STATE UNIVERSITY OF MEDICINE AND PHARMACY

NICOLAE TESTEMITANU OF THE REPUBLIC OF MOLDOVA

Rodica GRAMMA, Adriana PALADI

BEHAVIORAL SCIENCES
Didactic material for medical students
COMPENDIUM

Chisinau, 2011

0
 STATE UNIVERSITY OF MEDICINE AND PHARMACY
NICOLAE TESTEMITANU OF THE REPUBLIC OF MOLDOVA

Chair of Philosophy and Bioethics

Rodica GRAMMA, Adriana PALADI

BEHAVIORAL SCIENCES
Didactic material for medical students
COMPENDIUM

Chisinau
Centrul Editorial-Poligrafic Medicina
2011

1
 CZU 316.62+ 316.77 (075.8)
G 76

Aprobat de Consiliul Metodic Central al USMF Nicolae Testemiţanu,

proces verbal nr. 2 din 18.03. 2010

Recenzenţi: Angela Spinei - doctor în filosofie, conferenţiar universitar (USM)

Tudor Grejdianu – dr. hab. în medicină, profesor universitar (USMF)
Redactor ştiinţific: Teodor N. Ţîrdea – dr. hab. în filosofie, profesor universitar
Coordonator: Vitalie Ojovanu, doctor în filosofie, conferenţiar universitar

În elaborare se realizează o incursiune în cele mai importante teme ale

ştiinţelor comportamentale, definindu-se concepte de bază, relatându-se variate
abordări, realizări şi probleme ale domeniului. Noţiunile cheie ale lucrării sunt:
comportament, comunicare, personalitate, sănătate, eficienţă etc. Compendiumul
este adresat studenţilor, cadrelor didactice şi tuturor celor interesaţi de
problematica domeniului.
The work includes the introduction into the most important themes of
behavioral sciences, via definition of the basic concepts, via exposure of different
approaches, achievements and problems of domain. The key words of the work
are: behavior, communication, personality, health, efficiency etc. The work is
designed for the students, professors and all interested in the subjects of matter.

DESCRIEREA CIP A CAMEREI NAŢIONALE A CĂRŢII

Gramma, Rodica; Paladi, Adriana
Behavioral sciences: Compendium. Didactic material for medical students /
Rodica Gramma, Adriana Paladi; red. Şt.: Teodor N.Ţîrdea; State Univ. Medicine and
Pharmacy „Nicolae Testemiţanu” of Rep. of Moldova, Chair of Philosophy and Bioethics.
– Ch.: CEP „Medicina”. 2011 – 158 p.
50 ex.
ISBN 978-9975-913-82-9
[316.62 +316.77]:61(075.8)
G76
ISBN 978-9975-913-82-9 © Catedra Filosofie şi Bioetică,
© CEP Medicina

2
Table of content

3
Preface……………………………………………………………… 5
1. Introduction in Behavioral Sciences
1.1.Behavior as a Concept …………………………………….. 6
1.2.Factors Influencing Human Behavior ……………………...
1.3. Abnormal Behavior ……………………………………….. 9
2. Behavior and Personality 18
2.1. Human Personality…………………………………………
2.2. Behavior and Temperament. Temperament Typology……. 27
2.3. Behavior and Human Somatic ……………………………. 29
2.4. Jung's Theory of Psychological Types ……………………. 31
3. Behavior and Society 38
3.1 The Society and its Structure ………………………………
3.2. The Concepts of Social Status and Role …………………... 45
3.3. Health Care as a Social System …………………………… 47
3.4. The Social Role of Doctors and Patients ………………….. 50
3.5. Deviations from the Role Obligations in the Doctor-Patient 58
Relationship ……………………………………………….
4. Communication. Definitions and Functions 67
4.1. What is Communication? ………………………………….
4.2. Communication Process..………………………………….. 73
4.3. Communication Functions ………… …………………….. 75
4.4. Communication and Health………………………………... 79
5. Metacommunication and Cultural Differences 81
5.1. Metacommunication as Interpretation ……………………..
5.2. Verbal Communication …………………………………… 88
5.3. Paraverbal Communication ……………………………….. 89
5.4. Body Language ……………………………………………. 93
5.5. Extraverbal Communication ……………………………… 94
5.6. Interaction of Verbal and Nonverbal Communication 101
……. 105
5.7. Appearance of Medical Students and Doctors. The Dress
Code…………………………………………………………….. 106
6. Barriers and Cleavages in Communication
6.1. Communication Distorting Factors ….……………………. 111
6.2. Stereotypes, Stigma and Discrimination ………………….. 117
6.3 Active Listening…………………………………………… 125

6.4 Barriers and Solutions for an Effective Medical 129

4
 Communication ...........................................................................
7. Behavior and Cultural Contexts 134
7.1. The Concept of Culture …………………………………… 135
7.2. Etiquette and Cultural Differences ………………………... 137
7.3. Conflict - Definition and Resolution ……………………… 142
7.4. Intercultural Communication……………………………….
8. Health Risk Behaviors and Communication in Risk Conditions. 146
8.1. Dangerous Factors Determining Appearance of Illness …... 147
8.2. Risky Health Lifestyles ………………………….………... 155
8.3. Behavior Change Communication …………………………

Preface

5
 What and how man is there are questions the humanity is interested in
for the ages but only in the modern times the more or less rigorous answers
are acquired. The modern sciences, shifting the accents and priorities in
studying humans and moving in deep, enrich our knowledge, enabling us for a
better understanding of human nature. What is really significant in this context
is that the modern argued approach to man, as to the bio-psycho-social
integrity, changes the dominant in present therapeutic attitudes towards person
as to the exclusively biologic entity. The hallmark for replacement of
biological therapeutic paradigm with that psychosomatic one is the inclusion
in medical schools’ curriculum the matter called Behavioral Sciences.
What are Behavioral sciences? It is a very complex domain; it is
actually a generic title of a cluster of discipline such as medical sociology,
medical psychology, communication sciences etc.
The textbook contains essential general issues in Behavioral sciences
and is designed to make an introduction in this field. Being conceived to cover
the most general and important subjects of the domain, it consists of eight
themes the content of which reveal the significance of such topics as: Normal
and Abnormal Behavior, Health risks behavior, Social roles of doctors and
patients, Physician – patient relationship, Human psychological types,
Communication and its significance in therapeutic context etc. At the end of
every theme the final questions and tasks are proposed so that to facilitate the
learning and at the same time to impulse for a critical thought. References to
the theme give the opportunity to study deeply the subject of interest.
The book is intended to familiarize the students with basic
achievements of behavioral sciences and to make them able to apply acquired
knowledge in their medical activity as well as in their daily life. At the end of
studying students are expected to know the human psychological types and
human behavior types, to understand their professional role (as doctors) as
well as the social role of their patients, to have the competences in constricting
an adequate communication and relationship in therapeutic context etc.
Knowledge acquainted with as a result of this textbook’s reading will aid the
students to be more self-confident and accordingly more efficient in their
future professional activity.

Chapter 1

6
 Introduction in Behavioral Sciences

Human behavior flows from three main sources:

desire, emotion, and knowledge
Plato

1.1. Behavior as a Concept

The concept of behavior became an important construct in early

20th century psychology. It was considered to be the phenomenon
passable for scientific analyses, and consequently the phenomenon
studying of which can lead us to the better understanding of human and
development. How can be defined this concept?
Behavior or behaviour is term refers to the actions of a system
or organism, usually in relation to its environment, which includes the
other systems or organisms around as well as the physical environment. It
is the response of the system or organism to various stimuli or inputs,
whether internal or external, conscious or subconscious, overt or covert,
and voluntary or involuntary. More generally, behavior can be regarded as
any action of an organism that changes its relationship to its environment.
Behavior provides outputs from the organism to the environment. It is
most commonly believed that complexity in the behavior of an organism is
correlated to the complexity of its nervous system. Generally, organisms
with more complex nervous systems have a greater capacity to learn new
responses and thus adjust their behavior. In the light of this supposition
human behavior is the most evolved or complex type. In Science and
Human behavior B.F. Skinner mentioned that human behavior is a
difficult subject matter, not because it is inaccessible, but because it is
extremely complex. Since it is a process, rather than a thing, it cannot
easily be held still for observation. It is changing, fluid, and evanescent,
and for this reason it makes great technical demands upon the ingenuity
and energy of the scientist. But there is nothing essentially insoluble about
the problems which arise from this fact. Nowadays behavior and
especially that human is studied by the many academic disciplines,

7
conventionally included in the domain called – domain of behavioral
sciences
Thus the term behavioral sciences (or behavioral sciences)
encompass all the disciplines that explore the activities of and interactions
among organisms in the natural world. It involves the systematic analysis
and investigation of human behavior through controlled and naturalistic
experimental observations and rigorous formulations. Behavioral sciences
include two broad categories: neural - decision sciences - and social -
communication sciences.
Decision sciences involves those disciplines primarily dealing
with the decision processes and individual functioning used in the survival
of organism in a social environment. These include anthropology,
psychology, cognitive science, organization theory, psychobiology, and
social neuroscience.
On the other hand, communication sciences include those fields
which study the communication strategies used by organisms and its
dynamics between organisms in an environment. These include fields like
anthropology, organizational behavior, organization studies, sociology and
social networks.
The material to be analyzed in a science of behavior comes from
two basic sources: observation and experiment. Observation is an act of
recognizing and noting a fact or occurrence often involving measurement
with instruments. Experiment can be define as an act or operation for the
purpose of discovering something unknown or of testing a principle,
supposition, etc. It is a test, trial, or tentative procedure etc. Therea many
kinds of observation and experiment. B.F. Skinner classified and described
them in this way:
(1) Casual observations. They are especially important in the early
stages of investigation. Generalizations based upon them, even without
explicit analysis, supply useful hunches for further study.
(2) In controlled field observation, the data are sampled more
carefully and conclusions stated more explicitly than in casual observation.
Standard instruments and practices increase the accuracy and uniformity
of field observation.
(3) Clinical observation has supplied extensive material. Standard
practices in interviewing and testing bring out behavior which may be
easily measured, summarized, and compared with the behavior of others.
Although it usually emphasizes the disorders which bring people to

8
clinics, the clinical sample is often unusually interesting and of special
value when the exceptional condition points up an important feature of
behavior.
(4) Extensive observations of behavior have been made under
more rigidly controlled conditions in industrial,military, and other
institutional research. This work often differs from field or clinical
observation in its greater use of the experimental method.
(5) Laboratory studies of human behavior provide especially
useful material. The experimental method includes the use of instruments
which improve our contact with behavior and with the variables of which
it is a function. Recording devices enable us to observe behavior over long
periods of time, and accurate recording and measurement make effective
quantitative analysis possible. The most important feature of the laboratory
method is the deliberate manipulation of variables: the importance of a
given condition is determined by changing it in a controlled fashion and
observing the result.
Current experimental research on human behavior is sometimes
not so comprehensive as one might wish. Not all behavioral processes are
easy to set up in the laboratory, and precision of measurement is
sometimes obtained only at the price of unreality in conditions. Those who
are primarily concerned with the everyday life of the individual are often
impatient with these artificialities, but insofar as relevant relationships can
be brought under experimental control, the laboratory offers the best
chance of obtaining the quantitative results needed in a scientific analysis.
(6) The extensive results of laboratory studies of the behavior of
animals below the human level are also available. The use of this material
often meets with the objection that there is an essential gap between man
and the other animals, and that the results of one cannot be extrapolated to
the other. To insist upon this discontinuity at the beginning of a scientific
investigation is to beg the question. Human behavior is distinguished by its
complexity, its variety, and its greater accomplishments, but the basic
processes are not therefore necessarily different. Science advances from
the simple to the complex; it is constantly concerned with whether the
processes and laws discovered at one stage are adequate for the next. It
would be rash to assert at this point that there is no essential difference
between human behavior and the behavior of lower species; but until an
attempt has been made to deal with both in the same terms, it would be
equally rash to assert that there is.

9
 A discussion of human embryology makes considerable use of
research on the embryos of chicks, pigs, and other animals. Treatises on
digestion, respiration, circulation, endocrine secretion, and other
physiological processes deal with rats, hamsters, rabbits, and so on, even
though the interest is primarily in human beings. The study of behavior
has much to gain from the same practice.

1.2. Factors Influencing Human Behavior

Human behavior as the population of behaviors exhibited by

humans is determined by many factors. It is influenced by biology,
through genes, neurotransmitters and other biological mechanisms; by
environment, through social factors; and psychology, through the structure
of the human brain and its many, varied functions. No one mentioned area
can entirely determine human behavior. It is influenced through all of
them. That mean it is influenced through the interaction of biological,
sociological and psychological factors. In what is follow we will focus on
these three factors and on the way these work together.
Biological basis of behavior
The nervous system
Behavior, which can vary from driving a car to making a difficult
mathematical exercise, depends on various processes in the human body.
The relation between these processes is regulated by the nervous system.
Here is an example of what your body has to do in order to make you stop
for a red traffic light. First you have to perceive the light, which means
that the light has to be caught by the eye. The eye sends signals to the
brain. The brain compares the signals with those received from the other
eye and stores the signals temporarily in your memory. (You know you
have to stop for the red light.) After that you have to push the brake pedal.
To make this happen, your brains have to send a signal to the leg muscles
to push the feet on the brake pedal. All these signals from and to your
brains are transported through nerve cells.
The nervous system is the most complex system of the human
body. The human brain itself consists of at least 10 billion neurons. Every
moment of the day your nervous system is active. It exchanges millions of
signals corresponding with feeling, thoughts and actions. A simple
example of how important the nervous system is in your behavior is
meeting a friend.

10
 First, the visual information of your eyes is sent to your brain by
nervous cells. There the information is interpreted and translated into a
signal to take action. Finally the brain sends a command to your voice or
to another action system like muscles or glands. For example, you may
start walking towards him. Your nervous system enables this rapid
recognition and action.
There are three general functions of the nervous system in man
and animals:
1. Sensing specific information about external and internal
conditions (in the example above, this is seeing your friend).
2. Integrating that information (this is the understanding of the
information coming from the eyes).
3. Issuing commands for a response from the muscles or glands
(this is the reaction of walking towards him).
The nervous system provides us the ability to perceive, understand
and react to environmental events. That is why the nervous system is so
extremely important for human behavior.
Genetic influences, the role of genes on behavior
How much of the behavior is accounted for by genetic factors or
heritability? This question is adresed by behavioral genetics - a field of
research in psychology which began in England with Sir Francis Galton
and his study of the inheritance of genius in families. He discovered that
genius 'runs in families' and concluded that it is to a significant degree a
heritable behavioral trait. Since Galton a lot of people tried to prove that
genetics play an important role in many aspects of behavior. Those people
proved that complex behaviors related to personality, psychopathology
and cognition are all influenced to some degree by genetics. They have
also found that genetics alone is never enough to explain behavior,
because behavior is also influenced by the enviroment.
Today, most psychologists believe that behavior reflects both
genetic and environmental aspects. They try to explain variability in a trait
like intelligence or height or musicality in terms of the genetic and
enviromental differences among people within that population.
Effect of the production of hormones on behavior
The word hormone is derived from the Greek word hormao and
means to excite or stir into action. Hormones are chemicals secreted into
the bloodstream by specialized organs and carried to other parts of the
body to perform their task. Organs that secrete and manufacture hormones

11
are known as endocrine glands. Exocrine glands such as tear glands
secrete their products outside the body. Whereas exocrine glands are also
called ductal glands, endocrine glands are ductless. Endocrine glands
come in a variety of sizes and are located through the whole body.
Hormones are found throughout the animal kingdom and even in
plants, but only the vertebrates have specialized organs to produce and to
store hormones. In many cases the structure of a hormone is the same over
a wide variety of animals, although its function can be different.
Some human hormones are not secreted by endocrine glands but come
from sources as neurons in the hypothalamus, or cells in the digestive
tract. Recently the heart has been found to produce a hormone that helps
regulate the blood pressure.
Until the beginning of the 20th century the communication within
the body was exclusively attributed to the nervous system. However,
investigators discovered that the endocrine system is also important for
this function. Yet, the role of endocrine glands was anticipated in several
ancient civilizations in which they were eaten to modify health or
behavior. In the fourth century B.C. Aristotle described the effects of
behavior in birds when removing the testes (castration). Although he did
not what mechanism was involved, it was clear to him that the testes were
important for the male characteristics. Nowadays we know that the testes
produce a certain hormone (testosterone) that causes a lower voice and
stronger muscles in male human beings.
Psychological factors
There are three psychological basic sub-systems which act on
human behavior: motivation, cognition and emotion.
Motivation
Motivation is the driving force of human behavior. It is a force by
which humans achieve their goals. One of the most widely discussed
theories of motivation is Abraham Maslow's theory. Accordingly to him
driving forces for human action are human heeds, structured by him
hierarchically from basic to most complexes as follows: Physiology
(hunger, thirst, sleep, etc.), Safety / Security / Shelter / Health,
Belongingness / Love/ Friendship, Self-esteem / Recognition /
Achievement, Self-actualization. Having a need (desire) human start to act
in order to satisfy it. The further the progress up the hierarchy, the more
individuality, humanness and psychological health a person will show.

