The doctor's voice: postdictor of successful referral of alcoholic patients

What can clients tell us about whether to use motivational interviewing? An analysis of early-session ambivalent language

BACKGROUND

Although motivational interviewing (MI) is an effective method for promoting change in problematic alcohol and other drug use, it does not benefit all clients. Clinicians have little empirical guidance on who is likely to benefit from MI and who is not. We hypothesized that differences in clients' spontaneously offered language early in the session would predict their responsiveness to MI during the remainder of the session.

METHOD

The study obtained coding data from 125 counseling sessions from a large randomized controlled trial of clinician training. A cluster analysis created one group of clients whose language reflected ambivalence, and one group whose language reflected readiness to change. We conducted a univariate analysis of variance to compare the mean change in percent change talk across the session between groups.

RESULTS

Clients whose language reflected ambivalence early in the session had a greater change in their percent change talk during the remainder of the session, compared to those whose language reflected greater readiness to change (F (1,90) = 63.02, t = 7.94, p < .001). Surprisingly, the group whose language reflected readiness had a decrease in their percent change talk during the remainder of the session (M = -10.9%, SD = 16.3%). Adjusting the results for regression to the mean effects did not eliminate these differences.

CONCLUSION

Clients' language early in the session may offer clinicians some guidance on whether MI is likely to be useful or counterproductive in the treatment of substance use disorder.

Capturing Behavior in Small Doses: A Review of Comparative Research in Evaluating Thin Slices for Behavioral Measurement

Thin slices are used across a wide array of research domains to observe, measure, and predict human behavior. This article reviews the thin-slice method as a measurement technique and summarizes current comparative thin-slice research regarding the reliability and validity of thin slices to represent behavior or social constructs. We outline decision factors in using thin-slice behavioral coding and detail three avenues of thin-slice comparative research: (1) assessing whether thin slices can adequately approximate the total of the recorded behavior or be interchangeable with each other (representativeness); (2) assessing how well thin slices can predict variables that are different from the behavior measured in the slice (predictive validity), and (3) assessing how interpersonal judgment accuracy can depend on the length of the slice (accuracy-length validity). The aim of the review is to provide information researchers may use when designing and evaluating thin-slice behavioral measurement.

Covert Communication in Laboratories, Classrooms, and the Truly Real World

Hundreds of research studies have demonstrated that one person's expectations for the behavior of another person can actually affect that other person's behavior. These studies implicate the operation of processes of covert communication, communication that is subtle, largely nonverbal, and ordinarily unintended. The earliest studies of these processes showed that through their expectations, laboratory researchers unwittingly affected the responses of their research participants. Later studies showed that teachers' experimentally induced expectations about their pupils affected the pupils' intellectual performance. Most recently, studies of covert communication processes have extended to diverse contexts, such as the judicial and health care systems. For example, research indicates that judges' beliefs about the guilt of trial defendants can be unwittingly communicated to juries by the judges' nonverbal behavior during jury instruction. In addition, studies of covert communication in medical contexts show that physicians' effectiveness in persuading their patients to enter into treatment can be predicted from their tone of voice in talking to or about their patients. For example, one study showed that surgeons who used a bossy tone of voice when talking to their patients were more likely to be sued by their patients than were surgeons who used a more respectful tone. In sum, then, we have learned a great deal about the importance of subtle processes of nonverbal communication, but a great deal more is yet to be learned about these processes as they occur in the relatively sheltered context of laboratories and classrooms and in the rough-and-tumble of the truly real world beyond.

Reliability and Validity of Nonverbal Thin Slices in Social Interactions

Four studies investigated the reliability and validity of thin slices of nonverbal behavior from social interactions including (a) how well individual slices of a given behavior predict other slices in the same interaction; (b) how well a slice of a given behavior represents the entirety of that behavior within an interaction; (c) how long a slice is necessary to sufficiently represent the entirety of a behavior within an interaction; (d) which slices best capture the entirety of behavior, across different behaviors; and (e) which behaviors (of six measured behaviors) are best captured by slices. Notable findings included strong reliability and validity for thin slices of gaze and nods, and that a 1.5-min slice from the start of an interaction may adequately represent some behaviors. Results provide useful information to researchers making decisions about slice measurement of behavior.

