing what is being said by the other person and is critical in cross-cultural interactions to establish trust.
Expressiveness & Gesturing: Americans tend to be moderately expressive when it comes to body language, gesturing freely compared to most Asians, but seeming constrained when compared to some Latin or Arab cultures. An American might misread an exaggerated use of hands or arms in conversation as an indication of excitability or distress in a person when, if fact, it means nothing of the sort. Keeping this in mind, providers should stay aware of how their own gesturing could be interpreted. Moving hurriedly and gesturing broadly might create discomfort for an Asian patient/parent but go relatively unnoticed by someone from the Middle East. Similarly, a western provider may over- or underestimate a patient’s level of pain based on the presence or absence of loud complaint, gesticulations, and other expressions of pain which are closely tied to a person’s culture. (Refer to the November 2009 newsletter for more on the cultural aspects of pain management.)
Use of Humor, Smiling, and Laughter: A wise interpreter will avoid translating humor for the good reason that jokes and sarcasm don’t translate well across cultures. In some cultures, humor can even be seen as aggression or dominance. Americans, because we are individualistic and confident, tend to do a lot of put-down humor. We love to poke fun at ourselves and others. This can be confusing for people from other cultures where close attention is paid to preserving the dignity of all people in a given interaction – in Asian cultures this is called saving face. A well-intentioned provider, whose position automatically conveys status, would confuse some families by poking fun at himself. It could easily disrupt the sense of trust vested in him or her, especially for patients from formal cultures.
Finally, in American culture, there’s a big difference between a wry smile and happy smile, just as in many Asian cultures a ‘masking smile,’ with corners of the mouth turned down, is a polite way of letting you know what you are doing is not appropriate. Similarly, in many Asian cultures laughter can be a sign of embarrassment rather than a response to humor as it typically is in the US. Healthcare workers interacting with patients from Asian cultures need to remember the difference between high and low context cultures. Reading facial expressions, body language, etc. is second nature to people from Asian cultures, but goes unnoticed by many Americans unless they make a concerted effort to pay closer attention in cross-cultural situations.
Keep in mind – it can’t be overstated – that any guidelines for non-verbal communication should be applied as informed generalizations. In most instances, following the patient’s lead is best. For example, if the patient moves closer or touches you in a casual manner, you may do the same. Developing a cross-cultural mindset requires being more observant and demonstrating a willingness to adjust your own behavior. With experience, you will develop your own practical style that demonstrates greater sensitivity and awareness and ultimately contributes to better communication and health outcomes for all patients.