12
 Generally speaking motivation is classified in two types: intrinsic
or extrinsic. Intrinsic motivation is called also internal. They say that the
person is intrinsically motivated if his action (behavior) is driven by an
interest or enjoyment in the task itself, rather than relying on any external
pressure. For instance students are likely to be intrinsically motivated if
they attribute their educational results to internal factors that they can
control (e.g. the amount of effort they put in); believe they can be effective
agents in reaching desired goals (i.e. the results are not determined by
luck).Extrinsic motivation is called also external. It comes from outside of
the individual. Common extrinsic motivations are rewards like money and
grades, coercion and threat of punishment. Competition is in general
extrinsic because it encourages the performer to win and beat others, not to
enjoy the intrinsic rewards of the activity.
Motivation is many times associated with volition. Nevertheless
there is difference among them. Motivation usually is seen as a process
that leads to the forming of behavioral intentions. Volition is seen as a
process that leads from intention to actual behavior. In other words,
motivation and volition refer to goal setting and goal pursuit, respectively.
Both processes require self-regulatory efforts.
Cognition
Cognition is a complex mental phenomenon that refers to
knowledge, to the way people acquired and use their knowledge.
Cognition includes processes like perception, attention, remembering,
producing and understanding language, solving problems, and making
decisions.
Perception
Perception is the process of attaining understanding of the
environment by organizing and interpreting information got from the
traditionally recognized five senses of sight (ophthalmoception), hearing
(audioception), taste (gustaoception), smell (olfacoception or
olfacception), and touch (tactioception), and other nontraditional senses
like temperature (thermoception), kinesthetic sense (proprioception), pain
(nociception), balance (equilibrioception) and acceleration
(kinesthesioception). Perception depends on complex functions of the
nervous system, but subjectively seems mostly effortless because this
processing happens outside conscious awareness.
Memory and attention

13
 Memory is an organism's ability to store, retain, and recall
information and experiences. The environment stimulates one or more
sensory systems. This environmental information then passes three levels
of memory called sensory memory, short-term memory and long-term
memory. At each level, cognitive processes operate on the information,
giving it meaning, refreshing it and integrating it. In the sensory memory,
the information is encoded to go to the short term memory. There the
information is encoded to go to the long term memory. The ability to look
at an item, and remember what it looked like with just a second of
observation, or memorization, is an example of sensory memory. Short-
term memory allows recall for a period of several seconds to a minute
without rehearsal. Long-term memory can store much larger quantities of
information for potentially unlimited duration (sometimes a whole life
span). For example, given a random seven-digit number we may
remember it for only a few seconds before forgetting, suggesting it was
stored in our short-term memory. On the other hand, we can remember
telephone numbers for many years through repetition; this information is
said to be stored in long-term memory. While short-term memory encodes
information acoustically, long-term memory encodes it semantically.
The amount of information that can be processed is limited. The
main bottle-neck is attention. If you are distracted by a TV program, while
you are trying to study, your attention will be divided over both the book
and the TV. When you would study without having the TV on, you would
have more attention to 'spend' on your study. Cognitive processes
determine which of the available information will be used and which will
be ignored.
Imagination and thought
Imagination is the ability of forming mental images, sensations
and concepts, in a moment when they are not perceived through sight,
hearing or other senses. Imagination is a fundamental facility through
which people make sense of the world, create the meanings. Make the
distinction between two forms of imagination: "reproductive» or
"constructive" imagination. Imagination can be confused with the process
of thinking, but this are two different processes, even thou interdependent.
"Thought" generally refers to any mental or intellectual activity which
relates with processing of information, with the producing and
arrangements of ideas accordingly with one’s needs, attachments,
objectives, plans, commitments, ends and desires.

14
 Using language
Human language can be defined in various ways. One definition
sees language primarily as the mental faculty that allows humans to
undertake linguistic behaviour: to learn languages and produce and
understand utterances. Another definition sees language as a formal
system of signs governed by grammatical rules of combination to
communicate meaning. This definition stresses the fact that human
languages can be described as closed structural systems consisting of rules
that relate particular signs to particular meanings. Yet another definition
sees language as a system of communication that enables humans to
cooperate. This definition stresses the social functions of language and the
fact that humans use it to express themselves and to manipulate objects in
their environment. The different definitions stress different aspects of
lanquage, simultaniously showing the great significans of language for
thinking, learning and social existance of humans. By the mean of
leanguage we produse and expres our ideas, we learn from the experience
of others, we comunicate with others for the better social existnce.
Intelligence
David Wechsler defines intelligence as “the aggregate or global
capacity of the individual to act purposefully, to think rationally, and to
deal effectively with his environment”. Howard Gardner say that a human
intellectual competence must entail a set of skills of problem solving —
enabling the individual to resolve genuine problems or difficulties that he
or she encounters and, when appropriate, to create an effective product —
and must also entail the potential for finding or creating problems — and
thereby laying the groundwork for the acquisition of new knowledge.
Sternberg & Salter consider intelligence as a goal-directed adaptive
behavior. Thus, numerous definitions of intelligence have been proposed
till now, but many of them contain such term as “ability of problem
solving”.
To indicate the intelligence of humans several tests have been
developed. We will explain some of them. The first intelligence test was
developed by Sir Francis Galton, a cousin of the famous Charles Darwin.
Galton was interested in the differences in intelligence between human
beings, and he believed that certain families were more intelligent than
others. Galton administered a battery of tests measuring qualities such as
reaction time, breathing capacity and head size.

15
 The intelligence test as we know it was formulated by the French
psychologist Binet. He assumed that intelligence should be measured by
tasks requiring reasoning and problem solving abilities. Binet thought that
a slow learning child was like a normal child but retarded in metal growth.
So he concluded that a slow learning child would perform the same as a
younger child in intelligence tests. He devised a scale of mental age.
Average mental age (MA) scores correspond to chronological mental age
(CA). A bright child's MA is above his CA, and a slow learning child's
MA is below his CA. An advantage of the mental aged scale is that it can
easily be interpreted.
The American psychologist Lewis Terman used Binet's method to
develop a scale for intelligence. This index is called Intelligence Quotient
(IQ), and this scale expresses intelligence as a ratio of mental age (MA) to
chronological age (CA):
IQ = MA/CA × 100
The 100 is used to make the result better to compare. Numbers
like 101, 125 and 89 are easier to handle than 1.01, 1.25 and .89. It is easy
to conclude that when a child is smarter than the average (his MA is higher
than his CA), his IQ will be above 100, and otherwise.
Failure on one kind of item is scored the same way as a failure on another
item. So this test does not show any particular strengths or weaknesses.
To distinguish between various aspects of intelligence, the
Wechsler Intelligence scale is developed. This test is almost identical to
Binet's test, but it is divided in two parts, a verbal scale and a performance
scale. Another failure of the tests is that performance increases with
practice. There are books containing intelligence tests, and when you
practice them a couple of time, you know how to handle every problem so
you will score pretty high on an IQ-test.
Emotions
The word emotion includes a wide range of observable behaviors,
expressed feelings, and changes in the body state. This diversity in
intended meanings of the word emotion makes it hard to study. For many
of us emotions are very personal states, difficult to define or to identify
except in the most obvious instances. Moreover, many aspects of emotion
seem unconscious to us. Even simple emotional states appear to be much
more complicated than states as hunger and thirst.
To clarify the concept of emotions, three definitions of various
aspects of emotions can be distinguished:

16
 1. Emotion is a feeling that is private and subjective. Humans can
report an extraordinary range of states, which they can feel or experience.
Some reports are accompanied by obvious signs of enjoyment or distress,
but often these reports have no overt indicators. In many cases, the
emotions we note in ourselves seem to be blends of different states.
2. Emotion is a state of psychological arousal an expression or
display of distinctive somatic and autonomic responses. This emphasis
suggests that emotional states can be defined by particular constellations
of bodily responses. Specifically, these responses involve autonomously
innervated visceral organs, like the heart or stomach.
3. Emotions are actions commonly "deemed", such as defending
or attacking in response to a threat. This aspect of emotion is especially
relevant to Darwin's point of view of the functional roles of emotion. He
said that emotions had an important survival role because they generated
actions to dangerous situations.
Some psychologists have tried to subdivide emotions in categories.
For example Wilhelm Wundt, the great nineteenth century psychologist,
offered the view that emotions consist of three basic dimensions, each one
of a pair of opposite states: pleasantness/unpleasantness, tension/release
and excitement/relaxation. However, this list has become more complex
over time. Plutchik suggests that there are eight basic emotions grouped in
four pairs of opposites:
1. joy/sadness
2. acceptance/disgust
3. anger/fear
4. surprise/anticipation
In Plutchik's view, all emotions are a combination of these basic
emotions, primary emotions could blend to form the full spectrum of
human emotional experience.
Emotions differ not only accordingly to criteria of primary/secondary.
They can be distinguished after their occurrence in time. Some emotions occur
over a period of seconds (for example, surprise), whereas others can last years
(for example, love). The latter could be regarded also as a long term tendency
not as a proper emotion. A distinction is then made between emotion episodes
and emotional dispositions. Dispositions are also comparable to character
traits, where someone may be said to be generally disposed to experience
certain emotions, though about different objects. For example an irritable

17
person is generally disposed to feel irritation more easily or quickly than
others do.
Social influences
Humans are social creatures. There is a fundamental human need
to belong to social groups, because survival and prosperity is more likely
if we live and work together. However, to live together, we need to agree
on common beliefs, values, attitudes and behaviors that reduce in-group
threats act for the common good. These biliefs, valuies and principles are
expresed in social tradition, laws, ethical codes and delivered among
humans by the mean of diferent social sistem: educational system,
juridical sistem, massmedia system etc. Society influence the behavior of
its members in many ways. It pass laws through its governmental
institutions, creating severe punishments for particular antisocial
behaviors. It develop a strong desire for ethics and morals, through its
religious institutions as well as secular education (begining with it
elimentary or family level end ending with highest institutional level ) and
tradition (seen as an ansambe of rituals that pressure people to behave in a
predictable fashion and that why seen as source of social stability).
As we grow and develop in society, we internalize the values of
the society around us by making these our own. The process through
which society influences individuals to internalize values (attitudes and
expectations) is called socialization. Individuals do not automatically
absorb, but gradually accept cultural attitudes and roles. The individual is
often unaware of his acceptance of these socially derived roles, roles are
often accepted unconsciously. This is usually accomplished through the
imitation of role models. We learn to conform to rules of other people.
And the more we see others behaving in a certain way or making
particular decisions, the more we feel obliged to follow suit.
When a person in a society or group does not conform to the rules
of society or group, then they may be considered a deviant and both
private and public advice may be given to them on how to fit in. If they
still do not obey norms, they will be marginalized (punished) by society or
will be ejected and membership of the group revoked.
A form of deviant behavior is criminal behavior. Generally social
influence is defined as change in an individual’s thoughts, feelings,
attitudes, or behaviors that results from interaction with another individual
or a group. Particularly when we discuss about concrete type of behavior

18
we have to mention the concert factor which determined it. Thus when in
concern is criminal behavior for instance in children and young people
same risk factors are to be mentioned:
Family
• Poor parental supervision and discipline;
• Family conflict;
• Family history of problem behaviour;
• Parental involvement / attitudes condoning problem behaviour;
• Low income and poor housing.
School
• Low achievement, beginning at primary school;
• Aggressive behaviour, including bullying;
• Lack of commitment, including truancy;
• School disorganisation.
Community
• Community disorganisation and neglect;
• Availability of drugs;
• Disadvantaged neighbourhood;
• High turnover and lack of neighbourhood attachment.
Individuals, friends and peers
• Alienation and lack of social commitment;
• Attitudes that condone problem behaviour;
• Early involvement in problem behaviour;
• Friends involved in problem behaviour.
Protective factors are linked to positive outcomes even when
children are growing up in adverse circumstances and heavily exposed to
risk. These are:
• Strong bonds with family, friends and teachers;
• Healthy standards set by parents, teachers and community leaders;
• Opportunities for involvement in families, schools and the
community;
• Social and learning skills to enable participation;
• Recognition and praise for positive behaviour.

1.3. Abnormal Behavior

The behavior of people (and other organisms or even mechanisms)

falls within a range with some behavior being common, some unusual,

19
some acceptable, and some outside acceptable limits. Even there is a large
diversity of human behavior people tend to divide it in two broad
categories: normal and abnormal one. When starting a discussion of
abnormal behavior, people sometimes ask, "How can anybody tell what is
abnormal, anyway?" The definition of the word abnormal is simple
enough: deviating from the norm. However, applying this to psychology
poses a complex problem: What is normal? Whose norm? For what age?
For what culture? Some would simply classify what is "good" as normal
and what is "bad" as abnormal, but this is a vague and narrow definition
and brings up many of the same questions for the definition of "good" as
does the definition for "normal". There are many more ways of
determining a more objective reference point. The following criteria are
used to determine whether a person behavior is abnormal or not:
1. Statistical abnormality (deviation from statistical norms). A
behavior may be judged abnormal if it is statistically unusual in a
particular population. The word abnormal means 'away from the norm'.
Many population facts are measured such as height, weight and
intelligence. Most of the people fall within the middle range of
intelligence, but a few are abnormally stupid. But according to this
definition, a person who is extremely intelligent would be classified as
abnormal too.
2. Violation of socially-accepted standards (deviation from social
norms). An abnormal behavior might be defined as one that goes against
common or majority or presumed standards of behavior. By this definition,
a person is abnormal if violating the expectations and values of a
community. For example, one might be judged abnormal in one's failure to
behave as recommended by one's family, church, employer, community,
culture, or subculture. The main problem with the "violation of standards"
definition of abnormality is that it is based upon cultural standards that
change from place to place and time to time. What is abnormal in one
culture may be regarded as acceptable in a different culture. What is
regarded as abnormal at one time may be regarded as normal several
decades later. For example, watching TV may be considered abnormal in
the Amish culture, where modern conveniences are avoided. Violation of
standards does not necessarily correlate with statistical rarity. Physical
abuse of a spouse is considered abnormal in the United States, although it
occurs in up to a fifth of marriages.

20
 3. Maladaptiveness of behavior. This criteria approach
abnormality by starting with a theory of personality development. If
normal development can be defined, then abnormality is defined by the
failure to develop in this way. For example, if adults normally arrive at a
moral stage that prohibits killing other people, and someone does not
arrive at this stage, that person might be called abnormal. This third
criterium is how the behavior affects the well-being of the individual
and/or social group.
4. Subjective abnormality. The fourth criterium considers
abnormality in terms of the individual's subjective feelings, personal
distress, rather than his behavior. Judging abnormality by subjective
discomfort raises a different set of problems. In the type of abnormality
called neurosis, personal distress may be the only symptom, because the
individual's behavior seems normal. Psychotic people, the most seriously
disordered of all mental patients, often feel perfectly normal and suffer
little distress, despite having markedly "crazy" and unrealistic thought
processes that could lead to behavior harmful to themselves or others.
5. Legal approuch. The legal definition of abnormality declares a
person insane when he is not able to judge between right and wrong.
6. Biological injury. Abnormal behavior can be defined or
equated with abnormal biological processes such as disease or injury.
Examples of such abnormalities are brain tumors, strokes, heart disease,
diabetes, epilepsy, and genetic disorders.
Many of the classic psychiatric syndromes we will discuss in this
chapter are now recognized as brain diseases involving abnormal levels of
neurotransmitters, the chemicals that neurons use to communicate. On the
other hand, people tend to refer to any behavior they do not like as a
disease or a disorder. The idea that alcoholism is a disease, for example, is
quite controversial, although it is a widely accepted idea.
Biological approaches to defining abnormal behavior of many
types seem to be gaining ground, because there are so many advancing
technologies for defining biological problems. Brain scans, analysis of
neurotransmitters, and genetic analysis all provide objective ways of
identifying biological disturbances. The vast majority of abnormal
behaviors discussed in this chapter (with a few exceptions such as the
personality, somatoform, and factitious disorders) are now thought to have
a biological basis. Many respond to medication, used alone or with
psychotherapy.

21
 Even when there are biological factors that contribute to a
problem, the environment usually plays a role as well. Biological
approaches to defining abnormality may encourage people to overlook
environmental factors that are easier to change than genetics or brain
disorders. A study of adopted children showed that two distinct risk factors
encouraged alcoholism: (1) familial alcoholism (one or both genetic
parents were alcoholic) and (2) drinking in the family environment (the
adoptive parents had drinking problems). Either heredity or environment
could increase risk of alcoholism, and obviously only the environment can
be manipulated or changed after a person is born, if one wants to prevent
alcoholism from developing.