Implementation of a nurse-led behaviour change intervention to support medication taking in type 2 diabetes: beyond hypothesised active ingredients (SAMS Consultation Study)

Background

Implementation of trial interventions is rarely assessed, despite its effects on findings. We assessed the implementation of a nurse-led intervention to facilitate medication adherence in type 2 diabetes (SAMS) in a trial against standard care in general practice. The intervention increased adherence, but not through the hypothesised psychological mechanism. This study aimed to develop a reliable coding frame for tape-recorded consultations, assessing both a priori hypothesised and potential active ingredients observed during implementation, and to describe the delivery and receipt of intervention and standard care components to understand how the intervention might have worked.

Methods

211 patients were randomised to intervention or comparison groups and 194/211 consultations were tape-recorded. Practice nurses delivered standard care to all patients and motivational and action planning (implementation intention) techniques to intervention patients only. The coding frame was developed and piloted iteratively on selected tape recordings until a priori reliability thresholds were achieved. All tape-recorded consultations were coded and a random subsample double-coded.

Results

Nurse communication, nurse-patient relationship and patient responses were identified as potential active ingredients over and above the a priori hypothesised techniques. The coding frame proved reliable. Intervention and standard care were clearly differentiated. Nurse protocol adherence was good (M (SD) = 3.95 (0.91)) and competence of intervention delivery moderate (M (SD) = 3.15 (1.01)). Nurses frequently reinforced positive beliefs about taking medication (e.g., 65% for advantages) but rarely prompted problem solving of negative beliefs (e.g., 21% for barriers). Patients’ action plans were virtually identical to current routines. Nurses showed significantly less patient-centred communication with the intervention than comparison group.

Conclusions

It is feasible to reliably assess the implementation of behaviour change interventions in clinical practice. The main study results could not be explained by poor delivery of motivational and action planning components, definition of new action plans, improved problem solving or patient-centred communication. Possible mechanisms of increased medication adherence include spending more time discussing it and mental rehearsal of successful performance of current routines, combined with action planning. Delivery of a new behaviour change intervention may lead to less patient-centred communication and possible reduction in overall trial effects.

Trial registration

ISRCTN30522359.

The secret of the care of the patient is in knowing and applying the evidence about effective clinical communication

American physicians and dentists conduct approximately 140 000-160 000 patient interviews in a practice lifetime, making the interview the most frequently performed medical procedure. Over the past 75 years, a steadily growing stream of scientific research has confirmed the fact that patient-clinician communication affects the course, direction, and both biomedical and functional outcomes of care. The field of clinical communication research has matured from anecdotes and aphorisms about 'bedside manner' to sophisticated randomized control trials and evidence-based outcomes that have been translated into reliable practice guidelines. Several key skills or habits of practice have been identified and studied in terms of their efficacy and effectiveness. These include the importance of agenda-setting, eliciting patients' perspectives about the nature of their ailments, communicating caring and concern, and testing for patient comprehension and agreement with proposed treatments. In addition to being effective, interpersonal communication can be deeply satisfying as well as offering a lower probability of law suits in the event of an adverse outcome.

Thin-slice judgments in the clinical context

Clinicians make a variety of assessments about their clients, from judging personality traits to making diagnoses, and a variety of methods are available to do so, ranging from observations to structured interviews. A large body of work demonstrates that from a brief glimpse of another's nonverbal behavior, a variety of traits and inner states can be accurately perceived. Additionally, from these "thin slices" of behavior, even future outcomes can be predicted with some accuracy. Certain clinical disorders such as Parkinson's disease and facial paralysis disrupt nonverbal behavior and may impair clinicians' ability to make accurate judgments. In certain contexts, personality disorders, anxiety, depression, and suicide attempts and outcomes can be detected from others' nonverbal behavior. Additionally, thin slices can predict psychological adjustment to divorce, bereavement, sexual abuse, and well-being throughout life. Thus, for certain traits and disorders, judgments from a thin slice could provide a complementary tool for the clinician's toolbox.

