Nonverbal Communication in Suicide Assessment

Summary: Suicide in correctional facilities is one of the most pressing problems faced by clinicians today. Suicide assessment has long relied on primarily verbal methods such as patient interviews and verbal or written suicide assessment resources. While these are helpful, and often reliable, these techniques do not identify the suicide denier. Nonverbal communication, which is not under the patient’s conscious control, may help identify the elusive suicide denier.

 

Abstract: The challenge of identifying suicidal people during an assessment has developed, over the years, into a mainly verbal evaluation, often relying on psychological tests, such as the Beck Inventories ([1] Beck, A: Pearson Assessments: https://www.pearsonassessments.com), Suicide probability Scale ([2] Cull, J and Gill, W: Suicide Probability Scale; WPS Publishing, 1982), and [3] MMPI Scales (Pearson Assessments: https://www.pearsonassessments.com), and mnemonic devices, like the SAD PERSONS Scale ([4] Wikipedia, 2024) and IS PATH WARM ([5] Wikipedia, 2024). These devices are extremely helpful to measure or document ideation and intent; however, they are face valid and can be time-consuming and expensive. In addition, it is obvious to the person being evaluated, which direction to answer if one wants to be left alone.

 

A person may self-identify as suicidal, which greatly assists the evaluator, but has the possibility of false positives. As a clinician, this does not seem a great a liability as suicide, so we are generally happy to accommodate this person. However, a person with strong suicidal intent has a vested interest in not sharing this information.

 

There are individuals who are suicidal, but will not be willing to disclose this, either verbally in interview, or on suicide scales or psychological tests. Identifying these persons is the art and science of suicide prevention.

 

People will tell you things nonverbally. Body posture, gait, eye gaze, and facial expression all reveal something about a person’s inner world. According to Albert Mehrabian, body language accounts for 55% of communications, 38% comes from tone of voice, and 7% comes from our actual words ([6] Mehrabian, A, Silent Messages: 1^st Edition: Belmont, CA: Wadsworth, 1971.).

 

Nonverbal behavior is not usually under voluntary control, and it cannot be faked, thus making it more trustworthy than verbal reports. The behavior in question occurs in a fraction of a second. It has been described as a “slice” of behavior ([7] Slepian, M and Bogart, K Thin Slice; Judgments in the Clinical Context: Annual Review of Clinical Psychology Vol. 10, 2014). Nevertheless, we are able to see and respond to these unspoken cues.

 

Nonverbal communication involves sending and receiving information through wordless clues. These indicators include:

1. Kinesics: Gestures, head movements and posture, eye contact and facial expression as non-verbal communication ([8] Muhammad, L, Villarreal, G, The Great Value of Non-Verbal Communication to Assess Suicide Risk in a Patient with Schizophrenia; Journal of Behavior, Albuquerque, New Mexico, 2017). The open body position suggests approachability and creates positive attitudes in receivers while the closed body position suggests a person who is closed off. Gestures and hand movements can send signals of agreement or disagreement. Body posture can communicate hostility, aggressiveness, submission, or defensiveness (ibid.). Eye contact can communicate intensity, hostility, assertiveness, and sadness. 
   
   When used in conjunction with a verbal report, these clues can be even more important. Consider the person with overtly angry affect and expression who denies the feeling of anger, or the patient who reports that he or she is fine with sad affect and noticeably swollen and red eyes. Note that facial expressions may be more limited in patients with blunted affect, making some clues less detectable.
   
   Fiquer, Boggio, and Gorenstein ([9] 2013) found that high energy and social interaction were indicated by eye contact, symmetric smile, illustrative gestures, raised brows, yes/no nodding, head up, head to side, verbal backchannel, and body posture in relation to the interviewer. Low energy, negative feelings, and/or social disinterest (which are frequent symptoms of depression) were indicated by folded arms, head down, shrug, asymmetric smile, adaptive gestures, crying, frowning, tight lips, lips down, and silence (ibid.).
   
   Some of the behaviors seen in people prior to committing suicide in correctional facilities were “pacing the cell,” “acting very peculiar,” “He was constantly watching the window in his cell door. ([10] Hayes, L: Suicide Risk despite Denial (Or When Actions Speak louder Than Words) Jail Suicide/Mental Health Update; Vol. 17, No. 1, Summer, 2007).” Agitation was also observed prior to completed suicides: “(He was) unstable, crying, rocking back and forth, rubbing his hands through his hair, holding his head tightly…” Lindsay Hayes observes “Once the decision to commit suicide has been made, a once agitated and/or despondent patient now feels a sense of relief and may display a sense of calm (ibid.).”
   
   
2. Proxemics: This refers to how space and distance influence communication. Muhammad, et al suggest that clinicians monitor any changes in the patient’s proxemics and be able to notice any changes. Patients may position themselves so that they are not in direct line of sight of the examiner, which is akin to the closed off position. Sometimes how a patient is feeling can be translated into physical distance as well.