Specific behavioral disorders

1. Divided Brain
This disease is also called split-brain, and the problem the patient
has is that the both brain parts cannot communicate with each other.
The brain has two hemispheres, the right and the left hemisphere.
Those two hemispheres do look like mirror images of each other, but a
closer examination reveals certain asymmetries. When the two
hemispheres are measured during an autopsy, the left one is almost always
larger than the right one. This anatomical difference are related to
differences in functions between the two hemispheres: the left hemisphere
is specialized for the use of language, while the right one is specialized for
mental imagery and the understanding of spatial relationships.
Speech and the production of sounds are usually located in the left
hemisphere. But some left-handed people have speech centers located in
the right hemisphere or divided between the two. Seeing is also
complicated, the two eyes of you give their information to the opposite
hemisphere; your right eye gives his information to the left hemisphere,
and your left eye to the right hemisphere. The brain transforms this
information so we see 'normal'. As a result of this the left hemisphere sees
the right hand in the right visual field, this is correct because your right
hemisphere controls you left body-half and otherwise. When someone is
suffering a split-brain his both hemispheres cannot communicate. In a
test, a person with a split brain is seated in front of a screen. Because of his
split brain he cannot use his right hand to take something he sees with his
left eye. When a word appears on the left side of the screen, the eye passes

22
the information through to the right hemisphere so he won't understand the
word because language depends on the left hemisphere.
Because people with split brain can not combine the information
of both hemispheres, their behavior is pretty strange. Because he is not
aware of everything that happens he can look stupid and his behavior can
be illogical and vague.
2. Schizophrenia
Schizophrenia is the label given to a group of psychotic disorders
characterized by distortion of reality, withdrawal from social interaction
and disorganization of thought. The word schizophrenia is derived from
the Greek words for to split (schidzein) and mind (phren). This splitting is
related to fragmenting of the thought processes.
Schizophrenia occurs in all cultures, also those that are remote
from western civilization and its stress. Because the disorder often
reoccurs and because the patient's suffer long from it, half of all
psychiatric hospital beds are occupied by patients suffering schizophrenia.
Schizophrenia usually appears in young adulthood. Sometimes the
disorder develops slowly, but sometimes it has a sudden onset. These are
often a result of stress with people living an isolated life. Whether the
disorder develops slowly or suddenly, the signs are many and varied. The
primary characteristics can be summarized as the following, although not
every schizophrenic person will show all of them:
1. Disturbance of thought and attention; people suffering
schizophrenia often cannot think logically and as the result of this they
cannot write a story, because every word they write down might make
sense, but are meaningless in relation to each other, and they cannot keep
their attention to the writing.
2. Disturbances of perception; during acute schizophrenic
episodes, people say that the world appears different to them, their bodies
appear longer, colors seem more intense and they cannot recognize
themselves in a mirror.
3. Disturbances of affect; schizophrenic persons fail to show
'normal' emotions. For example, a patient may smile while talking over
tragic events
4. Withdrawal from reality; during schizophrenic episodes, the
individual becomes absorbed in his inner thoughts and fantasies. The self-

23
absorption may be so intense that the individual may not know the month
or day or the place where he is staying.
5. Delusions and hallucinations; in most cases the former
characteristics are accompanied by delusions. The most common are
beliefs that other persons are trying to control his thoughts, he may
become suspicious of friends (paranoid), this is the reason why Robert
Kennedy was assassinated.
The results of schizophrenia are many and varied, but these are the
main characteristics. Not everybody has the same opinion about the causes
of schizophrenia, but some factors have certainly influence on
schizophrenics. Disturbed home life and early trauma are frequently found
in the background of schizophrenics. The early death of one or more
parents, emotionally disturbed parents and strife between parents are found
with greater frequency in the background of schizophrenics.
3. Alzheimer's Disease
Alzheimer's Disease is a progressive degenerative disease of the
brain now considered a leading cause of dementia. Alzheimer's disease
was first described by the German neuropathologist Alois Alzheimer in
1906, it affects an estimated 2.5 to 3 million people in the United States. In
the United Kingdom, the number of individuals with this condition is
estimated to rise to over 1 million by the year 2010. Percentage rates
(cases per 100 individuals of 65 years and over) worldwide vary
considerably between 0.6 in China to 10.3 in Massachusetts, United States.
The incidence of the disease increases with advancing age, but there is no
evidence that it is caused by the aging process.
The average life expectancy of people with the disease is between
five and ten years, although many patients now survive 15 years or more
due to improvements in care and medical treatment. The cause of this
disease has not been discovered, although palliative therapy is available.
The ability of doctors to diagnose Alzheimer's disease has improved in
recent years, but this remains a process of elimination and final diagnosis
can be confirmed only by post-mortem. Alzheimer's patients show nerve
cell loss in the parts of the brain associated with cognitive functioning.
The hallmark lesions of Alzheimer's disease include the formation of
abnormal proteins. Alzheimer's disease is also characterized by profound
deficits in the brain's neurotransmitters which has been linked with
memory function.

24
 4. Autism
Autism (from the Greek word autos, which means self) is a severe
infant disorder of behavior that develops before the age of three. The term
is used to describe many types of mental disorders, but, as originally
named in 1943 by the American child psychologist Leo Kanner, early
infantile autism describes a rare cluster of symptoms. Its incidence is
approximately 1 in 2,500. An autistic child is unable to use language
meaningfully or to process information from the environment. About half
of all autistic children are mute, and those who speak often only repeat
what they have heard. The term autism refers to their vacant, withdrawn
appearance, but its connotation of voluntary detachment is inappropriate.
Other characteristics of autism include an uneven pattern of development,
a fascination with mechanical objects, a ritualistic response to
environmental stimuli, and a resistance to any change in the environment.
Some autistic children have precocious ability, such as mathematical
skills. The cause, prognosis, and treatment of autism are still under study.
Research suggests a genetic defect as the cause of the disorder, which may
be some form of autoimmune disease or degenerative disease of nerve
cells in the brain. The best treatment is special education, stressing
learning in small groups, and strict behavioral control of the child.
Treatment with drugs such as fenfluramine and haloperidol is also being
tested. In general, prognosis is poor for those autistic children who remain
mute past the age of five. Children who speak fare better, and some of
them recover.
5. Phobias
Phobias are excessive fears in specific situations when there is no
real danger or fears that are totally out of proportions. Most of the time the
person with a phobia realizes that his fear is irrational and illogical but he
still feels anxiety. Avoiding the feared situation can only relieve this
anxiety. Most of us are afraid for something; snakes, heights, doctors,
injury or death are the most reported fears. But a fear is different from a
phobia. A fear is usually not diagnosed as a phobia unless it causes big
problems in the person's daily life. An example of this is a person with a
phobia for enclosed places, he/she will notice his/her phobia when he/she
want to use elevators.

25
 There are a number of explanations about how phobias develop.
Some phobias may result from frightening experiences. For example, you
might develop fear for flying after experiencing a near air disaster. Once
such a phobia develops, the individual may go to great lengths to avoid the
feared situation, and so eliminating a possible fear. Other phobias may be
learned through observation. fearful parents tend to produce children who
share their fears. This phobia might be inherited, but it is more likely that
parents provide a model and that the children imitate that model. Other
phobias might develop because they are rewarded. When a child is afraid
of going to school because he will be separated from his parents for a
while, he will say he has a stomachache or something like that. Then his
parents reward him with the comfort of staying home with his parents.
Behavioral techniques have proved successful in treating phobias,
especially simple and social phobias. One technique, systematic
desensitization, involves confronting the phobic person with situations or
objects that are feared. Exposure therapy, another behavioral method, has
recently been shown to be more effective. In this technique, phobias are
repeatedly exposed to the feared situation or object so that they can see
that no harm befalls them; the fear gradually fades. Antianxiety drugs have
also been used as palliatives. Drugs to treat depression have also proved
successful in treating some phobias.
► Exercises and Discussions:
1. What is the subject-matter of behavioral sciences?
2. What are the methods (sources) of knowledge in behavioral
sciences?
3. Describe the factors that influence human behavior (biological,
psychological and social).

4. What is abnormal behavior? Abnormal behavior types.

5. Construct your own definition of term “behaviors” in the light of

acquired knowledge.
► Recommended Essays
1. The importance of behavioral science for medical activity.
Psycho – somatic model of treatment.
2. A. Maslow’s conception of Motivation.
3. Emotion as incentive of human behavior.
4. Age and behavior.

26
 ► Literature:
1. Fadem Barbara. Behavioral science. Lippincott Williams &
Wilkins, 2008.
2. Milliken Mary Elizabeth, Honeycutt Alyson. Understanding
human behavior: a guide for health care providers. Cengage Learning,
2004.
3. Stoudemire Alan. Human behavior: an introduction for medical
students. Lippincott Williams & Wilkins, 1998.
4. Skinner B. F. Science and human behavior. The B.F. Skinner
Foundation, 2005.

27
 Chapter 2

Behavior and Personality

"Personality is the supreme realization of the innate
idiosyncrasy of a living being. It is an act of courage
flung in the face of life, the absolute affirmation
of all that constitutes the individual, the most
successful adaptation to the universal
conditions of existence, coupled with the greatest
possible freedom of self-determination."
C.G. Jung, 1875-1961

2.1. Human Personality

Almost every day we describe and assess the personalities of the
people around us. Whether we realize it or not, these daily musings on
how and why people behave as they do are similar to what personality
psychologists do. While our informal assessments of personality tend to
focus more on individuals, personality psychologists instead use
conceptions of personality that can apply to everyone. Even there is no
consensus concerning the definition of personality to understand what is
meant by the term personality it is the first step into the field of personality
psychology.
The term "personality" originates from the Latin persona, which
means mask. Significantly, in the theatre of the ancient Latin-speaking
world, the mask was not used as a plot device to disguise the identity of a
character, but rather was a convention employed to represent or typify that
character. Now day most people, when they think of personality, are
actually thinking of personality differences - types and traits and the
like. Scientists define personality as a dynamic and organized set of
characteristics possessed by a person that uniquely influences his or her
cognitions, motivations, and behaviors in various situations. In other
words personality is made up of the characteristic patterns of thoughts,

28
feelings and behaviors that make a person unique. In addition to this,
personality arises from within the individual and remains fairly consistent
throughout life.
Some of the fundamental characteristics of personality include
which can be summarized as follow:
 Consistency - There is generally a recognizable order and
regularity to behaviors. Essentially, people act in the same ways or similar
ways in a variety of situations.
 Psychological and physiological - Personality is a psychological
construct, but research suggests that it is also influenced by biological
processes and needs.
 Impact behaviors and actions - Personality does not just
influence how we move and respond in our environment; it also causes us
to act in certain ways.
 Multiple expressions - Personality is displayed in more than just
behavior. It can also be seen in out thoughts, feelings, close relationships
and other social interactions.
The study of personality has a broad and varied history in
psychology. Personality research has led to the development of a number
of theories that help explain how and why certain personality develops.
We have dozens and dozens of theories, each emphasizing different
aspects of personhood, using different methods, sometimes agreeing with
other theories, sometimes disagreeing.
Some of major theoretical perspectives on personality include:
 Type theories are the early perspectives on personality. These
theories suggested that there are a limited number of "personality types"
which are related to biological influences. Type theories include
temperamental conception of Galen and constitutional conception of
William Sheldon
 Trait theories viewed personality as the result of internal
characteristics that are genetically based. Gordon Allport was an early
pioneer in the study of traits, which he sometimes referred to as
dispositions. Significant contribution to this approach Hans Eysenck had.
 Psychodynamic theories of personality are heavily influenced
by the work of Sigmund Freud, and emphasize the influence of the
unconscious on personality. Psychodynamic theories include Sigmund
Freud’s psychosexual stage theory and Erik Erikson’s stages of
psychosocial development.

29
  Behavioral theories suggest that personality is a result of
interaction between the individual and the environment. Behavioral
theorists study observable and measurable behaviors, rejecting theories
that take internal thoughts and feelings into account. Behavioral theorists
include B. F. Skinner and John B. Watson.
 Humanist theories emphasize the importance of free will and
individual experience in the development of personality. Humanist
theorists include Carl Rogers and Abraham Maslow.
In following paragraphs we will unfold the main features of some
significant type personality theories.
2.2. Behavior and temperament. Temperament typology
The concept of personality type refers to the psychological
classification of different types of individuals. An early form of
personality type theory was the Four Temperaments system. What is
temperament? From at least classical times, temperament has referred to
an individual's stable pattern of behaviour or reaction, one that persists
across time, activity, and space.
Temperament theory has its roots in the ancient four humors
theory developed by the Greek physician Hippocrates (460-370 BC). He
believed certain human moods, emotions and behaviors were caused by
body fluids (called "humors"): blood, yellow bile, black bile, and phlegm.
Next, Galen (AD 131-200) developed the first typology of temperament in
his dissertation De temperamentis. He mapped them to a matrix of
hot/cold and dry/wet taken from the Four Elements (fire, air, earth, water).
The word "temperament" itself comes from Latin "temperare", "to mix". In
the ideal personality, the complementary characteristics or warm-cool and
dry-moist were exquisitely balanced. In four less ideal types, one of the
four qualities was dominant over all the others. In the remaining four
types, one pair of qualities dominated the complimentary pair; for
example; warm and moist dominated cool and dry. These latter four were
the temperamental categories Galen named "sanguine", "melancholic",
"choleric" and "phlegmatic" after the bodily humors. Each was the result
of an excess of one of the humors that produced, in turn, the imbalance in
paired qualities. Thus sanguine suppose the excess of blood and
dominance of hot/wet qualities, choleric – yellow bile - hot/dry ,
melancholic – black bile - cold/dry and phlegmatic – phlegm - cold/wet.
Although each person was deemed to have his or her own individual

30
temperament, they were generally described as variations on four basic
types: choleric, melancholic, sanguine, and phlegmatic. What are the basic
features of each type of temperaments?
Sanguine
The Sanguine temperament personality is fairly extroverted.
People of a sanguine temperament tend to enjoy social gatherings and
making new friends. They tend to be creative and often day dream.
However, some alone time is crucial for those of this temperament.
Sanguine can also mean very sensitive, compassionate and thoughtful.
Sanguine personalities generally struggle with following tasks all the way
through, are chronically late, and tend to be forgetful and sometimes a
little sarcastic. Often, when pursuing a new hobby, interest is lost quickly--
when it ceases to be engaging or fun.
Choleric
A person who is choleric is a doer. They have a lot of ambition,
energy, and passion, and try to instill it in others. They can dominate
people of other temperaments, especially phlegmatic types. Many great
charismatic military and political figures were cholerics.
Melancholic
A person who is a thoughtful pondered has a melancholic
disposition. Often very kind and considerate, melancholic can be highly
creative – as in poetry and art - and can become occupied with the tragedy
and cruelty in the world. A melancholic is also often a perfectionist. They
are often self-reliant and independent.
Phlegmatic
Phlegmatic tend to be self-content and kind. They can be very
accepting and affectionate. They may be very receptive and shy and often
prefer stability to uncertainty and change. They are very consistent,
relaxed, rational, curious, and observant, making them good administrators
and diplomats. Unlike the Sanguine personality, they may be more
dependable.
Common traits of temperaments
From the beginning, with Galen's ancient temperaments, it was
observed that pairs of temperaments shared certain traits in common,
related especially to the rapidity of the responses to the stimulus and to the
sustainability of the responses.
Sanguine - quick, impulsive, and relatively short-lived reactions.
(hot/wet)

31
 Phlegmatic - a longer response-delay, but short-lived response.
(cold/wet)
Choleric - short response time-delay, but response sustained for a
relatively long time. (hot/dry)
Melancholic - long response time-delay, response sustained at
length, if not, seemingly, permanently. (cold/dry)
From this schema it is evident that the sanguine and choleric
shared a common trait: quickness of response, while the melancholy and
phlegmatic shared the opposite, a longer response. The melancholy and
choleric, however, shared a sustained response, and the sanguine and
phlegmatic shared a short-lived response. That meant, that the Choleric
and melancholy both would tend to hang on to emotions like anger, and
thus appear more serious and critical than the fun-loving sanguine, and the
peaceful phlegmatic. However, the choleric would be characterized by
quick expressions of anger, while the melancholy would build up anger
slowly, silently, before exploding.
The medical theory of temperament began to lose favor in the
early modern period. As a characterization of a person's psychological
state, however, temperament continued to be employed by both
psychologists and the lay public well into the twentieth century. The
temperamental theories as well as tests were developed in contemporary
periods by David Keirsey, Myers-Briggs, Ernst Kretschmer etc.

2.3. Behavior and Human Somatic

One very famous though discussable personality type conception
belong to William Sheldon (1898-1977). He was an American
psychologist who devoted his life to observing the variety of human
bodies and temperaments. He taught and did research at a number of U.S.
universities and is best known for his series of books on the human
constitution. For his study of the human physique, Dr. Sheldon started
with 4,000 photographs of college-age men, which showed front, back and
side views. By carefully examining these photos he discovered that there
were three fundamental elements which, when combined together, made
up all these physiques or somatotypes. With great effort and ingenuity he
worked out ways to measure these three components and to express them
numerically so that every human body could be described in terms of three

32
numbers, and that two independent observers could arrive at very similar
results in determining a person's body type.
These basic elements he named endomorphy, mesomorphy and
ectomorphy, for they seemed to derive from the three layers of the human
embryo, the endoderm, the mesoderm and the ectoderm. So:
Endomorph is centered on the abdomen, and the whole digestive
system.
Mesomorph is focused on the muscles and the circulatory system.
Ectomorph is related to the brain and the nervous system.
We have all three elements in our bodily makeup, just as we all
have digestive, circulatory and nervous systems. No one is simply an
endomorph without having at the same time some mesomorph and
ectomorph, but we have these components in varying degrees. Sheldon
evaluated the degree a component was present on a scale ranging from one
to seven, with one as the minimum and seven as the maximum.
The Extreme Endomorph - Roundness
In this physique the body is round and soft, as if all the mass had
been concentrated in the abdominal area. The arms and legs of the extreme
endomorph are short and tapering, and the hands and feet comparatively
small, with the upper arms and thighs being hammed and more developed
than the lower arms and legs. The body has smooth contours without
projecting bones, and a high waist. There is some development of the
breast in the male and a fullness of the buttocks. The skin is soft and
smooth like that of an apple, and there is a tendency towards premature
baldness beginning at the top of the head and spreading in a polished
circle. The hair is fine and the whole head is spherical. The head is large
and the face broad and relaxed with the features blending into an over-all
impression of roundness. Santa Claus is our society's image of the extreme
endomorph.
The Extreme Mesomorph – Muscles
The chest area, which Sheldon likened to an engine room,
dominates over the abdominal area and tapers to a relatively narrow, low
waist. The bones and muscles of the head are prominent as well, with
clearly defined cheek bones and a square, heavy jaw. The face is long and
broad and the head tends towards a cubical shape. The muscles on either
side of the neck create a pyramid-like effect. Both the lower and upper
arms and legs are well-developed and the wrists and fingers are heavy and

33
massive. The skin is thick and tends towards coarseness. It takes and holds
a tan well and can develop a leathery appearance with heavy wrinkles.
Sheldon compared it to the skin of an orange. The hair is basically heavy-
textured, and baldness, usually starts at the front of the head. The extreme
mesomorph is Mr. Universe or Tarzan.
Women on the whole tend to have less mesomorph than men and
more endomorph. Women who are primarily mesomorphs rarely show the
same degree of sharp angularity, prominent bone structure and highly
relieved muscles found in their male counterparts. Their contours are
smoother, yet the chest area clearly dominates over the abdominal area and
both upper and lower arms and legs are well-muscled. The skin tends to be
finer than in the male mesomorph, but shows some of the same
characteristics in terms of tanning and wrinkling.
The Extreme Ectomorph – Linear
The highly ectomorph physique is fragile and delicate with light
bones and slight muscles. The limbs are relatively long and the shoulders
droop. In contrast to the compactness of the endomorph and mesomorph,
the ectomorph is extended in space and linear. The ribs are visible and
delicate and the thighs and upper arms weak. The fingers, toes and neck
are long. The features of the face are sharp and fragile, and the shape of
the face as a whole is triangular with the point of the triangle at the chin.
The teeth are often crowded in the lower jaw which is somewhat receding.
The skin is dry and is like the outer skin of an onion. It tends to burn and
peel easily and not retain a tan. The relatively great bodily area in relation
to mass makes the ectomorph suffer from extreme heat or cold. The hair is
fine and fast-growing and sometimes difficult to keep in place. Baldness is
rare. The extreme ectomorph in our society is the absent-minded
professor.
Once we had grasped these three basic elements we tried to
recognize them in ourselves and our friends. We, indeed, found some
people who were extreme endomorphs, or mesomorphs or ectomorphs,
with little of the other components, but there were not many of them. Most
of the people we knew were a bewildering variety of combinations, and we
practiced mentally weighing how much of each component they had.
Sheldon liked to draw a body type diagram on which he plotted the
different body types. Here's where he placed the extreme endomorph,
mesomorph and ectomorph:

34
Other people were strong in two elements, and had less of the third. They fell
in between the poles of Sheldon's diagram. Four of these combinations
captured our attention. There was the hefty muscular person, the muscular thin
person, and close to him, the thinner yet still muscular person, and between the
ectomorph and the endomorph the person who was spread out and round
without really being muscular.
In the middle are mid-range physiques well endowed with all the basic
elements. And somewhere in this panoramic rainbow of physiques is you. Can
you find yourself?