Agenda setting in psychiatric consultations: an exploratory study

OBJECTIVE

Patient- or consumer-centeredness has been recognized as a critical component of quality in primary health care, but is only beginning to be recognized and studied in mental health. Among the first opportunities to be consumer-centered is collaboratively producing an agenda of topics to be covered during a clinic visit. Early agenda setting sets the stage for what is to come and can affect the course, direction, and quality of care. The purpose of this work is to study agenda setting practices among 8 prescribers (5 psychiatrists and 3 nurse practitioners) at the beginning of their encounters with 124 consumers diagnosed with schizophrenia spectrum disorders (56%), bipolar disorder (23%), major depression (15%), and other disorders (6%).

METHOD

We modified an extant agenda-setting rubric by adding behaviors identified by a multidisciplinary team who iteratively reviewed transcripts of the visit openings. Once overall consensus was achieved, two research assistants coded all of the transcripts. Twenty-five transcripts were scored by both raters to establish interrater reliability.

RESULTS

We identified 10 essential elements of agenda setting. Almost 10% of visits had no agenda set, and only 1 of 3 encounters had partial or complete elicitation of a single concern. Few additional concerns (4%) were solicited, and no encounter contained more than 6 essential elements.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Collaborative agenda setting represents a unique opportunity to translate the concept of consumer-centeredness into mental health care. Initial results suggest the rating system is reliable, but the essential elements are not being used in practice.

Thin-slice perception develops slowly

Body language and facial gesture provide sufficient visual information to support high-level social inferences from "thin slices" of behavior. Given short movies of nonverbal behavior, adults make reliable judgments in a large number of tasks. Here we find that the high precision of adults' nonverbal social perception depends on the slow development, over childhood, of sensitivity to subtle visual cues. Children and adult participants watched short silent clips in which a target child played with Lego blocks either in the (off-screen) presence of an adult or alone. Participants judged whether the target was playing alone or not; that is, they detected the presence of a social interaction (from the behavior of one participant in that interaction). This task allowed us to compare performance across ages with the true answer. Children did not reach adult levels of performance on this task until 9 or 10 years of age, and we observed an interaction between age and video reversal. Adults and older children benefitted from the videos being played in temporal sequence, rather than reversed, suggesting that adults (but not young children) are sensitive to natural movement in social interactions.

Slicing it thin: new methods for brief sampling analysis using RIAS-coded medical dialogue

OBJECTIVE

To explore the relationship between one-minute slices and full-session interaction and the predictive validity of the slices to ratings of affect and rapport.

METHODS

Third-year medical students (n=253) were videotaped during an OSCE. All interaction was coded using the Roter Interaction Analysis System (RIAS) and samples were drawn at minutes 1, 5, and 9 and extracted from the coded database. The slices were related in multivariate analysis to full-session interaction, corrected for slice content, and correlated with affect ratings of participants and independently rated judgments of rapport.

RESULTS

One-minute slices explained 33% of full-session variance in student interaction and 30% of variance in standardized patient interaction. Slices were significantly correlated with affective ratings of participants and independent judgments of rapport in a similar pattern as full-session interaction analysis.

CONCLUSIONS

One-minute slices of interaction can provide a meaningful degree of insight into OSCE session communication with both concurrent and predictive validity to ratings of session affect and rapport.

PRACTICE IMPLICATIONS

Evidence of concurrent and predictive validity further supports use of this approach as a research tool that provides an efficient means of analyzing processes of care, examining variation in communication throughout a visit and predicting visit outcomes.