3. Vocalics: This includes the vocal qualities that accompany speech, such as pitch, volume, rate, vocal quality, and prosody. Prosody refers to the qualities of speech, including duration, intensity, and pitch. Very soft voices are sometimes linked with depression, but beware the person who purports to be fine, but says this wistfully. This behavior is incongruent with the verbal report of “fine.”

4. Haptics: This refers to the study of communication by touch. While these clues can be more limited in the correctional setting, the patient may touch his hands or face, or objects during the interview, and the clinician can notice any changes in behavior.

Clinicians who are making determinations of suicide risk need to be aware of attempts to deceive. Persons who deny suicidal intent may give behavioral clues to their genuine thoughts, feelings, and more importantly, future suicidal behavior. It is important to observe when a patient’s nonverbal communication does not match the verbal report.

 

Studies

Ekman and his colleagues developed the Facial Action Coding System found that two specific behaviors related to deception ([11] Ekman., P, Friesen, WV: Nonverbal Leakage and Clues to Deception. Psychiatry 1969; 32 (1):88-106.). The first is the Imposter smile. The Imposter smile is hiding something. This smile is consciously produced to bring about a desired effect. This smile is deliberately produced to conceal the experience of negative emotion ([12] Khushminder, C, The Utility of Assessing Nonverbal Communication in the Psychiatric Evaluation; The American Journal of Psychiatry Resident’s Journal: August 2017). The Imposter smile does not activate the muscles around the eye orbits; thus, it is a smile that does not reach the eyes.

 

The Imposter Smile should be distinguished from the “Duchenne smile.” The “Duchenne smile” is a smile of genuine enjoyment and the positive effects of happiness ibid. ([11] Ekman., P, Friesen, WV: Nonverbal Leakage and Clues to Deception. Psychiatry 1969; 32 (1):88-106). The genuine smile cannot be faked. When the “Duchenne smile” is falsified, the facial muscled do not act the same. There is leakage of those muscles that cannot be contained (ibid.).

 

The second behavior related to deception is the facial expression for “disgust” ([12] Khushminder, C, The Utility of Assessing Nonverbal Communication in the Psychiatric Evaluation; The American Journal of Psychiatry Resident’s Journal: August 2017). Disgust is a feeling of revulsion or disgust aroused by something unpleasant or offensive; therefore, a person will attempt to remove the disgusting stimulus, whether it is a physical substance or thought (ibid.). This expression consists of a raised upper and lower lip, a raised and wrinkled nose, lowered eyebrows, and raised cheeks (ibid.). Disgust is an important clue, especially when made in the context of denying suicidality and/or agreeing to ask for help.

 

Heller and Haynal ([13] 2005) observed that the emotional expression for “contempt” was seen in 5 of the 17 suicidal depressed patients in their study, but none of their nonsuicidal depressed patients displayed this feeling. They also found that suicidal depressed patients show a reduced activity in the upper face compared to nonsuicidal depressed patients (Heller, M, and Haynal, V: Depression and Suicide Faces; aqualide.com). No sadness or disgust was seen in the faces of suicidal reattempt patients, only contempt. Finally asymmetric expressions were only observed among suicidal patients, particularly the suicidal patients with reattempts (ibid.).

 

One study followed 59 patients who were admitted to a hospital after a suicide attempt. Following videotaped interviews of these patients a psychiatrist assessed their suicide risk on a four-point scale. At a 24-month follow-up, ten patients had re-attempted suicide. They were matched with 11 of the non-repeaters, on age, gender, and number of previous suicide attempts. The Facial Action Coding System (FACS) was used to analyze behavioral differences between groups. Results indicated average activation of all coded units, peri-ocular activation, and duration of the psychiatrist’s gaze straight at the patient, were all significantly higher, and distinguished accurately 88-90% of the patients who later attempted suicide. Of note, the doctor’s written predictions classified the suicide risk of the patients correctly only 22.7% of the time. ([14] Haynal-Reymond, V, Jonsson, GK, and Magnusson, M: Nonverbal Communication in Doctor Patient Interview: Amsterdam IOS Press, 2005). The psychiatrist scrutinized the repeater suicide attempt longer than the non-repeaters, and thus may have been more disruptive for her. This study concluded that the “dance” performed by the therapist and patient yields information on body and facial movement that can be used to differentiate patients’ suicide risk.

 

Using the same data set as the above study Heller, Haynal-Reymond, Haynal, and Archinard [15] found that a combination facial action units in both doctor and patient discriminated 80% of those patient’s suicide reattempt risk. Lip movements are representative of an “ostentatious way of regulating disagreeable feelings (Italics in original),” according to the authors. They posit that this implies three steps; 1) Patient feels a blend of strong feelings, such as sadness, despair, anger, or contempt. 2) Patient needs to keep these feelings under control in order to prevent an outburst. 3) Patients explicitly communicate that he or she is making a considerable effort to self-regulate such feelings (ibid.). 