The classification of body types was not Sheldon's ultimate goal.

He wanted to help resolve the age-old question: Whether our body type
was connected with the way we acted (eat and sleep, laugh and snore,
speak and walk)? In short, he wanted to explore the link between body and
temperament, understood as body type in action. Sheldon's procedure in
looking for the basic components of temperament was much like the one
he used in discovering the body type components. He interviewed in depth
several hundred people and tried to find traits which would describe the
basic elements of their behavior. He found there were three basic
components which he called viscerotonia, somatotonia and cerebrotonia,
and named endotonia, mesotonia and ectotonia.
Endotonia is seen in the love of relaxation, comfort, food and people.
Mesotonia is centered on assertiveness and a love of action.
Ectotonia focuses on privacy, restraint and a highly developed
self-awareness.
Sheldon devised a way of numerically rating the strength of each
area based on a check-list of 60 characteristics (see the end of  this chapter

35
for a simplfied version) that describe the basic components. The 7-1-1 was
the extreme endotonic, the 1-7-1 the extreme mesotonic and the 1-1-7 the
extreme ectotonic. He found a strong correspondence between the
endomorphic body type and the endotonic temperament, the mesomorphic
body type and the mesotonic temperament, and the ectomorphic body type
and the ectotonic temperament. Just as in our body type we have all three
elements, so, too, with our temperament.
A look at the three extremes in temperament will give us some
idea of what these components are like.
The Extreme Endotonic - Friendliness
The endotonic shows a splendid ability to eat, digest and socialize.
A good deal of his energy is oriented around food, and he enjoys sitting
around after a good meal and letting the digestive process proceed without
disturbance. They fall readily to sleep and their sleep is deep and easy;
they lie limp and sprawled out and frequently snore.
Endotonic are relaxed and slow-moving. Their breathing comes
from the abdomen and is deep and regular. Their speech is unhurried and
their limbs often limp. They like sitting in a well-upholstered chair and
relaxing. All their reactions are slow, and this is a reflection on a
temperament level of a basal metabolism, pulse, breathing rate and
temperature which are all often slower and lower than average. The
circulation in their hands and feet tends to be poor.
The endotonic love to socialize their eating, and the sharing of
meals becomes an event of the highest importance. They treat guests well.
They love company and feel more complete with other people around.
They like people simply because they are people. They have a strong
desire to be liked and approved of, and this often leads them to be very
conventional in their choices in order not to run the risk of social
disapproval. The endotonic are open and even with their emotions which
seem to flow out of them without any inhibitions. Whether they are happy
or sad, they want the people around them to know about it, and if others
express emotion they react directly and convincingly in sympathy. When
an endotonic has been drinking he becomes even more jovial and radiates
an expansive love of people. Endotonic are family-oriented and love
babies and young children and have highly developed maternal instincts.
They express affection and approval readily and need both back in kind.

36
 The Extreme Mesotonic - Action
They are always ready for action, and good posture is natural to
them. They get up with plenty of energy and seem tireless. They can work
for long periods of time and both need and like to exercise. If they are
forced into inactivity they become restless and dejected.
The mesotonic tends to eat his food rapidly and somewhat
randomly, often neglecting set meal times. He sleeps the least of the three
types and sometimes contents himself with six hours. He is an active
sleeper who thrashes about. He shows insensitivity to pain and a tendency
to high blood pressure and large blood vessels.
The mesotonic has no hesitation in approaching people and
making known his wants and desires. The tendency to think with his
muscles and find exhilaration in their use leads him to enjoy taking
chances and risks, even when the actual gain is well-known to be minimal.
They can become fond of gambling and fast driving and are generally
physically fearless. They can be either difficult and argumentative, or slow
to anger, but always with the capacity to act out physically and usually
with some sort of history of having done so on special occasions.
This physical drive manifests itself on the psychological level in a
sense of competition. The mesotonic wants to win and pushes himself
forward. He tends to walk roughshod over the obstacles in his path and the
people who stand in the way of his achieving what he wants. On the
positive side this is called being practical and free from sentimentality, but
on the negative side it is called ruthlessness or obnoxious aggressiveness.
This outward energetic flow makes mesotonic generally noisy.
Their voices carry and sometimes boom out as if speech were another
form of exercise. When alcohol reduces their inhibitions, they become
more assertive and aggressive. They look older than their chronological
age. The extraversion of action that is so strong here goes together with a
lack of awareness of what is happening on the subjective level. He likes
wide-open spaces and freedom.
The female mesotonic shows the same extraversion of action, but
how this action expresses itself has a different quality. There is not the
same overt physical combativeness and competitive aggressiveness. The
action is more muted and flows in more socially acceptable channels. The
mesotonic woman should be compared not with men but with other
women, and it is in relation to other women that she shows the distinctive
mesotonic traits in a feminine way.

37
 The Extreme Ectotonic - Reflection
The outstanding characteristic of the ectotonic is his finely-tuned
receptive system. His spread-out body acts like a giant antenna picking up
all sorts of inputs. He is like a sonar operator who must constantly be wary
of a sudden loud noise breaking in on the delicate sounds he is trying to
trace. He likes to cross his legs and curl up as if he is trying to minimize
his exposure to the exterior world. He tries to avoid making noise and
being subjected to it. He shrinks from crowds and large groups of people
and likes small, protected places.
The ectotonic suffers from a quick onset of hunger and a quick
satiation of it. He is drawn to a high protein, high calorie diet, with
frequent snacking to match his small digestive system. He has a nervous
stomach and bowels. He is a quiet sleeper, but a light one, and he is often
plagued by insomnia. He tends to sleep on one side with his legs drawn up,
and his sleep, though slow in coming, can be hard to shake off. His energy
level is low, while his reactions are fast he suffers from a quasi-chronic
fatigue and must protect himself from the temptation to exercise heavily.
His blood pressure is usually low and his respiration shallow and rapid
with a fast and weak pulse. His temperature is elevated slightly above
normal and it rises rapidly at the onset of illness. The ectotonic is resistant
to many major diseases, but suffers excessively from insect bites and skin
rashes. His hypersensitivity leads not only to quick physical reactions but
to excessively fast social reactions as well. It is difficult for this type to
keep pace with slow-moving social chit-chat. He races ahead and trips
over his own social feet.
Self-awareness is a principle trait of ectotonia. The feelings of the
ectotonic are not on display, even though they can be very strong, and so
he is sometimes accused of not having any. When they are in a situation of
dealing with someone who has authority over them or with someone of the
opposite sex whom they are interested in, they often make a poor first
impression. They are uncomfortable in coping with social situations where
overt expressions of sympathy are called for or where general idle
conversation is the norm, for example in parties and dinners where they
have no intimate acquaintances.
The ectotonics are hypersensitive to pain because they anticipate it
and have a lower pain threshold as well. They do not project their voices
like the mesotonics, but focus it to reach only the person they are
addressing. They appear younger than their age and often wear an alert,

38
intent expression. They have a late adolescence, consider the latter part of
life the best, and are future-oriented. The more extreme ectotonics have a
distaste for alcohol and their accentuated consciousness fights alcohol,
drugs, anesthesia and is resistant to hypnosis. When they become troubled
they seek privacy and solitude in order to try to work out the difficulty.
2.4. Jung's Theory of Psychological Types
While typologies of all sorts have existed throughout time the
most influential idea of psychological types originated in the theoretical
work of Carl Jung, published as Psychological Types in 1921. According
to Jung, the conscious psyche is an apparatus for adaptation and
orientation, and consists of a number of different psychic functions.
Among these he distinguishes four basic functions:
• sensing - perception by means of the sense organs;
• intuition - perceiving in unconscious way or perception of
unconscious contents.
• thinking - function of intellectual cognition; the forming of logical
conclusions;
• feeling - function of subjective estimation;
These functions are putted by author in pair accordingly to the
criteria of rationality. Thus, thinking and feeling functions are rational,
while sensing and intuition are nonrational.
Rationality consists of figurative thoughts, feelings or actions
with reason — a point of view based on objective value, which is set by
practical experience.
Non-rationality is not based in reason. Jung notes that elementary
facts are also nonrational, not because they are illogical but because, as
thoughts, they are not judgments.
In a person one function of pair is dominant while other is
auxiliary.
Thinking and feeling
Women use feeling more than thinking, and men use thinking
more than feeling.
This seems to be a general rule, though each of us has both
functions and what function we use most has nothing to do with the
question of intelligence.

39
 Suppose a couple wants to buy a house. The husband may think of
the house in terms of its price, closeness to work, maintenance and so
forth, while his wife might consider the purchase in terms of how she
might feel when friends and relatives come over and how the house will
look during next year's Thanksgiving dinner.
Sensation and Intuition
Just as there are two equally valid ways to arrive at a judgment,
Jung saw that there were two ways of perception: sensation and intuition.
Sensation is easy to grasp. It means perception by means of our
various senses. It means contact with people and things by way of sight,
hearing, touch, taste and smell. Sensation is in touch with the here and
now in all its rich detail.
Intuition means the perception of possibilities. If sensation is
oriented to the present, intuition revels in the future.
When sensation is in a room, it glories in all the shades of color,
and the styles of decoration it finds there, while intuition immediately
looks for the nearest window in order to float out of it and search out
hidden possibilities in the future.
According to the direction of psychic energy Carl Jung elaborate
other typology. He divides human personality in introvert and extrovert. If
a person’s energy usually flows outwards, he or she is an extravert, while
if this energy normally flows inwards, this person is an introvert.
Extraverts feel an increase of perceived energy when interacting with a
large group of people, but a decrease of energy when left alone.
Conversely, introverts feel an increase of energy when alone, but a
decrease of energy when surrounded by a large group of people.In more
details Extraversion is "the act, state, or habit of being predominantly
concerned with and obtaining gratification from what is outside the self".
Extraverts tend to enjoy human interactions and to be enthusiastic,
talkative, assertive, and gregarious. They take pleasure in activities that
involve large social gatherings, such as parties, community activities,
public demonstrations, and business or political groups. Acting, teaching,
directing, managing, brokering are fields that favor extraversion. An
extraverted person is likely to enjoy time spent with people and find less
reward in time spent alone. They enjoy risk-taking and often show
leadership abilities.

40
 An extravert is energized when around other people. Extraverts
tend to "fade" when alone and can easily become bored without other
people around. Extraverts tend to think as they speak. When given the
chance, an extravert will talk with someone else rather than sit alone and
think.
Introversion is "the state of or tendency toward being wholly or
predominantly concerned with and interested in one's own mental life".
Introverts tend to be low-key, deliberate, and relatively less engaged in
social situations. They often take pleasure in solitary activities such as
reading, writing, drawing, watching movies, and using computers. The
archetypal artist, writer, sculptor, composer and inventor are all highly
introverted. An introverted person is likely to enjoy time spent alone and
find less reward in time spent with large groups of people (although they
tend to enjoy interactions with close friends). They prefer to concentrate
on a single activity at a time and like to observe situations before they
participate. Introversion is not the same as shyness. Introverts choose
solitary over social activities by preference, whereas shy people avoid
social encounters out of fear. An introvert is energized when alone.
Introverts tend to "fade" when with people and can easily become
overstimulated with too many others around. Introverts tend to think
before speaking.
To give a complete description of a person's psychological type,
Jung refers to both the function and attitude type. As a result we have
eight personality types:
The Extraverted Sensation Type is a realist who seeks to
experience as many concrete sensations as possible - preferably, but not
necessarily, ones that are pleasurable. These experiences are seen as ends
in themselves and are rarely utilized for any other purpose.
Such persons are sensualists or aesthetes who are attracted by the
physical characteristics of objects and people. They dress, eat and entertain
well, and can be very good company.
Not at all reflective nor introspective, they have no ideals except
sensory enjoyment. They generally mistrust inner psychological processes
and prefer to account for such things in terms of external events (e.g., they
may blame their moods on the weather).
If extreme, they are often crudely sensual and may exploit
situations or others in order to increase their own personal pleasure. When

41
neurotic, repressed intuition may be projected onto other people, so that
they may become irrationally suspicious
The Introverted Sensation Type is subjectively filtered. Perception
is not based directly on the object, but is merely suggested by it.
Perception depends crucially upon internal psychological
processes that will differ from one person to the next. At its most positive,
introverted sensation is found in the creative artist. At its most extreme, it
produces psychotic hallucinations and a total alienation from reality.
The introverted sensation type reacts subjectively to events in a
way that is unrelated to objective criteria. Often this is seen as an
inappropriate and uncalled-for overreaction.
The person may perceive the world as illusory or amusing. In
extreme (psychotic) cases, this may result in an inability to distinguish
illusion from reality. The subjective world of archaic images may then
come to dominate consciousness completely, so that the person lives in a
private, mythological realm of fantasy.
Repressed intuition may also be expressed in vaguely imagined
threats or an apprehension of sinister possibilities.
The Extraverted Intuition Type - is an excellent diagnostician and
exploiter of situations. Such people see exciting possibilities in every new
venture and are excellent at perceiving latent abilities in other people.
They get carried away with the enthusiasm of their vision and often inspire
others with the courage of their conviction.
As such, they do well in occupations where these qualities are at a
premium - for example in initiating new projects, in business, politics or
the stock market. They are, however, easily bored and stifled by
unchanging conditions. As a result they often waste their life and talents
jumping from one activity to another in the search for fresh possibilities,
failing to stick at any one project long enough to bring it to fruition.
Furthermore, in their commitment to their own vision, they often
show little regard for the needs, views or convictions of others.
When neurotic, repressed sensation may cause this type to become
compulsively tied to people, objects or activities that stir in them primitive
sensations such as pleasure, pain or fear. The consequence of this can be
phobias, hypochondriacal beliefs and a range of other compulsions.

42
 The Introverted Intuition Type - is directed inward to the contents
of the unconscious. It attempts to fathom internal events by relating them
to universal psychological processes or to other archetypal images.
Consequently it generally has a mythical, symbolic or prophetic quality.
Such a person has a visionary ideal that reveals strange,
mysterious things. These are enigmatic, 'unearthly' people who stand aloof
from ordinary society. They have little interest in explaining or
rationalizing their personal vision, but are content merely to proclaim it.
Partly as a result of this, they are often misunderstood. Although
the vision of the artist among this type generally remains on the purely
perceptual level, mystical dreamers or cranks may become caught up in
theirs. The person's life then becomes symbolic, taking on the nature of a
Great Work, mission or spiritual-moral quest.
If neurotic, repressed sensation may express itself in primitive,
instinctual ways and, like their extraverted counterparts, introverted
intuitive often suffers from hypochondria and compulsions.
The Extraverted Thinking Type - is driven by the objective
evidence of the senses or by objective (collective) ideas that derive from
tradition or learning. Thinking is never carried out for its own sake, merely
as some private, subjective enterprise.
The extraverted thinking type bases all actions on the intellectual
analysis of objective data. Such people live by a general intellectual
formula or universal moral code, founded upon abstract notions of truth or
justice. They also expect other people to recognize and obey this formula.
This type represses the feeling function (e.g., sentimental attachments,
friendships, religious devotion) and may also neglect personal interests
such as their own health or financial well-being.
If extreme or neurotic, they may become petty, bigoted, tyrannical
or hostile towards those who would threaten their formula. Alternatively,
repressed tendencies may burst out in various kinds of personal
'immorality' (e.g., self-seeking, sexual misdemeanors, fraud or deception).
The Introverted Thinking Type - is contemplative, involving an
inner play of ideas. It is thinking for its own sake and is always directed
inward to subjective ideas and personal convictions rather than outward to
practical outcomes. The introverted thinking type tends to be impractical
and indifferent to objective concerns. These persons usually avoid notice
and may seem cold, arrogant and taciturn.

43
 Alternatively, the repressed feeling function may express itself in
displays of childish naivety. Generally people of this type appear caught
up in their own ideas which they aim to think through as fully and deeply
as possible.
If extreme or neurotic they can become rigid, withdrawn, surly or
brusque. They may also confuse their subjectively apprehended truth with
their own personality so that any criticism of their ideas is seen as a
personal attack. This may lead to bitterness or to vicious counterattacks
against their critics.
The Extraverted Feeling Type - is based upon accepted or
traditional social values and opinions. It involves a conforming, adjusting
response to objective circumstances that strives for harmonious relations
with the world.
The extraverted feeling type follows fashion and seeks to
harmonize personal feelings with general social values.
Thinking is always subordinate to feeling and is ignored or
repressed if intellectual conclusions fail to confirm the convictions of the
heart. When this type is extreme or neurotic, feeling may become gushing
or extravagant and dependent upon momentary enthusiasms that may
quickly turn about with changing circumstances. Such a person may
therefore seem hysterical, fickle, moody or even to be suffering from
multiple personality. Repressed thinking may also erupt in infantile,
negative, obsessive ways. This can lead to the attribution of dreaded
characteristics to the very objects or people that are most loved and
valued.
The Introverted Feeling Type - is unrelated to any external object.
It devalues objective reality and is rarely displayed openly. When it does
appear on the surface, it generally seems negative or indifferent. Such a
person aims to be inconspicuous, makes little attempt to impress and
generally fails to respond to the feelings of others.
The outer, surface appearance is often neutral, cold and
dismissive. Inwardly, however, feelings are deep, passionately intense, and
may accompany secret religious or poetic tendencies. The effect of all this
on other people can be stifling and oppressive. When extreme or neurotic,
this type may become domineering and vain.