It May Be a Dog's Life But the Relationship with Her Owners Is Also Key to Her Health and Well Being: Communication in Veterinary Medicine

Effective communication is necessary for achieving important outcomes in veterinary practice, including patient health, accuracy, efficiency, and economic viability. Communication is a series of learned skills. Daily practice, feedback, and refinement are the ingredients for continued practice success.

Emotional expression and diurnal cortisol slope in women with metastatic breast cancer in supportive-expressive group therapy: a preliminary study

We examined coded emotional expression during an initial therapy session and its association with a known physiological risk factor for early death, aberrant diurnal cortisol slope, in women with metastatic breast cancer. Out of 64 women with metastatic breast cancer randomized to a multi-site clinical intervention trial of supportive-expressive group therapy (SET), a subsample of 29 met eligibility criteria for this study. We tested whether longer mean durations of primary negative affect (fear, sadness, and anger) expression were associated with steeper diurnal cortisol slopes after adjusting for speaking time, repressive-defensiveness, anxiety, and the interaction between repressive-defensiveness and anxiety. We found that steeper cortisol slopes were related to lower repressive-defensiveness and greater primary negative affect expression in line with a priori hypotheses. Additionally we explored whether coded positive affect, defensive/hostile affect, constrained anger, and the interaction between primary negative affect and repressive-defensiveness explained additional variance in diurnal cortisol patterns.

The expression of emotion through nonverbal behavior in medical visits. Mechanisms and outcomes

Relationship-centered care reflects both knowing and feeling: the knowledge that physician and patient bring from their respective domains of expertise, and the physician's and patient's experience, expression, and perception of emotions during the medical encounter. These processes are conveyed and reciprocated in the care process through verbal and nonverbal communication. We suggest that the emotional context of care is especially related to nonverbal communication and that emotion-related communication skills, including sending and receiving nonverbal messages and emotional self-awareness, are critical elements of high-quality care. Although nonverbal behavior has received far less study than other care processes, the current review argues that it holds significance for the therapeutic relationship and influences important outcomes including satisfaction, adherence, and clinical outcomes of care.

Effects of exam-room computing on clinician-patient communication: a longitudinal qualitative study

OBJECTIVE

To evaluate the impact of exam-room computers on communication between clinicians and patients.

DESIGN AND METHODS

Longitudinal, qualitative study using videotapes of regularly scheduled visits from 3 points in time: 1 month before, 1 month after, and 7 months after introduction of computers into the exam room.

SETTING

Primary care medical clinic in a large integrated delivery system.

PARTICIPANTS

Nine clinicians (6 physicians, 2 physician assistants, and 1 nurse practitioner) and 54 patients.

RESULTS

The introduction of computers into the exam room affected the visual, verbal, and postural connection between clinicians and patients. There were variations across the visits in the magnitude and direction of the computer's effect. We identified 4 domains in which exam-room computing affected clinician-patient communication: visit organization, verbal and nonverbal behavior, computer navigation and mastery, and spatial organization of the exam room. We observed a range of facilitating and inhibiting effects on clinician-patient communication in all 4 domains. For 2 domains, visit organization and verbal and nonverbal behavior, facilitating and inhibiting behaviors observed prior to the introduction of the computer appeared to be amplified when exam-room computing occurred. Likewise, exam-room computing involving navigation and mastery skills and spatial organization of the exam-room created communication challenges and opportunities. In all 4 domains, there was little change observed in exam-room computing behaviors from the point of introduction to 7-month follow-up.

CONCLUSIONS

Effective use of computers in the outpatient exam room may be dependent upon clinicians' baseline skills that are carried forward and are amplified, positively or negatively, in their effects on clinician-patient communication. Computer use behaviors do not appear to change much over the first 7 months. Administrators and educators interested in improving exam-room computer use by clinicians need to better understand clinician skills and previous work habits associated with electronic medical records. More study of the effects of new technologies on the clinical relationship is also needed.