 

This study also demonstrated that suicide re-attempter patients had a systematic tendency to display more oral activation than attempters (ibid.). One variable, the chin raise, discriminated patient’s suicide reattempt risk at an efficiency of 78%, with the suicide re-attempter raising their chins. The authors speculate that this sis because the chin raise is clearly involved in expressions of sadness or despair. 

 

Clinical Cases

A 25-year-old patient with Schizophrenia had been seen in an outpatient psychiatric facility for two years ([8] Muhammed, L and Villareal, G: The Great Value of Non-Verbal Communication to Assess Suicide Risk in a Patient with Schizophrenia; University of New Mexico, Albuquerque, 2016). He had 5 previous suicide psychiatric hospitalizations and one serious suicide attempt two years ago in which he inflicted a stab wound to the anterior neck requiring emergency surgery. During a routine screening for suicide, the patient denied suicide ideation and described plans for the future. His mental health provider was familiar with his non-verbal behavior and noted these changes from baseline: His prosody of speech was different (including duration, intensity, and pitch of speech), the patient was guarded (looked like he was cautious and having possible reservations) while speaking about his future, his posture changed from being open (sitting with open legs, and open arms) to closed (arms and legs crossed), he also lost eye contact for a while talking about his future. The patient’s change in nonverbal behavior, which was incongruent to his spoken words, prompted the interviewer to explore further, which eventually revealed that the patient had a plan to kill himself “I found the 100% sure way to kill me if I shoot myself in the eye (ibid.).”

 

A young man was seen for a suicide assessment following a suicide attempt by ligature. He required medical attention in order to revive him. On presentation the next day, he reported that he was deeply sorry about his suicide attempt. He said that he was so very happy that he had survived. His affect was outwardly bright, but it appeared to be forced. He denied suicidal ideation vigorously. His eyes were bloodshot from his prior suicide attempt. Because the nonverbal cues were incongruent to his behavior, and due to the fact that the crisis precipitating his suicide attempt remained unresolved, he remained on a continuous suicide watch. In an interview the following day, he appeared and he sounded depressed. He said that yesterday he wanted to kill himself with a ligature that he had in his possession, and would have attempted suicide again. 

 

Nonverbal Indications of Suicide:

The patient presents as guarded while denying suicide

The patient makes little to no eye contact while denying suicide

The patient’s speech (prosody) has changed during suicide assessment 

Increased nervousness, increased eye blinking, fidgeting during assessment, or

Patient presents as calm and upbeat, but this causes an effort to maintain

Incongruence between stated content and facial expression

You feel that this interview is more taxing than others

 

Summary:

Persons who want to commit suicide may not verbalize these thoughts and feelings to their clinician. Nonverbal communication provides useful information about a person’s overall mood and the suicidal intent of a person, even if he or she does not report suicidal ideation. When there are inconsistencies in different modes of communication, tone, voice, and bodily movement are more trustworthy than verbal content. Careful attention to any incongruence occurring between the spoken words of a patient, and his or her nonverbal behavior, can save a life.

 

References

1. Beck Scales: Pearson Assessments: https://www.pearsonassessments.com
2. Cull, J and Gill, W: Suicide Probability Scale; WPS Publishing, 1982
3. MMPI Scales (Pearson Assessments: https://www.pearsonassessments.com
4. SAD PERSONS Scale (Wikipedia, 2024) 
5. IS PATH WARM (Wikipedia, 2024)
6. Mehrabian, A, Silent Messages: 1^st Edition: Belmont, CA: Wadsworth, 1971
7. Slepian, M and Bogart, K Thin Slice; Judgments in the Clinical Context: Annual Review of Clinical Psychology Vol. 10, 2014
8. Muhammad, L, Villarreal, G, The Great Value of Non-Verbal Communication to Assess Suicide Risk in a Patient with Schizophrenia; Journal of Behavior, Albuquerque, New Mexico, 2017
9. Fiquer, JT, Boggio, PS, and Gorenstein, C: Talking Bodies: Nonverbal Behavior in the Assessment of Depression Severity; Journal of Affective Disorders, Vol. 150, Issue 3, 2013
10. Hayes, L: Suicide Risk Despite Denial (Or When Actions Speak Louder Than Words, Jail Suicide/Mental Health Update; Vol. 17, No. 1, Summer, 2007
11. Ekman, P, Friesen, WV: Nonverbal Leakage and Clues to Deception. Psychiatry 1969; 32 (1):88-106
12. Khushminder, C, The Utility of Assessing Nonverbal Communication in the Psychiatric Evaluation; The American Psychiatry Resident’s Journal: August 2017
13. Heller, M, and Haynal, V: Depression and Suicide Faces; aqualide.com, 2005
14. Haynal-Reymond, V, Jonsson, GK, and Magnusson, M: Nonverbal Communication in Doctor Patient Interview: Amsterdam IOS Press, 2005
15. Heller, M, Haynal-Reymond, V, Haynal, A, and Archinard, M: Can Faces Reveal Suicide Risks? In The Flesh of the Soul; Bern, 2001: Peter Lang