44
 Negative repressed thinking may also be projected so that these
persons may imagine they can know what others are thinking. This may
develop into paranoia and into secret scheming rivalries.
► Exercises and Discussions:
a. Give a definition of personality.
b. What are the basic approaches or theories about personality?
c. Describe the classical conception of temperament.
d. What is somatotype and how many personality types were
established by Sheldon?
e. Sketch the significant moments of Jung’s conception of
personality types.
f. Make the comparison between conceptions analyzed in the
chapter.
g. Chose one of the three conceptions analyzed which is more
relevant in your opinion. Justify you option.
► Recommended Essays
h. Psychodynamic conception of personality.
i. Behaviorist conception of personality.
j. Humanist conception of personality.
k. Personality disorders.
►Literature:
1. Stoudemire Alan. Human behavior: an introduction for medical
students. Lippincott Williams & Wilkins, 1998.
2. Engler Barbara. Personality Theories: An Introduction. Cengage
Learning, 2008.
3. Lindsay J. E.,Carter Barbara. Honeyman Heath. Somatotyping-
development and applications. Cambridge University Press, 1990.
4. Sharp Daryl. Personality types: Jung's model of typology. Inner
City Books, 1987.

45
 Chapter 3

Behavior and Society

One of the greatest diseases

is to be nobody to anybody.
Mother Teresa

3.1 Human Society and its Structure

The term society came from the Latin word societas, which in turn
was derived from the noun socius ("comrade, friend, ally"). Thus this term
is used to describe an interaction among parties that are friendly. Human
society is consequently a group of people related to each other through
persistent relations, that must be friendly or at least civil so that to be
efficient. There is a common vision among scientist that tendency of
humans for association (forming and living in groups) is conditioned
primarily by the heed to cope. A society allows its members to realize
needs or wishes they cannot fulfill alone. In this circumstance they need to
work for the global success of the society as a prerequisite for achieving
their own individual success. As such, society is a collaborative means to
accomplish individual ends.
Societies can differ from each other on the level of historical,
economical or technological development, on the types of government and
political structure on the specific of cultural traditions, but all human
societies have more or less alike structures. Formally social structure
consists of individuals, groups, and other social entities, and of the
networks of social ties between them. Functionally social structure
consists of statuses, roles, and social institutions. Formally and
functionally social structure is patterned social arrangements which form
the society as a whole, and which determine, regulate the interactions

46
among members of the society. To understand better the significance the
meanings of each defying element will be describe.
An individual is a person or any specific object or thing in a
collection. Individuality is the state or quality of being an individual; a
person separate from other persons and possessing his or her own needs,
goals, and desires.
Social group is an association of two or more humans who
interact with one another, share similar characteristics and collectively
have a sense of unity. To have a sense of unity mean interacting with each
other with respect to:
1. Common motives and goals;
2. An accepted division of labor, i.e. roles;
3. Established status (social rank, dominance) relationships;
4. Accepted norms and values with reference to matters relevant to
the group;
5. Development of accepted sanctions (praise and punishment) if
and when norms were respected or violated.
Characteristics shared by members of a group may include
interests, values, representations, ethnic or social background, and kinship
ties. Thus a true social group is a group that exhibits some degree of social
cohesion and is not a simple collection or aggregate of individuals, such as
people waiting at a bus stop, or people waiting in a line. Social groups can
be many types, but sociologist divided into two big categories: primary
and secondary groups. Primary groups are small groups with intimate,
kinship-based relationships: families, for example. They commonly last
for many years or even generations. They are small and display face-to-
face interaction. Secondary groups, in contrast to primary groups, are large
groups involving formal and institutional relationships. They may last for
years or may disband after a short time. The formation of primary groups
happens within secondary groups. Primary groups can be present in
secondary settings. For example, attending a university exemplifies
membership of a secondary group, while the friendships that are made
there would be considered a primary group that you belong to. Likewise,
some businesses care deeply about the well being of one another, while
some immediate families have hostile relations within it.
Social status is the honor or prestige attached to one's position in
society. It is the position or rank of a person or group within the society.

47
 Social role is a set of connected behaviors, rights and obligations
of a person or group in a social situation or position.
Social institution is any structure or mechanism of social order
and cooperation governing the behavior of groups within a given human
community. Institutions are identified with a social purpose and
permanence, transcending individual human lives and intentions, and with
the making and enforcing of rules governing cooperative human behavior.

3.2. The Concepts of Social Status and Role

The first person who gives the definition to the concept of status
was R. Linton (1936). He defined status simply as a position in a social
system. Eventually one occupies the statuses son or daughter, playmate,
pupil, husband, mother bread-winner, cricket fan, and so on, one has as
many statuses as there are groups of which one is a member. For analytical
purposes, statuses are divided into two basic types: ascribed and achieved.
Ascribed statuses are those which are fixed for an individual at birth.
Ascribed statuses that exist in all societies include those based upon sex,
age, race, ethnic group and family background. Achieved statuses are
those which the individual acquires during his or her lifetime as a result of
the exercise of knowledge, ability, skill and/or perseverance. In other
words achieved status is when people are placed in the stratification
structure based on their individual merits or achievements. This status can
be achieved through education, occupation, and marital status. Their place
within the stratification structure is determined by society's bar, which
often judges them on success, success being financial, academic, and
political and so on. America most commonly uses this form of status with
jobs. The higher you are in rank the better off you are and the more control
you have over your co-workers.
Societies vary in both the number of statuses that are ascribed and
achieved and in the rigidity with which such definitions are held. Both
ascribed and achieved statuses exist in all societies and these are directly
related to the stratification of society that describes the way people are
placed in society. It is associated with the ability of individuals to live up
to some set of ideals or principles regarded as important by the society or
some social group within it. The German sociologist Max Weber
developed a theory proposing that stratification is based on three factors
that have become known as "the three p's of stratification": property (i.e.

48
material possessions), prestige (respect) and power (i.e. ability to do what
one wants, regardless of the will of others). These factors all together or
one by one can show the position of a person in the society. For example,
a teacher may have a high status because of the prestige of the profession
while having no propriety or power.
In relation to the stratification of society is elaborated and idea of
status groups. Status groups are communities that are based on ideas of
proper lifestyles and the honor given to people by others. These groups
only exist because of people's ideas of prestige or dishonor. Also, people
in these communities are only supposed to associate with people of like
status, and all other people are looked at as inferiors. Thus human are
likely to interact with people with the same personal income, the same
political views/position, the same religion, nationality, race or social class.
Status can be changed through a process of social mobility,
understood as change of position within the stratification system. A move
in status can be upward (upward mobility), or downward (downward
mobility). Social mobility allows a person to move to another social status
other than the one he or she was born in. Social mobility is more frequent
in societies where achievement rather than ascription is the primary basis
for social status.
The term social role is borrowed by social scientists originally
from the Greek Drama. Greek actors wore masks when they performed in
their drama. This leads us directly to the definition of the concept of social
role. A social role is a set of social norms that govern a person's behavior
in a group and determine his relationships with other group members. Put
somewhat differently a role is the expected pattern of behavior associated
with a given social status. Status and role are reciprocal aspects of the
same phenomenon. Status, or position, is the static aspect that fixes the
individual's position in a group; role is the dynamic behavioral aspect that
defines how the person who occupies the status should behave in different
situations. Each of the statuses involves a role, set of behavior or action-
patterns that people belonging to a given status are expected to perform.
One plays as many roles as he has statuses. A given man may both
concurrently and sequentially enact the roles of husband, father bread-
winner, and football fan and so on.
Social roles may be linked to blue-prints for behavior that are
handed to the individual, hypothetically, when he becomes a member of a
group. As such these constitute the group's expectations concerning how

49
one would behave. Thus, whereas the status of a person tells us what he is,
his role will tell us what he does as a member of a status group. There are
no roles without statuses and no statuses without roles. Indeed, there are
some exceptions. Though all statuses imply some role or roles, it is not
always possible to infer people's statuses from what they do, as for
example, two persons, who bear the title of knighthood and thus holding
same social positions, might be performing completely different roles.
Also, many statuses are wholly or partly defined with reference to roles
which their occupants are expected to perform. For example policemen,
poets, etc.
As was said above a person can play simultaneously many roles,
but in order to play any role, individuals must meet certain conditions, for
instance biological or sociological. A boy cannot take the biological role
of mother because of biological reason as well as a doctor cannot practice
medicine without certificate (social reason). The role achievement and
development can be also influenced by a additional factors. Some of them
ate as follow:
Societal factor: The structure of society often forms individuals
into certain roles based on the social situations they choose to experience.
Parents enrolling their children in certain programs at a young age increase
the chance that the child will follow that role.
Genetic predisposition: People take on roles that come naturally to
them. Those with athletic ability generally take on roles of athletes. Those
with mental genius often take on roles devoted to education and
knowledge. This does not mean that people must choose only one path,
multiple roles can be taken on by each individual
Cultural influence: Different cultures place different values on
certain roles based on their lifestyle. For instance, soccer players are
regarded higher in European countries than in the United States, where
soccer is less popular.
Situational influence: Roles can be created or altered based on the
situation a person is put in outside their own influence. For instance a
person must assume the role of leader even such a position is improper for
his personality.
In many case a person performs many roles consistently, but there
are situations in which it is not possible, there are situation when one is
forced to take on two different and incompatible roles at the same time.
This situation is called the situation of role conflict. For example, a person

50
may find conflict between her role as a mother and her role as an
employee of a company when her child's demands for time and attention
distract her from the needs of her employer.

3.3. Health Care as a Social System

As define above in the first paragraph an institution is a term that
refers to any structure or mechanism of social order and cooperation
governing the behavior of a set of individuals within a given human
community for acquiring a purpose important to a society as a hole. The
interaction of these structures and mechanisms (i.e. institutions) constitute
social systems. In the light of this definition medicine is a system or is a
form of organization of activity directed towards health improvement.
World Medical Organization defines a Health System as the structured and
interrelated set of all actors and institutions contributing to health
improvement. "A health system consists of all organizations, people and
actions whose primary intent is to promote, restore or maintain health.
This includes efforts to influence determinants of health as well as more
direct health-improving activities…”
Medical organization
Medical organization is an institution that provides preventive,
curative, promotional or rehabilitative health care services in a systematic
way to individuals, families or communities. Among medical organization
can be listed: Hospital, Health care centre, Medical nursing home,
Pharmacies and drug stores, Medical laboratory and research etc.
A hospital is an institution for health care providing patient
treatment by specialized staff and equipment, and often, but not always
providing for inpatient care (is the care of patients whose condition
requires admission to a hospital) or longer-term patient stays. Today,
hospitals are usually funded by the public sector, by health organizations
(for profit or nonprofit), health insurance companies or charities, including
by direct charitable donations. Historically, however, hospitals were often
founded and funded by religious orders or charitable individuals and
leaders.
Health care centers, including clinics (i.e. health care facility that
is primarily devoted to the care of outpatients) and ambulatory surgery
centers (i.e. health care centers where surgical procedures not requiring an

51
overnight hospital stay are performed), serve as first point of contact with
a health professional and provide outpatient medical, nursing, dental and
other types of care services.
Medical nursing homes, including residential treatment centers
(i.e. live-in health care facility providing therapy for substance abuse,
mental illness, or other behavioral problems) and geriatric care facilities
(i.e. elder care management), are health care institutions which have
accommodation facilities and which engage in providing short-term or
long-term medical treatment of a general or specialized nature not
performed by hospitals to inpatients with any of a wide variety of medical
conditions.
Pharmacies and drug stores comprise establishments engaged in
retailing prescription or nonprescription drugs and medicines, and other
types of medical goods. Regulated pharmacies may be based in a hospital
or clinic or they may be privately operated, and are usually staffed by
pharmacists, pharmacy technicians and pharmacy aides.
A medical laboratory or clinical laboratory is a laboratory where
tests are done on biological specimens in order to get information about
the health of a patient. Such laboratories may be divided into categorical
departments such as microbiology, hematology, clinical biochemistry,
immunology, serology, histology, cytology, cytogenetics, or virology. In
many countries, there are two main types of labs that process the majority
of medical specimens. Hospital laboratories are attached to a hospital, and
perform tests on these patients. Private or community laboratories receive
samples from general practitioners, insurance companies, and other health
clinics for analysis.
Health care practitioners
Health care practitioner is an individual or an institution that
provides preventive, curative, promotional or rehabilitative health care
services in a systematic way to individuals, families or communities.
Health care practitioners include physicians (including general
practitioners and specialists), dentists, physical therapists, audiologists,
speech pathologists, physician assistants, nurses, midwives,
pharmacologists/pharmacists, dietitians, therapists, psychologists,
chiropractors, clinical officers, phlebotomists, occupational therapists,
optometrists, emergency medical technicians, paramedics, medical
laboratory technicians, medical prosthetic technicians, radiographers,

52
social workers, and a wide variety of other human resources trained to
provide some type of health care service. They often work in hospitals,
health care centers and other service delivery points, but also in academic
training, research and administration. Some provide care and treatment
services for patients in private homes. Many countries have a large number
of community health workers who work outside of formal health care
institutions. Managers of health care services, medical records and health
information technicians, and other assistive personnel and support workers
are also considered a vital part of health care teams.
In what will follow is clarified the significance of basic terms
assigned to health givers.
A physician also known as medical practitioner, doctor of
medicine, medical doctor, or simply doctor — is a person which practices
the ancient profession of medicine, which is concerned with maintaining
or restoring human health through the study, diagnosis, and treatment of
disease or injury. This properly requires both a detailed knowledge of the
academic disciplines (such as anatomy and physiology) underlying
diseases and their treatment — the science of medicine — and also a
decent competence in its applied practice — the art or craft of medicine.
The word physician comes from the Ancient Greek word φύσις
(physis) and its derived adjective physikos, meaning "nature" and
"natural". From this, amongst other derivatives came the Vulgar Latin
physicus, which meant a medical practitioner. After the Norman Conquest,
the word entered Middle English, via Old French fisicien, as early as 1100.
Originally, physician meant a practitioner of physic (pronounced with a
hard C). This archaic noun had entered Middle English by 1300 (via Old
French fisique). Physic meant the art or science of treatment with drugs or
medications (as opposed to surgery), and was later used both as a verb and
also to describe the medications themselves.
In modern English, the term physician is used in two main ways,
with relatively broad and narrow meanings respectively. This is the result
of history and is often confusing. These meanings and variations are
explained below.
Especially in North America, the title physician is now widely
used in the broad sense, and applies to any medical practitioner holding a
medical degree. In the United States and Canada, the term physician
usually describes all those holding the degrees of Doctor of Medicine
(MD) and Doctor of Osteopathic Medicine (DO). Within North America,

53
the title physician, in this broad sense, also describes the holders of
medical degrees from other countries that are equivalent to the North
American Doctor of Medicine degrees; typical examples of such degrees
from Commonwealth countries are MB BS, MB BChir etc.
Physician is still widely used in its older, narrower sense,
especially outside North America. In this usage, a physician is a specialist
in internal medicine or one of its many sub-specialties (especially as
opposed to a specialist in surgery). This traditional meaning of physician
conveys a sense of expertise in treatment by drugs or medications, rather
than by the procedures of surgeons.
Currently, a specialist physician in this older, narrower sense
would probably be described in the United States as an internist. Another
term, hospitalist, was introduced in 1996, to describe US specialists in
internal medicine who work largely or exclusively in hospitals. Such
'hospitalists' now make up about 19% of all US general internists, who are
often called general physicians in Commonwealth countries.
The older, more narrow usage of physician as an internist is
common in the United Kingdom and other Commonwealth countries (such
as Australia, Bangladesh, India, New Zealand, Pakistan, South Africa, Sri
Lanka, Zimbabwe), as well as in places as diverse as Brazil, Hong Kong,
Indonesia, Japan, Ireland, and Taiwan. In such places, the more general
English terms doctor or medical practitioner are prevalent, describing any
practitioner of medicine (whom an American would likely call a
physician, in the newer, broad sense). In Commonwealth countries,
specialist pediatricians and geriatricians are also described as specialist
physicians who have sub-specialized by age of patient rather than by organ
system.
Nurse practitioners (NPs) are not described as physicians; the
American College of Nurse Practitioners do not describe themselves this
way. They are classified as advance practice registered nurses/clinicians,
and are also known as mid-level (healthcare) practitioners in US
government regulations. Nurse practitioners may perform work similar to
that of physicians, especially within the realm of primary care, but use
advanced nursing models instead of medical models. A nurse is a
healthcare professional who, in collaboration with other members of a
health care team, is responsible for: treatment, safety, and recovery of
acutely or chronically ill individuals; health promotion and maintenance
within families, communities and populations; and, treatment of life-