Physical therapists' nonverbal communication predicts geriatric patients' health outcomes

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. Brief samples of therapists' nonverbal behavior were rated by naive judges. Judges' ratings were then correlated with clients' physical, cognitive, and psychological functioning at admission, at discharge, and at 3 months following discharge. Therapists' distancing behavior was strongly correlated with short- and long-term decreases in their clients' physical and cognitive functioning. Distancing was expressed through a pattern of not smiling and looking away from the client. In contrast, facial expressiveness, as revealed through smiling, nodding, and frowning, was associated with short- and long-term improvements in functioning. In Study 2, elderly subjects perceived distancing behaviors of therapists more negatively than positive behaviors.

Covert communication in classrooms, clinics, courtrooms, and cubicles

Interpersonal expectancy effects refer to the phenomena whereby one person's expectation for another person's behavior comes to serve as a self-fulfilling prophecy. The author examines the history and diversity of this area of inquiry, showing that the expectations of psychological researchers, classroom teachers, judges in the courtroom, business executives, and health care providers can unintentionally affect the responses of their research participants, pupils, jurors, employees, and patients. Using meta-analytic procedures, the author examines (a) moderator variables associated with the magnitude of interpersonal expectancy effects and (b) mediator variables implicated in the communication of interpersonal expectations. The author considers the social importance of the magnitudes of the obtained effects and points out research still needed to clarify issues in the mediation of these effects.

Surgeons' tone of voice: a clue to malpractice history

BACKGROUND

Interpersonal aspects of care, such as the communication behaviors of physicians, are often cited as central to patients' decisions to initiate malpractice litigation. Relatively little is known, however, about the impact of the communication behaviors of surgeons. In the current study, we investigated the relationship between judgments of surgeons' voice tone and their malpractice claims history.

METHODS

We examined the relationship between surgeons' voice tone during routine office visits and their history of malpractice claims. Surgeons were audiotaped while speaking to their patients during office visits, and very brief samples of the conversations were rated by coders blind to surgeons' claims status. Two 10-second clips were extracted for each surgeon from the first and last minute of their interactions with 2 different patients. Several variables were rated that assessed warmth, hostility, dominance, and anxiety from 10-second voice clips with content and 10-second voice clips with just voice tone.

RESULTS

Controlling for content, ratings of higher dominance and lower concern/anxiety in their voice tones significantly identified surgeons with previous claims compared with those who had no claims (odds ratio [OR] 2.74, 95% confidence interval [CI] 1.16 to 6.43 for dominance; OR 0.46, 95% CI 0.21 to 1.01 for concern/anxiety).

CONCLUSIONS

Surgeons' tone of voice in routine visits is associated with malpractice claims history. This is the first study to show clear associations between communication and malpractice in surgeons. Specific types of affect associated with claims can be judged from brief audio clips, suggesting that this method might be useful in training surgeons.

The voice of emotional memory: content-filtered speech in panic disorder, social phobia, and major depressive disorder

We asked patients with either panic disorder, social phobia, or major depressive disorder and healthy control participants to describe their most frightening experience and to describe an emotionally neutral experience. Both fear and neutral autobiographical memories were audiotaped and processed through a low-pass filter that eliminated frequencies above 400 Hz, thereby abolishing semantic content but leaving paralinguistic aspects like rate, pitch, and loudness intact, and these convey emotional cues. Raters blind to content and diagnosis rated the content-filtered speech clips on emotional dimensions. The results revealed that content-filtered fear memories received significantly higher ratings on anxious, aroused, and dominant (but not sad or negative) scales than did content-filtered neutral memories, irrespective of the diagnostic status of the speaker. Content-filtered speech appears promising as an on-line probe of emotional processing during accessing of autobiographical memories.

