“Nonverbals” Can Convey Implicit Bias

Kris English, PhD

Professor Emeritus, Audiology

The University of Akron

In an earlier installment, we learned that clinicians-in-training tend to report feeling more comfortable conveying empathy with nonverbal communication, compared to the worry about “finding the right words” – and on the receiving end, patients seem to prefer and appreciate “nonverbals” as well.

However, complications occur when clinicians and patients differ by race: in these circumstances, “nonverbals” may not communicate empathy as intended. Nonverbal communication behaviors (NCBs) – eye gaze, body language, facial expressions, tone of voice – are usually unconscious and automatically activated, and therefore difficult to control and monitor.1 Since the 1930’s, researchers have consistently found that NCBs tend to communicate our unconscious (implicit) biases, usually without our awareness or intention.2,3 For example, in cross-racial appointments, clinicians with high implicit bias are likely (without realizing it) to speak faster, make less eye contact, rush appointments, and be less patient-centered.4,5 It is vital to appreciate that NCBs “reflect feelings and intentions that often go unspoken; they mirror and reinforce dominance and status hierarchies; they illustrate, buttress, and occasionally contradict the verbal stream…“ (p. 671).2

(Click here for an indepth description of “The Neuroscience of Prejudice and Stereotyping”)

Not surprisingly, within a matter of seconds, racial and ethnic minority patients perceive the “unspoken” and understandably distrust the overall situation, including clinical recommendations.6,7 We cannot ignore how this dynamic undermines our goal of providing racially equitable healthcare – indeed, we are obligated to address the problem.

Implicit racial biases are “habits of mind,” acquired and over-learned across time, and may seem intractable, given the uneven record for intervention effectiveness.8 However, when research focuses specifically on patient-centeredness, the results are more encouraging.9 For example, a systematic review (2017) showed that “irrespective of patient or physician race… when the physician displayed [nonverbal behaviors such as] positive emotion, made eye contact, and appeared attentive, physician race was not correlated to [negative] patient evaluations” (p. 416).10  

The research on patient-centered care reports similar results when measuring verbal behaviors.11,12  Not yet explained, however: when we actively strive for patient-centeredness, either verbally or nonverbally, the positive experience seems to matter more to a patient than the negative impact of implicitly biased “nonverbals.” While researchers work on this question, we should continue to encourage students to use “nonverbals” to communicate patient-centered, respectful empathy.

Time to “Reframe”?

Students of counseling theory will recall a basic principle of cognitive behavioral therapy (CBT):13 changing how we think helps us change how we feel and act.” Because of the emphasis on thinking, the interactivity of this theory’s components is often overlooked: in fact, each component influences the others. Using a classic CBT strategy, we can reframe the usual process, and describe a different approach: “changing how we act helps us change how we feel and think” as we work to break implicit-bias habits. Or, to put it more simply, “We are what we repeatedly do.”14

Three Take-Away Points

  1. Clinicians are generally unaware that their nonverbal behaviors can communicate implicit racial bias.
  2. Patients, on the other hand, can quickly “read” those behaviors and decide the clinician is not trustworthy.
  3. Intentional, mindful nonverbal patient-centered behaviors have the potential to assure patients that their clinician is committed to equitable health care.


  1. Baugh A., et al. (2020). Communication training is inadequate: The role of deception, non-verbal communication, and cultural proficiency. Medical Education Online, 25:1
  2. Dovidio JF, LaFrance M. (2013). Race, ethnicity, and nonverbal behavior. In J.A. Hall & M.L. Knapp, M. L. (Eds.), Nonverbal communication (pp. 671-695). Berlin: De Gruyter, Inc.
  3. Halberstadt AG. (1985). Race, socioeconomic status, and nonverbal behavior. In A. W. Siegman & S. Feldstein (Eds.), Multichannel integrations of nonverbal behavior (pp. 227–266). Hillsdale, NJ: Erlbaum.
  4. Penner LA, et al. (2010). Aversive racism and medical interactions with Black patients: A field study. Journal of Experimental Social Psychology, 46, 436–440.
  5. Cooper LA, et al. (2012). The associations of clinicians’ implicit attitudes about race with medical visit communication and patient ratings of interpersonal care. American Journal of Public Health, 102, 979-987.
  6. Castelli L, et al. (2012). The power of the unsaid: The influence of nonverbal cues on implicit attitudes. Journal of Applied Social Psychology, 42(6), 1376–1393.
  7. Dovidio JF, et al. (2002). Why can’t we just get along? Interpersonal biases and interracial distrust. Cultural Diversity & Ethnic Minority Psychology, 8, 88–102.
  8. FitzGerald C, et al (2019). Interventions designed to reduce implicit prejudices and implicit stereotypes in real world contexts: A systematic review. BMC Psychology, 7(29).
  9. Street R, et al. (2008). Understanding concordance in patient-physician relationships: Personal and ethnic dimensions of shared identity. Annals of Family Medicine, 6(3), 198-205.
  10. Lorié A, et al. (2017). Culture and nonverbal expressions of empathy in clinical settings: A systematic review. Patient Education and Counseling, 100, 411–424.
  11. Burgess D., et al. (2007). Reducing racial bias among health care providers: Lessons from social-cognitive psychology. Journal of General Internal Medicine, 22, 282-287.
  12. Penner LA, et al. (2014). A social psychological approach to improving the outcomes of racially discordant medical interactions. Journal of General Internal Medicine, 28(9), 1143-1149.
  13. Ellis A. (1992). Group rational-emotive and cognitive-behavioral therapy. International Journal of Group Psychotherapy, 42(1), 63-80.
  14. Durrant, W. (1927). The story of philosophy. NY: Simon & Schuster.