54
threatening emergencies in a wide range of health care settings. Nurses
perform a wide range of clinical and non-clinical functions necessary to
the delivery of health care, and may also be involved in medical and
nursing research.
The scope of practice for a Nurse Practitioner in the United States
is defined by individual state boards of registration in nursing, as opposed
to state boards of registration in medicine. Physician Assistants are also
classified as midlevel advance practice clinicians, have a similar scope of
practice as nurse practitioners, and are regulated by state boards of
registration in medicine.
A paramedic is a medical professional, usually a member of the
emergency medical services, who primarily provides pre-hospital
advanced medical and trauma care. A paramedic is charged with providing
emergency on-scene treatment, crisis intervention, life-saving stabilization
and transport of ill or injured patients to definitive emergency medical and
surgical treatment facilities, such as hospitals and trauma centers.
The use of the specific term paramedic varies by jurisdiction, and
in some places is used to refer to any member of an ambulance crew. In
countries such as Canada and South Africa, the term paramedic is used as
the job title for all EMS personnel, who are then distinguished by the
terms primary or basic (e.g. Primary Care Paramedic) intermediate, or
advanced (e.g. Advanced Care Paramedic). This approach may be
completely appropriate in such jurisdictions, where primary care staff
receive more than double the classroom and clinical training of an EMT,
and in fact more than those in some jurisdictions permitted by law to call
themselves paramedics. In countries such as the United States and the
United Kingdom, the use of the word paramedic is restricted by law, and
the person claiming the title must have passed a specific set of
examinations and clinical placements, and hold a valid registration (in the
UK, with the Health Professions Council), certification, or license with a
governing body. Even in countries where the law restricts the title, lay
persons may incorrectly refer to all emergency medical personnel as
'paramedics', even if they officially hold a different qualification, such as
emergency medical technician - basic.
Pharmacists are health professionals who practice the science of
pharmacy. In their traditional role, pharmacists typically take a request for
medicines from a prescribing health care provider in the form of a medical
prescription, evaluate the appropriateness of the prescription, dispense the

55
medication to the patient and counsel them on the proper use and adverse
effects of that medication. In this role pharmacists act as a learned
intermediary between physicians and patients and thus ensure the safe and
effective use of medications. Pharmacists also participate in disease-state
management, where they optimize and monitor drug therapy or interpret
medical laboratory results – in collaboration with physicians and/or other
health professionals. Advances into prescribing medication and in
providing public health advices and services are occurring in Britain as
well as the United States and Canada. Pharmacists have many areas of
expertise and are a critical source of medical knowledge in clinics,
hospitals, medical laboratory and community pharmacies throughout the
world. Pharmacists also hold positions in the pharmaceutical industry as
well as in pharmaceutical education and research and development
institutions.
In much of the United Kingdom and the British Commonwealth
pharmacists are customarily sometimes referred to as chemist (or
dispensing chemists), a usage which can, especially without a context
relating to the sale or supply of medicines, cause confusion with scientists
in the field of chemistry. This term is a historical one, since some
pharmacists passed an examination in Pharmaceutical Chemistry (PhC) set
by the then Pharmaceutical Society of Great Britain in 1852 and these
were known as "Pharmaceutical Chemists". This title is protected by the
Medicines Act 1968 section 78.
Notion of Patient
The word patient originally meant 'one who suffers'. This English
noun comes from the Latin word patiens, the present participle of the
deponent verb, patior, meaning 'I am suffering,' and akin to the Greek verb
πάσχειν (= paskhein, to suffer) and its cognate noun πάθος (= pathos).
A patient is any person who receives medical attention, care, or
treatment. The person is most often ill or injured and in need of treatment
by a physician or other health care professional, although one who is
visiting a physician for a routine check-up may also be viewed as a patient.
Nowadays we can mentioned several types of patients.
An outpatient is a patient who is not hospitalized overnight but
who visits a hospital, clinic, or associated facility for diagnosis or
treatment. Treatment provided in this fashion is called ambulatory care.
Outpatient can be met even in surgery. Outpatient surgery eliminates

56
inpatient hospital admission, reduces the amount of medication prescribed,
and uses a doctor's time more efficiently. More procedures are now being
performed in a surgeon's office, termed office-based surgery, rather than in
an operating room. Outpatient surgery is suited best for healthy people
undergoing minor or intermediate procedures (limited urologic,
ophthalmologic, or ear, nose, and throat procedures and procedures
involving the extremities).
An inpatient on the other hand is "admitted" to the hospital and
stays overnight or for an indeterminate time, usually several days or weeks
(though some cases, like coma patients, have been in hospitals for years).
Due to concerns such as dignity, human rights and political
correctness, the term "patient" is not always used to refer to a person
receiving health care. Other terms that are sometimes used include health
consumer, health care consumer or client. These may be used by
governmental agencies, insurance companies, patient groups, or health
care facilities. Individuals who use or have used psychiatric services may
alternatively refer to themselves as consumers, users, or survivors.
In nursing homes and assisted living facilities, the term resident is
generally used in lieu of patient, but it is not uncommon for staff members
at such a facility to use the term patient in reference to residents.
Similarly, those receiving home health care are called clients.
The term 'virtual patient' is used to describe interactive computer
simulations used in health care education. Virtual patients allow the
learner to take the role of a health care professional and develop clinical
skills such as making diagnoses and therapeutic decisions The use of
virtual patient programs is increasing in healthcare education, partly in
response to increasing demands on health care professionals and education
of students but also because they allow opportunity for students to practice
in a safe environment. There are many different formats a virtual patient
may take. However the overarching principle is that of interactivity - a
virtual patient will have mechanisms for the learner to interact with the
case and material or information is made available to the learner as they
complete a range of learning activities.
Medical procedures
A medical procedure is a course of action intended to achieve a
result in the care of persons with health problems. Medical procedure also
is define as the act or conduct of diagnosis, treatment, or operation.

57
 Diagnosis (from ancient Greek διάγνωσις = discernment) is the
identification of the nature and cause of anything. Diagnosis is used in
many different disciplines. In medicine diagnosis is establishment of the
nature and cause of patient’s illness. A patient typically presents a set of
complaints (the symptoms) to the physician, who then obtains further
information about the patient's symptoms, previous state of health, living
conditions, and so forth. The physician then makes a review of systems
(ROS) or systems inquiry, which is a set of ordered questions about each
major body system in order: general (such as weight loss), endocrine,
cardio-respiratory, etc. Next comes the actual physical examination and
often laboratory tests; the findings are recorded, leading to a list of
possible diagnoses. These will be investigated in order of probability.
Therapy (in Greek: θεραπεία), or treatment, is the attempted
remediation of a health problem, usually following a diagnosis. In the
medical field, it is synonymous with the word "treatment". A supportive
therapy is one that does not treat or improve the underlying condition, but
instead increases the patient's comfort. Supportive treatment may be
palliative care.
A therapeutic effect is a consequence of a particular treatment
which is judged to be desirable and beneficial. This is true whether the
result was expected, unexpected, or even an unintended consequence of
the treatment. In talk therapy a therapeutic effect can be brought on by
insight from the client that is caused by the clinician asking thoughtful and
discerning questions regarding the past and/or present moment. Freud's
main purpose in therapy was to make the unconscious conscious.
A treatment treats a problem, and may lead to its cure, but
treatments more often ameliorate a problem only for as long as the
treatment is continued. For example, there is no cure for AIDS, but
treatments are available to slow down the harm done by HIV and delay the
fatality of the disease. Treatments don't always work. For example,
chemotherapy is a treatment for some types of some cancers, which may
in some cases enact a cure, but not in all cases for all cancers.
Cures are a subset of treatments that reverse illnesses completely
or end medical problems permanently. A cure is the end of a medical
condition. The term may refer specifically to a substance or procedure that
ends the medical condition, such as a medication, a surgical operation, a
change in lifestyle, or even a philosophical mindset that helps a person
suffer. It may also refer to the state of being healed, or cured.

58
 The proportion of people with a disease that are cured by a given
treatment, called the cure fraction or cure rate, is determined by
comparing disease-free survival of treated people against a matched
control group that never had the disease. If everyone treated for a disease
is cured, then they will all remain disease-free and live as long as any
person that never had the disease.
Inherent in the idea of a cure is the permanent end to the specific
instance of the disease. When a person has the common cold, and then
recovers from it, the person is said to be cured, even though the person
might someday catch another cold. Conversely, a person that has
successfully managed a disease, such as diabetes mellitus, so that it
produces no undesirable symptoms for the moment, but without actually
permanently ending it, is not cured.
Remission is the state of absence of disease activity in patients
with known chronic illness that cannot be cured. It is commonly used to
refer to absence of active cancer or inflammatory bowel disease when
these diseases are expected to manifest again in the future. The term can
be used incorrectly with mental illness when the illness is under control. A
partial remission may be defined for cancer as 50% or greater reduction in
the measurable parameters of tumor growth as may be found on physical
examination, radiologic study, or by biomarker levels from a blood or
urine test. A complete remission is defined as complete disappearance of
all such manifestations of disease. Each disease or even clinical trial can
have its own definition of a partial remission.
Prevention is another important medical action it is a way to avoid
an injury, sickness, or disease in the first place, and generally it will not
help someone who is already ill (though there are exceptions). For
instance, many babies and young children are vaccinated against polio and
other infectious diseases, which prevent them from contracting polio. But
the vaccination does not work on patients who already have polio. A
treatment or cure is applied after a medical problem has already started.
3.4. The Social Role of Doctors and Patients
The doctor-patient relationship is central to the practice of
healthcare and is essential for the delivery of high-quality health care in
the diagnosis and treatment of disease. The quality of the patient-physician
relationship is important to both parties. The better the relationship in
terms of mutual respect, knowledge, trust, shared values and perspectives

59
about disease and life, and time available, the better will be the amount
and quality of information about the patient's disease transferred in both
directions, enhancing accuracy of diagnosis and increasing the patient's
knowledge about the disease. Where such a relationship is poor the
physician's ability to make a full assessment is compromised and the
patient is more likely to distrust the diagnosis and proposed treatment.
Doctor - patient relationship can be analyzed in different manners.
Sociologists conceptualized it in context of social roles. As was exposed
above social role is understood as the expected behaviors (including) of
someone with a given position (status) in society towards others with the
same or other status.  Accordingly the relation between doctor and patient
is an ensemble of rights and obligations of doctor towards patient as well
as vice versa. The first who define the doctor-patient relationship in term
of social role was Talcott Parsons (1951). He consider that the illness is a
form of dysfunctional deviance that requires reintegration with the social
organism. Illness, or feigned illness, exemptes people from work and other
responsibilities, and thus is potentially detrimental to the social order if
uncontrolled. Maintaining the social order required the development of a
legitimized "sick role" to control this deviance, and make illness a
transitional state back to normal role performance. In Western society,
there are four norms (rights and obligations) governing the functional sick
role.
Rights:
 (1)   The sick person is exempt from “normal” social roles.  An
individual’s illness is grounds for his or her exemption from normal role
performance and social responsibilities.  This exemption, however, is
relative to the nature and severity of the illness.  The more severe the
illness, the greater the exemption. Exemption requires legitimating by the
physician as the authority on what constitutes sickness.  Legitimating
serves the social function of protecting society against malingering
(attempting to remain in the sick role longer than social expectations allow
– usually done to acquire secondary gains, or additional privileges
afforded to ill persons).
(2)   The sick person is not responsible for his or her
condition. An individual’s illness is usually thought to be beyond his or
her own control. A morbid condition of the body needs to be changed and
some curative process apart from person will power or motivation is
needed to get well.

60
 Obligations:
 (1)   The sick person should try to get well. The first two
aspects of the sick role are conditional upon the third aspect, which is
recognition by the sick person that being sick is undesirable. Exemption
from normal responsibilities is temporary and conditional upon the desire
to regain normal health. Thus, the sick person has an obligation to get
well.
(2)   The sick person should seek technically competent help
and cooperate with the physician. The obligation to get well involves a
further obligation on the part of the sick person to seek technically
competent help, usually from a physician. The sick person is also expected
to cooperate with the physician in the process of trying to get well.
What are the rights and obligations of physician? The physician's
role is to represent and communicate these norms to the patient to control
their deviance. Physicians exemplify the shift to "affect-neutral"
relationships in modern society, with physician and patient being protected
by emotional distance. Medical education and social role expectations
impart normative socialization to physicians to act in the interests of the
patient rather than their own material interests, and to be guided by an
egalitarian universalism rather than a personalized particularism. Because
physicians have mastered a body of technical knowledge, it is functional
for the social order to allow physicians professional autonomy and
authority, controlled by their socialization and role expectations.
Summarizing we can say that the physician’s role includes following
norms:
Rights or privileges:
(1)access to patient’s physical and personal intimacy;
(2)professional autonomy;
(3)professional dominance.
Obligations
(1)Acting for the benefit of patient’s well-being (orientation
towards collective and not personal interest);
(2)Behavior according to professional rules (universality/to treat
all in the same way/ vs. particularity);
(3)Application to a high degree of acquired knowledge and skills
to treatment of disease;

61
 (4)Objectivity and emotional neutrality /do not adjudicate the
patient or make them closer than it is requested by the principles of
objectivity/.
Parsons mention the idea of asymmetric physician dominance in
relation with sick person. The features of this dominance are following:
1. Higher status and power;
2. Professional prestige;
3. Situational physician authority, a monopoly over what the
patient wants: since demand exceeds supply;
4. Physician is advantageous because the patient has to come to
him;
5. Situational dependency to receive medical care, the patient has
to consent to condition prescribed by physician.
Thus, the role of doctor is an active but the role of patient is
passive one.
Talcott Parsons have a great contribution in analyses of doctor-
patient relationships as a relation of roles. Firstly because creates an
original conception on it and secondly because his conception stimulates
other sociologists to formulate different approaches to the doctor- patient
relation, essentially via criticism to this original conception. The main
these approaches being exposed below.
Thus, Hafferty (1988) accuses Parson of having been overly
optimistic about the success of physician socialization to universalism and
affective-neutrality. Physicians often react negatively to dying patients,
patients they do not like, and patients they believe are complainers.
Physicians also are subject to personal financial and personal interests in
patient care. Kelly (1987) considers that while the basic notion that norms
and social roles influence illness and doctoring has remained robust, there
have been numerous qualifications to the particular elements that Parsons
attributed to the patient-physician role relationship. For instance,
physicians and the public consider some illnesses in the West and in other
societies to be the responsibility of the ill, such as lung cancer, AIDS and
obesity, making it more difficult for them to be normatively reintegrated
into society. Physicians and other providers react less favorably to patients
who are held responsible for their illness than to "innocent" patients.
Another weakness of Parsons' description is that it was specific to
acute illness, and did not speak to the increasingly prevalent chronic
illnesses and disabilities, a sick role which is permanent and not

62
transitional. Szasz and Hollender's (1956) work refined Parsons by
elaborating different doctor-patient models arising around different types
of illness:
(1) Patient passivity and physician assertiveness are the most
common reactions to acute illness;
(2) Less acute illness is characterized by physician guidance and
patient cooperation;
(3) Chronic illness is characterized by physicians participating in a
treatment plan where patients had the bulk of the
responsibility to help themselves.
Critics have also shown that there is a great deal of inter-cultural
and inter-personal variation in sick roles and norms. The "American" sick
role is not as useful a concept as the more specific "white, Midwestern,
Scandinavian, male" sick role. There is also cross-class variation. Some of
the poor adapt to their lack of access to medical care by becoming
fatalistic, rejecting the necessity of medical treatment, and coming to see
illness and death as inevitable. On the other hand, the educated classes
have become more assertive in the relationship, rejecting the norm of
passivity in favor of self-diagnosis or negotiated diagnosis. There is also
inter-cultural variation in physician roles, and variation among physicians
in the success of their role socialization. While Parsons' model of doctors'
affective neutrality, collective-orientation, and egalitarianism towards
patients did express the professional ideal, some physicians are more
affectively neutral than others. Following Parsons' lead, some sociologists
began to focus on the socialization (professionalization) of physicians and
the factors in medical school and residency that facilitated or discouraged
optimal role socialization to doctor-patient relationships.
Thus, Conrad (1989) considers that the Parsons’ work generally
took the division of labor in medicine for granted, and painted a more or
less heroic picture of medical self-sacrifice. Beginning to focus on aspects
of the physician role and medical education which themselves militated
against humanistic patient care he suggested that medical schools and
residencies socialized physicians into "dehumanization," and to place
professional identity and camaraderie before patient advocacy and social
idealism.
James "J." Hughes considers that the most important weakness of
Parsons' functionalist account of the doctor-patient relationship arose from
his poor understanding of the ecological concepts of dysfunction and niche

63
width. Social structures cannot be assumed to be functional for the social
system simply because they exist, any more than an organic structure, such
as an appendix, can be assumed to be functional for its organism. All that
can be said about a structure, or in this case a role relationship, is that it
has not yet pushed the organism outside its niche, causing its extinction. In
other words, the study of doctor-patient relationships in one society does
not indicate how many the particular structures and norms of the provider-
patient relationship are simply the result of historical chance, rather than
necessitated by the nature of illness and healing in industrial society. And
second, such a study does not indicate whether the particular practices and
norms are leading in a dysfunctional direction. A critical sociology of the
doctor-patient relationship thus arose to challenge the internal
contradictions of the Parsonsian biological metaphor: were American
doctors the perfect immune system for society, or had they developed into
a parasitic growth threatening the health of society?
To the more critical 60's generation of social scientists, inspired by
growing resistance to unjust claims to power, physicians' defense of
professional power and autonomy appeared to be merely self-interested
authoritarianism. Physicians' battle-cry of the sacred nature of the doctor-
patient relationship sounded hollow in their struggles against universal
health insurance. Physicians' high incomes and defense of autonomy
appeared to result in both bad medicine and bad health policy, and
physician's unaccountable power appeared all the more nefarious because
of medicine's intimate invasion of the body.
In this context, Eliot Freidson's work (1961, 1970, 1975, 1986)
crystallized the notion that professional power was more self-interested
than "collectivity-oriented." Freidson saw the doctor-patient relationship
as a bargained interface between a professional system and a lay system,
each with its own interests and hence with the high potentiality of conflict.
Freidson's approach to the sick role went beyond Parsons to assert that
doctors create the legitimate categories of illness. Professionalization
grants physicians a monopoly on the definition of health and illness, and
they use this power over diagnosis to extend their control. This control
extends beyond the claim to technical proficiency in medicine, to claims of
authority over the organization and financing of health care, areas which
have little to do with their training.