Clinicians' impact on the quality of substance use disorder treatment

Clinicians' impact on substance use disorder treatment has been much less studied than therapy and patient variables. Yet, in this selective review of literature, a growing body of empirical work on clinicians' impact highlights several key issues that have relevance both to clinical practice and future research. These issues include clinicians' effect on treatment retention and outcome, professional characteristics, recovery status, adherence to protocols, counter-transference, alliance, personality, beliefs about treatment, and professional practice issues. Specific recommendations are offered to help improve the quality of care clinicians provide. In particular, it is suggested that greater accountability for clinicians' performance be balanced with increased support for their very difficult role. Methodological issues in studying clinicians are also addressed.

Variations in therapist effectiveness in the treatment of patients with substance use disorders: an empirical review

Despite the widespread use of psychotherapy for patients with substance use disorders, the effectiveness of psychotherapists conducting such treatment has received little research attention. In this paper, empirical studies of therapists' differences in patient outcome and dropout rates are comprehensively reviewed. The main conclusions are that therapists show diverse rates of effectiveness, and that such differences appear independent of both therapists' professional background and of patient factors at the start of therapy. The primary therapist characteristic thus far associated with higher effectiveness is the possession of strong interpersonal skills. Guidelines for research on therapist effectiveness are presented.

Attitudes toward problem drinkers, revisited: patient-therapist factors contributing to the differential treatment of patients with alcohol problems

Although there are many treatment alternative open to people with drinking problems, health professionals still exhibit negative attitudes towards alcoholics. In a previous study, the author demonstrated that those patients who were self-labelled alcoholics were treated in a less preferential manner than those who did not identify as such. This study used both overt and unobtrusive measures to determine whether negative attitudes of intake interviewers towards problem drinkers were elicited by the patients' self-label as an alcoholic or by other variables related to perceived treatment outcome. Pre- and postinterview data on patient likability, doctor's eagerness to work with the patient, interview content, treatment disposition, and patient compliance were collected from first-time patients, and from their interviewers, in the walk-in psychiatry and alcohol treatment units of a large, urban teaching hospital. The results elucidate how stereotypes interact with patient characteristics to influence both professional behavior and patient compliance.

It's how you say it: physicians' vocal behavior

The present study was designed to assess evaluations of physicians interacting with patients via the telephone. Observers used ten adjective scales which resulted in three variables: empathic, dominant, and calm. Thirty doctor-patient interactions were presented in two different communication modes: audio-only and typed transcript-only. As predicted, female listeners rated doctors as more empathic, dominant, and calm, and communication modes were significantly different with audio segments rated as more empathic, dominant and calm. Middle phases of the conversation also were evaluated more positively than greeting phases. Significant interactions between temporal phase and mode indicated that audio segments were interpreted more positively during middle phases. Also, female listeners were more sensitive to audio segments. Physicians' amplitude and speech rate were positively correlated with dominance.

Improving physician-patient interactions: a review

The interaction between physician and patient comprises aspects of communication common to any two human beings and other aspects peculiar to the roles exclusively adopted by physicians and patients. In this review, nonverbal and verbal elements of general communication are discussed, detailing important aspects of vocal tone, body postures, appearance, and verbal cues that may influence attributions made of physicians by patients. Role-related elements of physician-patient interactions are discussed in light of findings from research on interactions between physicians and patients. Developmental elements of general communication are discussed, relating stages tht evolve in interactions to physician-patient interactions. Finally, an examination is made of how interpersonal skills are taught to physicians and medical students. Discussion of what skills are specified for teaching, whether they are effectively taught, and whether the learning of these skills produces desired patient health-related outcomes is presented.

