In previous columns I have talked about the various ways we communicate with our patients. Here, I shall be discussing a silent dialogue and, as the title suggests, how space speaks. It deals with such questions as: How much personal space do patients want when talking with a doctor or nurse? How close should one be to others in conversation? It is interesting to note how threatened certain individuals feel when health professionals invade their territory; it often disrupts their psychological homeostasis, creates anxiety, and produces feelings of loss of control. This is particularly so in acute care settings where trespassers enter without knocking, perform various procedures, and leave without saying a word.
World famous anthropologist, Edward Hall, coined the term "proxemics." He defined it as the interrelated observations and theories of man's use of space as a specialized elaboration of culture. When we use the space that can be perceived directly, we are communicating within the proximate environment, i.e., everything that is physically present to the individual at a given moment. To better understand proxemic communication, five interrelated concepts must be taken into consideration: space, distance, territory, crowding, and privacy. Let us look at each of these concepts and, in turn, see how they relate to the practice of chiropractic.
Hall speaks of three types of space: fixed, semifixed, and formal. Fixed space in a doctor's office is correlated with function, e.g., treatment room, waiting room, consultation room, bathroom, etc. Each has a fixed function. Semifixed space refers to the placement of things in the doctor's office; e.g., furniture, plants, modalities, adjusting tables, and file cabinets. These items quality as semifixed because of their flexible function; they can be moved about according to personal preference. Perhaps the most important communicative function of semifixed space is the degree to which it promotes involvement or withdrawal between those using such space (doctor, nurse, receptionist, patient).
Another dimension of space is its non-fixed feature; it is the space that immediately circumscribes every individual. For example, every doctor and patient has a personal bubble -- an invisible sphere that surrounds them and, by so doing, predetermines their degree of approachability. This bubble, however, is not symmetrical. Some patients have little difficulty with frontal closeness, but are extremely uncomfortable when approached from behind. Still others have varying degrees of discomfort with lateral closeness. Patients, therefore, may prefer certain techniques over others. Only experience, sensitivity, and awareness will enable the doctor to determine which techniques are most compatible with a patient's proxemic preference.
The negotiation of space in your office should be dictated by certain professional parameters. Which of us has not observed a new patient, unfamiliar with an office layout, inadvertently enter a room where another patient is either undressing or receiving treatment? Patients must be oriented to how space is organized and managed in your office.
In some busy offices, patients are often seated in the waiting room according to their turn. As one patient goes in, another patient moves up. If no such arrangement exists, patients are often confused as to who goes in next. In most offices, however, the nurse or receptionist calls out the name of the next patient to be seen by the doctor.
Once a patient has begun treatment and comes on a regular basis, another proxemic phenomenon may occur. Some patients acquire a preference for a particular treatment room or treatment table. If it is occupied, they may be willing to wait until it becomes available. Both patients and health teams very quickly establish an explicit management of their particular space.
In the doctor's private office, the seating arrangement also deserves proxemic consideration. As a rule, the doctor sits behind a desk and the patient sits in a chair located at the side of the desk. While this spatial arrangement is traditional, it does not always facilitate direct eye contact. The kitty-cornered placement of the patient's chair, unless the patient turns slightly in the doctor's direction, causes an oblique interaction. The doctor can usually adjust to this situation because of a chair that swivels; the patient cannot. To avoid such physical obliquity, simply have the patient's chair face the doctor more directly. Another spatial imperative to be acknowledged is the doctor-patient field of vision. It should not be obstructed by a desk lamp or any other object that can occlude their line of sight.
Territories have been categorized into two classes: primary and secondary. An example of primary space would be the doctor's private office. Also included under this designation would be the doctor's patient files. Primary territories are most often respected by other members of the staff and not violated by encroachers without explicit permission from the doctor. The desk of a nurse or secretary, likewise, qualifies as primary territory not to be violated without specific permission.
Secondary territories are not usually central to the functioning of the doctor or nurse. The waiting room, unless otherwise indicated, could be taken to be a secondary territory because patients can usually sit where they please, change seats, or sift through available magazines. Where a television set is present, patients may be extended the privilege of changing channels.