64
 All these approaches mentioned above criticizing Parson’s vision,
have expose the weaknesses of the relationship in concern but also suggest
a historical evolution in patient and physician relation.
The history of medicine has witnessed a gradual erosion of the
physician's time-honored role as all-knowing healer. Whether physicians
were experts in their fields, self-taught folk healers, or complete quacks,
the doctor's words, for generations, were accepted as correct, complete,
final, and to be obeyed. Indeed, the language of the 1847 Code of Medical
Ethics of the American Medical Association, titled "Obligations of
Patients to Their Physicians", endorsed this paradigm: “The obedience of a
patient to the prescriptions of his physician should be prompt and implicit.
He should never permit his own crude opinions as to their fitness, to
influence his attention to them. A failure in one particular may render an
otherwise judicious treatment dangerous, and even fatal”.
The patient was treated like a child; innocent, unschooled, and too
simple to know how to take care of himself or herself. This wise father-
simple child relationship led to an inherently paternalistic model of the
physician-patient relationship.
But while science and technology have filled medical books with
more and more treatment options and diseases are better understood, the
instantaneous dissemination of news around the world has simultaneously
rendered the public hyper-aware of the new capabilities of medicine. As a
result, patients have shifted from approaching physicians with hope and
faith to approaching them with high expectations of precision, of speed, of
a virtual superstore of treatment options.
Patients have taken the reins of health care with both hands. They
come to doctor's offices armed with reams of printouts from health Web
sites. They specifically request medicines or treatments advertised in
popular magazines, on television, and on the Internet. In response to this
type of informed (though sometimes misinformed) patient, many
physicians have come to grant a greater level of autonomy or shared
decision making to all the patients in their practices.
A turning point in the shift from physician paternalism to respect
for patient autonomy was the requirement for the patient's informed
consent to treatment. The concept of informed consent did not exist in
writings on Egyptian, Greek, or Roman medicine. Indeed, the phrase
"informed consent" was not used until the 1950s. The notion of "consent
to treatment" was a consequence of the Nuremberg Trials that later

65
became enshrined in the research and treatment codes of democratic
nations.
There have been major changes in the doctor-patient relationship
over the past decades; both from patients' and doctors' point of view. There
is, indeed, some evidence that changes in society and health care have
resulted in real changes in what people expect from their doctors and in
how doctors view patients. Many patients want more information than
they are given. Many also say that they want to take an active part in
decisions about their treatment, in the light of its chances of success and
any side effects. Concepts like 'patient empowerment', 'informed consent',
'shared decision making' and 'consumerism' have been introduced to label
this transformation of the patient role from that of passive dependency to
active autonomy. According to the literature, the traditional paternalistic
model is no longer the only, nor the preferred doctor-patient relationship
model. There is a wide consensus that a model based on a more equal
doctor-patient relationship is both beneficial for patients and more in
keeping with current ethical views.
Today, most procedures in a hospital are preceded by explanations
and discussions at the patient's bedside that make clear all the risks and
benefits of the procedure. The consent conversation must be conducted by
an MD, and the patient must be able to understand what he or she is being
asked to agree to.
Reflecting the importance of informed consent in modern health
care, an opinion from the current AMA Code of Ethics, on "Fundamental
Elements of the Patient-Physician Relationship" states: "The patient has
the right to make decisions regarding the health care that is recommended
by his or her physician. Accordingly, patients may accept or refuse any
recommended medical treatment".
As a physician, the doctor-patient relationship greatly impacts the
approach to education, motivation, and negotiation of treatment plans. In
literature are described the following four models of the physician-patient
relationship:
 Paternalistic - The physician is parental, recommending what
he/she feels is best for the patient. The patient chooses whether or not to
follow the recommendations.
 Informative - This is a "consumer" model of care. The
physician provides information about all available treatment choices in as

66
accurate and as unbiased a manner as possible. The patient chooses from
the available options.
 Interpretive - In this model, the patient is not expected to
simply choose among available options because he/she lacks medical
training. Instead, the physician tries to understand or interpret the patient’s
general values and preferences. The physician then recommends the
treatment option which is most consistent with the patient’s values.
 Deliberative - In this model, part of the physician’s role is to
promote health by influencing the patient’s health-related choices, using
non-coercive approaches to motivate the patient.
All these model of doctor- patient interaction occur within the
limits of professional sets of norms designed to guide the behavior in
medical context. One of such a set of norm is A U.S. Patient's Bill of
Rights is a statement of the rights to which patients are entitled as
recipients of medical care. Typically, a statement articulates the positive
rights which doctors and hospitals ought to provide patients, thereby
providing information, offering fair treatment, and granting them
autonomy over medical decisions.

Shrewsbury Surgery Center PATIENT BILL OF RIGHTS

1.Information Disclosure. Consumers have the right to receive
accurate, easily understood information and some require assistance in
making informed health care decisions about their health plans,
professionals, and facilities.
2.Choice of Providers and Plans. Consumers have the right to a
choice of health care providers that is sufficient to ensure access to
appropriate high-quality health care.
3.Access to Emergency Services. Consumers have the right to
access emergency health care services when and where the need arises.
Health plans should provide payment when a consumer presents to an
emergency department with acute symptoms of sufficient severity --
including severe pain -- such that a "prudent layperson" could reasonably
expect the absence of medical attention to result in placing that
consumer's health in serious jeopardy, serious impairment to bodily
functions, or serious dysfunction of any bodily organ or part.
4.Participation in Treatment Decisions. Consumers have the right
and responsibility to fully participate in all decisions related to their
health care. Consumers who are unable to fully participate in treatment

67
decisions have the right to be represented by parents, guardians, family
members, or other conservators.
5.Respect and Nondiscrimination. Consumers have the right to
considerate, respectful care from all members of the health care system at
all times and under all circumstances. An environment of mutual respect
is essential to maintain a quality health care system.
6.Confidentiality of Health Information. Consumers have the
right to communicate with health care providers in confidence and to have
the confidentiality of their individually identifiable health care
information protected. Consumers also have the right to review and copy
their own medical records and request amendments to their records.
7.Complaints and Appeals. All consumers have the right to a fair
and efficient process for resolving differences with their health plans,
health care providers, and the institutions that serve them, including a
rigorous system of internal review and an independent system of external
review.
8.Consumer Responsibilities. In a health care system that protects
consumers' rights, it is reasonable to expect and encourage consumers to
assume reasonable responsibilities. Greater individual involvement by
consumers in their care increases the likelihood of achieving the best
outcomes and helps support a quality improvement, cost-conscious
environment.
3.5. Deviations from the Role Obligations in the Doctor-Patient
Relationship
As was mention above one basic obligation of physician is to
behave in the best interest of patient while the last is to find the most
qualitative health aid. Medical practice exposes the significant deviation
from these obligations via medical malpractice and patient self-
medication.
Medical malpractice is professional negligence by act or omission
by a health care provider in which care provided deviates from accepted
standards of practice in the medical community and causes injury to the
patient. Standards and regulations for medical malpractice vary by country
and jurisdiction within countries. Most medical malpractice actions are
filed against doctors who have failed to use reasonable care to treat a
patient. But the legal concept of medical malpractice is not limited to the
conduct of medical doctors, but applies also to nurses, anesthesiologists,

68
health care facilities, pharmaceutical companies, and others that provide
health care services. Common types of medical malpractice, including bad
diagnosis, sub-standard care, lack of "informed consent", as well as breach
of doctor-patient confidentiality. Cases of medical malpractice usaly are
brought in court.
When someone considers that was injured in medical care context
he addresses to lawsuit, whose goal to pay him back if a doctor injures
him. For a successful medical malpractice claim a plaintiff must establish
the elements of the tort of negligence. These are as follow:
1.A duty was owed: a legal duty exists whenever a hospital or health
care provider undertakes care or treatment of a patient.
2.A duty was breached: the provider failed to conform to the
relevant standard of care. The standard of care is proved by expert
testimony or by obvious errors.
3.The breach caused an injury: The breach of duty was a proximate
cause of the injury.
4.Damages: Without damages (losses which may be pecuniary or
emotional), there is no basis for a claim, regardless of whether the medical
provider was negligent. Likewise, damages can occur without negligence,
for example, when someone dies from a fatal disease.
The plaintiff's damages may include compensatory and punitive
damages. Compensatory damages are both economic and non-economic.
Economic damages include financial losses such as lost wages (sometimes
called lost earning capacity), medical expenses and life care expenses.
These damages may be assessed for past and future losses. Non-economic
damages are assessed for the injury itself: physical and psychological
harm, such as loss of vision, loss of a limb or organ, the reduced
enjoyment of life due to a disability or loss of a loved one, severe pain and
emotional distress. Punitive damages are only awarded in the event of
wanton and reckless conduct. Malpractice lawsuits are time consuming
and costly for doctors, even if the doctor is insured or wins the case. Thus,
medical professionals are required to maintain professional liability
insurance to offset the risk and costs of lawsuits based on medical
malpractice. The fear of malpractice is meant to keep doctors from making
medical mistakes and from acting carelessly. In this way, the law can
control the quality of health care. Malpractice puts the responsibility on
doctors to act in a way that will not result in an injury to you. If doctors are

69
forced to pay for the costs of their medical mistakes, they will be more
careful to make sure that mistakes do not happen in the first place.
Confidentiality violation as a form of malpractice
The ethical principle of confidentiality requires that information
shared by the client with the therapist in the course of treatment is not
shared with others. This is important for the therapeutic alliance, as it
promotes an environment of trust. However, there are important
exceptions to confidentiality, namely where it conflicts with the clinician's
duty to warn or duty to protect. This includes instances of suicidal or
homicidal ideation, child abuse, elder abuse and dependent adult abuse.
Confidentiality shows a respect for an individual's autonomy and
their right to control the information relating to their own health. In
keeping information about the patient secret the doctor is acting
beneficently. Disclosing information without the patient's consent can
damage the patient. For instance if a doctor were to reveal privileged
information about a celebrity patient to the newspapers then this would be
the very reverse of beneficent i.e. maleficent.
Drug misuse
Drug misuse is a term used commonly for prescription
medications with clinical efficacy but abuse potential and known adverse
effects linked to improper use, such as psychiatric medications with
sedative, anxiolytic, analgesic, or stimulant properties. Prescription misuse
has been variably and inconsistently defined based on drug prescription
status, the uses that occur without a prescription, intentional use to achieve
intoxicating effects, route of administration, co-ingestion with alcohol, and
the presence or absence of abuse or dependence symptoms. Tolerance
relates to the pharmacological property of substances in which chronic use
leads to a change in the central nervous system, meaning that more of the
substance is needed in order to produce desired effects. Stopping or
reducing the use of this substance would cause withdrawal symptoms to
occur.
Self-medication
It is a term used to describe the use of drugs other self-soothing
forms of behavior to treat untreated and often undiagnosed distress. Every
day, everywhere, consumers reach for self-care products to help them
through their common health problems. They do so because it may be
easier for them, it may be more cost or time efficient, they may not feel
their situation merits making an appointment with a healthcare

70
professional, or they may have few or no other options. Self medication
can be very dangerous for the health of people, because of delaying of
professional aid, addiction, adverse effects of substance consumed. In
condition when there is evidence that consumer can and do practice self-
medication, which can be harmful, the obligation of governments is to
elaborate a responsible framework for self-medication.
In this circumstance The World Medical Association (WMA) has
developed the statement to provide guidance to physicians and their
patients regarding responsible self-medication. This statement is adopted
by the 53rd WMA General Assembly, Washington, DC, USA, October
2002.
1. Distinction between Self-Medication and Prescription
Medicines
a. Medicinal products can generally be divided into two separate
categories: prescription and non-prescription medicines. This classification
may differ from country to country. The national authorities must assure
that medicines, categorized as non-prescription medicines, are sufficiently
safe not to be harmful to health.
b. Prescription medicines are those which are only available to
individuals on prescription from a physician following a consultation.
Prescription medicines are not safe for use except under the supervision of
a physician because of toxicity, other potential or harmful effects (e.g.
addictiveness), the method of use, or the collateral measures necessary for
use.
c. Responsible self-medication, as used in this document, is the
use of a registered or monographed medicine legally available without a
physician’s prescription, either on an individual’s own initiative or
following advice of a healthcare professional. The use of prescription
medicines without a prior medical prescription is not part of responsible
self-medication.
d. The safety, efficacy and quality of non-prescription medicines
must be proved according to the same principles as prescription medicines.
2. Use of Self-Medication in conjunction with Prescription
Medication
A course of treatment may combine self-medication and
prescription medication, either concurrently or sequentially. The patient
must be informed about possible interactions between prescription
medicines and non-prescription medicines. For this reason the patient

71
should be encouraged to inform the physician about his / her self-
medication.
3. Roles & Responsibilities in Self-Medication
a. In self-medication the individual bears primary responsibility
for the use of self-medication products. Special caution must be exercised
when vulnerable groups such as children, elderly people or pregnant
women use self-medication.
b. If individuals choose to use self-medication, they should be
able:
i. to recognize the symptoms they are treating;
ii. to determine that their condition is suitable for self-medication;
iii. to choose an appropriate self-medication product;
iv. to follow the directions for use of the product as provided in the
product labelling.
c. In order to limit the potential risks involved in self-medication
it is important that all health professionals who look after patients should
provide:
i. Education regarding the non-prescription medicine and its
appropriate use, and instructions to seek further advice from a physician if
they are unsure. This is particularly important where self-medication is
inappropriate for certain conditions the patient may suffer from;
ii. Encouragement to read carefully a product’s label and leaflet (if
provided), to seek further advice if necessary, and to recognize
circumstances in which self-medication is not, or is no longer, appropriate.
d. All parties involved in self-medication should be aware of the
benefits and risks of any self-medication product. The benefit-risk balance
should be communicated in a fair, rational manner without
overemphasizing either the risks or the benefits.
e. Manufacturers in particular are obliged to follow the various
codes or regulations already in place to ensure that information provided
to consumers is appropriate in style and content. This refers in particular to
the labelling, advertising and all notices concerning non-prescription
medicines.
f. The pharmacist has a professional responsibility to recommend,
in appropriate circumstances, that medical advice be sought.
4. Role of Governments in Self-Medication
Governments should recognize and enforce the distinction
between prescription and non-prescription medicines, and ensure that the

72
users of self-medication are well informed and protected from possible
harm or negative long-term effects.
5. The Promotion and Marketing of Self-Medication Products
a. Advertising and marketing of non-prescription medicines
should be responsible, provide clear and accurate information and exhibit
a fair balance between benefit and risk information. Promotion and
marketing should not encourage irresponsible self-medication, purchase of
medicines that are inappropriate, or purchases of larger quantities of
medicines than are necessary.
b. People must be encouraged to treat medicines (prescription and
non-prescription) as special products and that standard precautions should
be followed in terms of safe storage and usage, in accordance with
professional advice.

► Exercises and Discussions:

1. What is society?
2. What is the structure of human society? Describe its elements.
3. Define the terms social status and role. What is difference
between them?
4. What are Role obligations and rights of physician and patient?
5. Listed the forms of role obligations’ deviation.
6. Find and describe the case of medical malpractice.
7. What is self medication? What risk it implies?
► Recommended Essays
1. Health and Social Class
2. Social factors influencing human health.
3. Self medication or addiction?
► Literature:
1. Parsons Talcott. Social System. Routledge, 1991.
2. Blum R. H. The Management of the Doctor-Patient
Relationship. McGraw-Hill, 1960.
3. Anderson Richard E. Medical malpractice: a physician's
sourcebook. Humana Press, 2005.

73
 Chapter 4

Communication: Definitions and Functions

Without knowing the force of words
it is impossible to know men.

Confucius
4.1. What is Communication?
Communication has existed since the beginning of human beings,
but it was not until the 20th century that people began to study the process.
When World War I ended, the interest in studying communication
intensified as communication technologies developed and the social-
science study was fully recognized as a legitimate discipline. During the
last decade, the outpouring of scientific research on human communication
has increased at a staggering rate. This burst of research activity is due to
the ever-widening usage of the term "communication" and to a declaration
of vested interest in communication research by numerous scientific
disciplines. One review of developments in the field lists more than twenty
academic disciplines which currently provide content and method for
research on some phase of human interaction. This increase in
communication research or studies reveals that communication is central
to the human experience and life. The interest of many discipline in
communication studies also reveal that communication is not so univocal
or obvious subject.
What is communication? The word communication derived from
Latin communis – common and communication - to give and make
something common. Beginning from these original meaning of Latin
words different modalities of defining or explaining communication were
elaborated. Each of modality emphasizes one aspect of communication as
phenomenon. Thus, communication can be defined as speech,
understanding, social process, reduction of uncertainties, transmission,
commonality, behavior modifying response, power etc.
Communication as speech: “Communication is the verbal
interchange of thought or idea” (Hoben, 1954).

74
 Communication as understanding: “Communication is the process
by which we understand others and in turn endeavor to be understood by
them. It is dynamic, constantly changing and shifting in response to the
total situation” (Anderson, 1959).
Communication as social process: “Interaction, even on the
biological level, is a kind of communication; otherwise common acts
could not occur” (Mead, reprinted 1963).
Communication as reduction of uncertainties: “Communication
arises out of the need to reduce uncertainty, to act effectively, to defend or
strengthen the ego” (Barnlund, 1964).
Communication as transfer, transmission: “The connecting thread
appears to be the idea of something’s being transferred from one thing, or
person, to another. We use the word ‘communication’ sometimes to refer
to what is so transferred, sometimes to the means, by which it is
transferred, sometimes to the whole process. In many cases, what is
transferred in this way continues to be shared; if I convey information to
another person, it does not leave my own possession through coming into
his. Accordingly, the word ‘communication’ acquires also the sense of
participation. It is, in this sense, for example, that religious worshipers are
said to communicate” (Ayer, 1955).
Communication as commonality: “It (communication) is a process
that makes common to two or several what was the monopoly of one or
some” (Gode, 1959).
Communication as Discriminative Response/Behavior Modifying
Response: “Communication is the discriminatory response of an organism
to a stimulus” (Stevens, 1950).
Communication as intention: “In the main, communication has as its
central interest those behavioral situations in which a source transmits a
message to a receiver(s) with conscious intent to affect the latter’s
behaviors” (Miller, 1966).
Communication as power: “Communication is the mechanism by
which power is exerted” (Schacter, 1951).
Communication as a process:” Communication can be define as a
process of conveying information from a sender to a receiver with the use
of a medium in which the communicated information is understood the
same way by both sender and receiver” (Shannon, 1963).