The use of systematic encouragement and community access procedures to increase attendance at Alcoholic Anonymous and Al-Anon meetings

A difficulty in the treatment of alcoholism is that many alcoholics referred to treatment programs never reach the referral destination, or if they do, they seldom remain involved in those programs. The present study attempted to increase participation in Alcoholics Anonymous and Al-Anon meetings. Twenty clients were selected from an outpatient mental health alcoholism treatment program and randomly assigned to either a standard referral procedure which involved giving the client information about Alcoholics Anonymous or Al-Anon; encouraging the client to attend; and providing information concerning time, date, and location of weekly meetings; or to a systematic encouragement and community access procedure which involved a phone call being made in the counseling session to a local Alcoholics Anonymous or Al-Anon member in which the member briefly talked to the client about the meeting, offered to give a ride to the client and to meet the client before the meeting and having the Alcoholics Anonymous or Al-Anon member call the client the night of the meeting to remind them of it and to encourage them to come. The results of this study showed that 100% of the experimental group attended Alcoholics Anonymous or Al-Anon within 1 week of referral and continued to attend, whereas none of the control group ever attended. The results of this study suggest that the systematic encouragement and community assess procedure are significantly more effective than standard referral systems.

Affect and verbal-nonverbal discrepancy in schizophrenic and non-schizophrenic family communication

Verbal and nonverbal communication of affect was examined in schizophrenic and control families, using audio tapes and transcripts of family interactions. In Study 1, data were available for parents interacting with their schizophrenic child (index session) or with a well child (well-sibling session), and for two parent-child sessions in normal families. In Study 2, data consisted of index sessions only with schizophrenic, non-schizophrenic psychiatric, and normal families. Audio tapes were electronically filtered, and ratings were obtained on nonverbal (filtered speech) and verbal (transcript) samples. The double-bind hypotheses of different nonverbal expression of affect and greater verbal-nonverbal discrepancy in schizophrenic as compared to normal families were not supported. In both studies no overall differences were found between diagnostic groups in terms of nonverbal ratings, indicating that clinical perceptions of inappropriate and conflicted affect in schizophrenic families are not based on spontaneously produced simultaneous discrepancy between verbal and nonverbal channels of spoken communication.

Patient participation in the patient-provider interaction: the effects of patient question asking on the quality of interaction, satisfaction and compliance

The purpose of this study was to investigate the effectiveness, dynamics, and consequences of a health education intervention designed to increase patient question asking during the patient's medical visit. Data were collected at a Baltimore family and community health center which provides outpatient services to a low income, predominantly black and female population. The majority of the study participants were, in addition, elderly and chronically ill. A total of 294 patients and 3 providers took part in the study. The study design included random assignment of patients to experimental and placebo groups with two non-equivalent (non-randomized) control groups. Findings included: (1) The experimental group patients asked more direct questions and fewer indirect questions than did placebo group patients. (2) The experimental group patient-provider interaction was characterized by negative affect, anxiety, and anger, while the placebo group patient-provider interaction was characterized as mutually sympathetic. (3) The experimental group patients were less satisfied with care received in the clinic on the day of their visit than were placebo patients. (4) The experimental group patients demonstrated higher appointment-keeping ratios (an average number of appointments kept divided by an average number of appointments made) during a four-month prospective monitoring period.

Minimal cues in the vocal communication of affect: Judging emotions from content-masked speech

Vocal expressions of emotions taken from a recorded version of a play were content. masked by using electronic filtering, randomized splicing and a combination of both techniques in addition to a no-treatment condition in a 2×2 design. Untrained listener-judges rated the voice samples in the four conditions on 20 semantic differential scales. Irrespective of the severe reduction in the number and types of vocal cues in the masking conditions, the mean ratings of the judges in all four groups agreed on a level significantly beyond chance expectations on the differential position of the emotional expressions in a multidimensional space of emotional meaning. The results suggest that a minimal set of vocal cues consisting of pitch level and variation, amplitude level and variation, and rate of articulation may be sufficient to communicate the evaluation, potency, and activity dimensions of emotional meaning. Each of these dimensions may be associated with a specific pattern of vocal cues or cue combinations. No differential effects of the type of content-masking for specific emotions were found. Systematic effects of the masking techniques consisted in a lowering of the perceived activity level of the emotions in the case of electronic filtering, and more positive ratings on the evaluative dimension in the case of randomized splicing. Electronic filtering tended to decrease, randomized splicing tended to increase inter-rater reliability.