Space management in treatment rooms also requires special mention. Because we lay on hands unlike any other branch of the healing arts, space-centered interpersonal relationships take on a uniquely personal character. We are, forever, invading the patient's bubble. While most patients recognize the necessity for such physical proximity, they may not always feel psychologically at ease when the doctor must assume a particular body position in order to execute a certain move. Without openly admitting it, the shy or introverted patient could be made to feel somewhat apprehensive when obliged to sit or lie in a given position. If a patient demonstrates discomfort or displeasure with a particular form of adjustment, it behooves the doctor to find an alternative technique.
While accommodating a patient's territorial idiosyncrasies may not always be possible, it is incumbent upon the doctor to be aware of them. Though seemingly unimportant, the placement of a patient's clothes could generate some uneasiness, i.e., moving their clothes to another room without their knowledge. To insure a greater sense of security, patients and their clothes should be kept as close to one another as possible.
No matter how we discuss the role space plays in the administration of chiropractic care, all individuals will be found to have well-developed proxemic expectations. Whether standing on a street corner waiting for a bus with others, seated on a crowded train, or eating in a busy restaurant, expectations with regard to interpersonal distancing are rather specific and quite predictable. These very same attitudes are present among recipients of chiropractic health care.
When people are not feeling well, their territorial sensibilities are apt to change; they may prefer to be left alone or, perhaps, resent anyone coming too close. Still others may perceive physical closeness as an indicator of psychological caring or concern. I say this to emphasize the fact that people who are hurting often tolerate space differently.
Whereas it is beyond the purview of this article to explore the cross-cultural implications of territoriality, there are many differences. As a brief example, research has indicated that North Americans feel more comfortable when interacting at great distances. They have the reputation of being a non-contact culture. Other non-contact cultures include Northern Europeans, Asians, Pakistani, and Indians. Contact cultures include Latin America, Southern Europeans, and Arab people. Space indeed speaks many languages.
The attitudes, values, and beliefs of a culture are ultimately revealed by the way they handle space. Here are a few examples: Germans object to individuals who get out of line. They have long emphasized orderliness and clearly demarcated territories, e.g., keep out, authorized personnel only.
Americans, unlike the Japanese, perceive space as "empty." In Japan, space is assigned specific meanings: intersections are given names, but not streets. The particular space, with its functional characteristics, is the thing of importance. The given space in a room serves a number of functions because the Japanese use movable walls and separators and, thereby, create the kinds of space they desire.
While Americans covet privacy by demanding their own offices and maintain their distance from others, Arabs know no such thing as privacy in public. In fact, they are offended by anything less than intimacy during a face to face conversation; it is commonplace for them to make eye contact, touch hands, and breathe into each other's face -- sensory inputs which Europeans find unbearably intense.
Perhaps the best way to appreciate how you handle space is to reflect upon your own territorial preferences. For instance, how many inches (nose-to-nose) do you customarily stand when in conversation with patients, friends, colleagues, and loved ones? How close will you allow them to stand before you become uncomfortable? If you don't know, test yourself by standing three to four inches closer to everyone you meet tomorrow. Notice your own reaction and the reaction of the person with whom you are speaking. While these distances will vary according to such factors as age, relationship, temperament, occupation, culture, and circumstance, the experience should provide you with a greater understanding of how space communicates.
The bottom line is this: As long as doctors maintain a distance their patients perceive as comfortable or appropriate, such physical proximity will be associated with trust, caring, credibility, honesty, and friendship. In summary, total healing may well depend upon the physical distance you maintain with your patients, not solely upon your therapeutic skill.
Abne Eisenberg, D.C., Ph.D.
Croton-on-Hudson, New York
Editor's Note:
As a professor of communication, Dr. Eisenberg is frequently asked to speak at conventions and regional meetings. For further information regarding speaking engagements, you may call (914) 271-4441, or write to Two Wells Avenue, Croton-on-Hudson, New York 10520.
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