75
 As can be seen human communication is understood in various
manners. This diversity is the result of communication complexity as well
as its being a subject - matter of a very broad constituency of disciplines
that includes Rhetoric, Journalism, Sociology, Psychology,
Anthropology, and Semiotics, and others. Because many fields of study
dedicate a portion of attention to communication, when speaking about
communication it is very important to be sure about what aspects of
communication one is speaking about.
Nevertheless beyond the diversity in understand or defining of
communication there are some common accepted things. All of humans
communicate. Communication occurs to all areas of life: home, school,
community, work, and beyond. Communication includes acts or interacts
that confer knowledge and experiences, share emotion, give advice and
commands, and ask questions. Communication requires a vast repertoire
of skills in intrapersonal and interpersonal processing such as listening,
observing, speaking, questioning, analyzing, and evaluating.
Communication requires skills in utilization of technique of encoding and
decoding, that is grammatical rules but also knowledge about culture,
habits, behavioral rules etc. Communication requires physical and
psychological capability to send and receive information, because the
efficiency in information interchanging depends in many respects on such
factor as anxiety, fatigue, boring, annoyance, and interest. Human
communication happened at many levels (i.e. verbal, nonverbal, para-
verbal, extra-verbal) take many forms (i.e. intrapersonal, interpersonal,
social mediated), in one of the various manners (i.e. verbal presentation,
letter, through movements, sounds, reactions, physical changes, gestures,
languages, breath, etc).
4.2. The Communication Process
In order to clarify what is communication and how does it occur
were created a lot of theoretical models of communication. The Shannon–
Weaver model of communication has been called the "mother of all
models”. This model was widely adopted into the social science fields,
such as education, organizational analysis, psychology, etc.
Shannon–Weaver model of communication
In 1949, the American engineer Shannon elaborated this model
with intention to explain what basically happens in communication. He

76
developed his ideas in a 1963 book with Warren Weaver titled The
Mathematical Theory of Communication.
Information
Source Transmiter Receiver Destination

Signal Recevied
Message Signal Message

Noise
Source

Shannon's diagram of a general communication system.

Here are laid out the basic elements of communication as they were
developed by Shannon and others:
1. Source, emissor, sender (by whom the information is conveyed?).
When we speak, write, smile, and make gesture we are in the posture of
sender. Information source produces a message or sequence of messages to be
communicated to the receiving terminal.
2. Message (what types of things and in what form are
communicated?). Message is information which is sent from a source to a
receiver. It may be any thought expressed in a language, prepared in a form
suitable for transmission by any means of communication. In communication
between humans, messages can be verbal or nonverbal:
A verbal message is an exchange of information using words.
Examples include face-to-face communication, telephone calls, voicemails,
etc. A nonverbal message is communicated through actions or behaviors
rather than words. Examples include the use of body language.
3. Encoding is a process of message production. To codify means to
translate our ideas, attitudes, emotions into language. Language may be
spoken and written (i.e. sounds and words). Also there are paralanguage (for
instance tone of voice, quality of voice, rhythm and intonation), and body
language (for instance posture and gesture).
4. Transmitter operates on the message in some way to produce
a signal suitable for transmission over the channel. In telephony this
operation consists merely of changing sound pressure into a proportional

77
electrical current. In telegraphy we have an encoding operation which
produces a sequence of dots, dashes and spaces on the channel
corresponding to the message.
5. Decoding is the opposite process. Sender is in this context the
encoder, but receiver is the decoder. A code is a rule for converting a piece
of information (for example, a letter, word or gesture) into another form or
representation (one sign into another sign), not necessarily of the same
type. Cod may also be defined as a system of sign and symbols in
communication.
6. The channel (through which medium is communication
realized?) is merely the medium used to transmit the signal from
transmitter to receiver. It may be a pair of wires, a coaxial cable, a beam of
light, etc. Channel, in communications, refers to the medium used to
convey information from a sender (or transmitter) to a receiver. It may be
for instance air in case of face-to-face communication, or telephone cable
in case of message telephonically sent.
7. Context (in what condition is communication realized?) refers
to the interrelated conditions of communication. It consists of everything
that is not in the message, but on which the message relies in order to have
its intended meaning. Context has several dimensions:
- Space (the physical place where the communication occurs).
- Time (that is hour, day, season when communication occurs)
- Social dimension (for example: relations between participants,
their assumed role).
- Psychological dimension (for instance official or nonofficial
character of communication; presence or absence of hostility in
communication).
8. Communication noisy is defined as all factors which impede
communication. Shannon in his conception of communication argued that
the input, or intended message, is sent by a sender via a channel. The
message received becomes the output. Input and output may differ
substantially as a channel is usually exposed to circumstances that may
alter its intended quality of transmission. For instance, the channel of a
telephone communication line is usually impaired with noise, which in
turn affects the outcome, i.e. output, of the message. Reiterating in
category of “noisy” as usual are included not only physical technical
impediments of communication but all type of communicative barriers.
These may be difficulties in intercultural communication, defective

78
perception, unclear message, social stress etc. There are many examples of
noise:
Environmental noise: Noise that physically disrupts
communication, such as standing next to loud speakers at a party, or the
noise from a construction site next to a classroom making it difficult to
hear the professor.
Physiological-Impairment noise: Physical maladies that prevent
effective communication, such as actual deafness or blindness preventing
messages from being received as they were intended.
Semantic noise: Different interpretations of the meanings of
certain words. For example, the word "weed" can be interpreted as an
undesirable plant in your yard, or as a euphemism for marijuana.
Syntactical noise: Mistakes in grammar can disrupt
communication, such as abrupt changes in verb tense during a sentence.
Organizational noise: Poorly structured communication can
prevent the receiver from accurate interpretation. For example, unclear and
badly stated directions can make the receiver even more lost.
Cultural noise: Stereotypical assumptions can cause
misunderstandings, such as unintentionally offending a non-Christian
person by wishing them a "Merry Christmas".
Psychological noise: Certain attitudes can also make
communication difficult. For instance, great anger or sadness may cause
someone to lose focus on the present moment. Disorders such as Autism
may also severely hamper effective communication.
9. Destination, receiver, target (whom is message conveyed to?)
person (or thing) for whom the message is intended. When we listen, read,
look at we are in posture of receiver. Receiver may be oneself and in this
case we say that occurs intrapersonal communication, may be another
person and in this case we have interpersonal communication, may be a
group of persons and when we can say that happens intercultural
communication.
10. Feedback is define as a mechanism, process or signal that is
looped back to control a system within itself. The purpose of feedback is
to alter messages so the intention of the original communicator is
understood by the second communicator. It includes verbal (i.e.
paraphrasing) and nonverbal (i.e. nodding your head to show agreement,)
responses to another person's message. Carl Rogers listed five main

79
categories of feedback. They are listed in the order in which they occur
most frequently in daily conversations.
o Evaluative: Making a judgment about the worth, goodness, or
appropriateness of the other person's statement.
o Interpretive: Paraphrasing - attempting to explain what the other
person's statement means.
o Supportive: Attempting to assist or bolster the other
communicator.
o Probing: Attempting to gain additional information, continue the
discussion, or clarify a point.
o Understanding: Attempting to discover completely what the other
communicator means by her statements.
4.3. Communication Functions
What we are communicating for? There are many significant and
much elaborated answers to this interrogation. In what proceed will be
exposed the most famous of them, that introduced by the Russian-
American linguist, Roman Jakobson (1960).
Jakobson distinguishes six communication functions, each
associated with a dimension of the communication process: context,
message, sender, receiver, channel, code. Jakobson allocates a
communicative function to each of the components.
The referential function refers to the context. Here we have the
function emphasizing that communication is always dealing with
something contextual, referential (the dominant function in a message like
'Water boils at 100 degrees'). The referential function of communication is
illustrated via the words: this, that, those etc.
The poetic function is allocated to the message and puts 'the focus
on the message for its own sake'. Messages convey more than just the
content. They always contain a creative 'touch' of our own. These
additions have no purpose other than to make the message "nicer".
Rhetorical figures, pitch or loudness are some aspects of the poetic
function.
The emotive function focuses on the sender, as in the interjections
'Bah!' and 'Oh!'. The sender's own attitude towards the content of the
message is emphasized. Examples are emphatic speech or interjections
(exclamation).

80
 The conative function is allocated to the addressee (imperatives
and apostrophes). It is directed towards the addressee. One example is the
vocative or appellative, imperative, interrogation.
The phatic function helps to establish contact, prolong or
discontinue communication and refers to the channel of communication.
Some of these utterances only serve to maintain contact between two
speakers, for instance via repetition, or confirm whether the contact is still
there (as in 'Hello?').
The metalinguistic function deals with the code itself; is used to
establish mutual agreement on the code. This is the function of language
about language (for example, a definition). This whole reader is an
example of metalanguage. We use it to examine the code. The
metalinguistic function is also predominant in questions like "Sorry, what
did you say?" where the code is misunderstood and needs correction or
clarification.
Naturally, several functions may be active simultaneously in
utterances. To find out which function predominates requires analysis. In a
proper analysis, we start by determining whether each of the functions of
language is present or absent. In theory, each factor is necessary to
communication. This does not necessarily mean that each function is
always present. We will assume that while one or more – or even all – of
the functions of language may be absent in short units (such as an isolated
sign), lengthy units can activate all of them. Where more than one function
is present, we will establish either: (1) a simple hierarchy, by identifying
the dominant function and not ranking the other functions, or (2) a
complex hierarchy, by specifying the degree of presence of some or all of
the functions.
Various criteria can be used to establish the functional hierarchy.
For example, Arcand and Bourbeau (1995) use an intention-based
criterion: "The dominant function is the one that answers the question,
'With what intention was this message transmitted?' and [...] the secondary
functions are there to support it." We must distinguish the intention
associated with each fragment from the overall intention, which is "a
sentence or series of sentences that corresponds to an intention" (1995).
Since the intention can be hidden, the function that is dominant in terms of
overt degree of presence may not be dominant in terms of intention.
Arcand and Bourbeau also distinguish between direct and indirect
manifestations of intention, which correlate to the opposition between

81
actual and overt functions. The appellative (conative) function is
manifested directly in "Go answer the door" and indirectly in "The
doorbell rang" (which is equivalent to "Go answer the door"), where the
overt function is the referential (or informative) function. In addition, we
need to distinguish between cause and effect functions, as well as ends and
means functions (the ends being the effect that is sought). For example,
when the phatic function (cause) is overactivated, it can trigger the poetic
function (effect); overactivation can be used for esthetic ends, and in this
case the poetic function is an end and the phatic function is a means.
4.4. Communication and Health
Communication is a means of survival. This statement is not just a
metaphor it is a conclusion based on the empirical studies. Without any
form of communication humans cannot live. Lack of communication or
inefficient communication could injure seriously the quality human life
and health. Public Health surveys show that:
 People who lack strong relationships have 2 - 3 times the risk of
early death, regardless of whether or not they smoke or drink.
 Terminal cancer strikes socially isolated people more often than
those who have close personal relationships.
 Divorced, separated, and widowed people are 5 - 10 times more
likely to need hospitalization for mental problems than their married
counterparts.
 Pregnant women under stress and without supportive
relationships have three times more complications than pregnant women
who suffer from the same amount of stress but have strong social
support.
 Studies show that social isolation is a major risk factor
contributing to coronary disease, comparable to physiological factors
such a s diet, smoking, obesity an lack of physical activity socially
isolated people are four times more susceptible to the common cold than
those who have active social networks
When the subject of communication and health is discussed of
interest is not only the impact of communication as such on the individual
health but rather the importance of communication to disease prevention,
health promotion, health care policy, and the business of health care as
well as enhancement of the quality of life and health of individuals within

82
the community. Nowadays Health communication is an important aria of
medical activity (theory and practice) which may be defined as “The art
and technique of informing, influencing, and motivating individual,
institutional, and public audiences about important health issues. Or it can
be define as an area of theory, research and practice related to
understanding and influencing the interdependence of communication
(symbolic interaction in the forms of messages and meanings) and health
related beliefs, behaviors and outcomes. Accordingly to this aria an
efficient communication is essential to successful public health practice at
every level of the ecological model; intrapersonal, interpersonal, group,
organizational, and societal. At each level there are a variety of
communication channels which must be considered, from face-to-face to
mass communications. The social contexts in which health communication
occurs are also widely varied and can include (but are not limited to)
homes, schools, doctor’s offices, and workplaces. Wherever, good
communication is associated with positive health outcomes, whereas poor
communication is associated with a number of negative outcomes. In
what is follow we will focus on three levels of heath communication: 1.
interpersonal medical communication emphasizing especially the
importance of communication between doctor and patient; 2.
Organizational level, emphasizing the importance of communication in
medical team; and 3. Societal level emphasizing the importance of
communication in public health.
The importance of communication in physician – patient
relationship
Good communication skills are essential to establish good doctor patient
relationship, which in turn has a positive impact on medical outcomes.
Good communication engenders meaningful and trusting
relationships between healthcare professionals and their patients. Studies
suggest that physician sensitivity - specifically a doctor's interest in people
- results in greater patient confidence and increased adherence to treatment
regimens.   We have much more confidence in our doctor if he or she can
communicate with us and seems sensitive to our needs. Good
communication skills are integral to medical and other healthcare practice.
In delivering care, doctors encounter a diverse range of patients
requiring different communication approaches - from the very young to
the elderly. Various patient subgroups may present particular difficulties in
terms of communication. For example, doctors may find it more difficult

83
to communicate with patients with a chronic or complex disease, a
terminal illness or those for whom there is no diagnosis. Under these
circumstances more effort must be made to communicate with the patient
sensitively. In some cases an explanation of the patient’s illness will need
to be paced over several sessions in order to suit the patient or family’s
emotional or cognitive ability to attend to, comprehend or incorporate the
information. Patients themselves may have communication difficulties
such as those with sensory impairments or speech problems, those with
language barriers or learning difficulties, and patients from different ethnic
groups. Communication with patients’ relatives is also commonly
required. To provide appropriate care, doctors must possess the
appropriate skills to communicate sensitively with people, irrespective of
cultural, social, religious or regional differences. In patient-doctor
interaction the main responsibility for cultural sensitivity and
understanding rests with the doctor. It is, therefore, imperative that
medical education includes intercultural communication training.
In all doctor-patient interactions a variety of communication skills
will be required for different phases of the consultation. During the start of
a consultation, doctors must establish a rapport and identify the reasons for
the consultation. They must go on to gather information, structure the
consultation, build on the relationship and provide appropriate
information.
A number of healthcare trends are increasing the need for strong
communication skills in medicine. In relation to communication with
patients, an increasing focus on shared decision making and
communication of risk are two of the most important factors. For example,
communication skills can help healthcare staff to explain the results of
epidemiological studies or clinical trials to individual patients in ways that
can help patients to understand risk. Doctors can do this more effectively
if they develop relationships with their patients and if they take into
account knowledge and perceptions of health risks in the general public.
Benefits of good communication can be identified for both doctors
and patients:
Benefits for patients
• The doctor-patient relationship is improved. The doctor is better
able to seek the relevant information and recognize the problems of the
patient by way of interaction and attentive listening. As a result, the
patient’s problems may be identified more accurately.

84
 • Good communication helps the patient to recall information and
comply with treatment instructions thereby improving patient satisfaction.
• Good communication may improve patient health and outcomes.
Better communication and dialogue by means of reiteration and repetition
between doctor and patient has a beneficial effect in terms of promoting
better emotional health, resolution of symptoms and pain control.
• The overall quality of care may be improved by ensuring that
patients ‘views and wishes are taken into account as a mutual process in
decision making.
• Good communication is likely to reduce the incidence of clinical
error.
Benefits for doctors
• Effective communication skills may relieve doctors of some of
the pressures of dealing with the difficult situations encountered in this
emotionally demanding profession. Problematic communication with
patients is thought to contribute to emotional burn-out and low personal
accomplishment in doctors as well as high psychological morbidity. Being
able to communicate competently may also enhance job satisfaction.
• Patients are less likely to complain if doctors communicate well.
There is, therefore, a reduced likelihood of doctors being sued ( of medical
malpractice).
The importance of good communication in medical team
Good communication within the healthcare team is essential in
order to ensure continuity of care and effective treatment for patients.
Moreover, poor communication between professional staff has been
identified as an underlying factor for failed communication with patients.
For example, a patient may be given different information
regarding their condition by different members of the healthcare team.
In today’s health care system, delivery processes involve
numerous interfaces and patient handoffs among multiple health care
practitioners with varying levels of educational and occupational training.
During the course of a 4-day hospital stay, a patient may interact with 50
different employees, including physicians, nurses, technicians, and others.
Effective clinical practice thus involves Successful Teamwork.
Components of Successful Teamwork are as follow:
- Non-punitive environment,
- Clear direction;
- Clear and known roles and tasks for team members;

85
 - Respectful atmosphere;
- Shared responsibility for team success;
- Appropriate balance of member participation for the task at
hand;
- Acknowledgment and processing of conflict;
- Clear specifications regarding authority and accountability;
- Clear and known decision-making procedures;
- Regular and routine communication and information sharing;
- Enabling environment, including access to needed resources;
- Mechanism to evaluate outcomes and adjust accordingly.
All these elements are determine by an open and effective
communication
When health care professionals are not communicating effectively,
patient safety is at risk for several reasons: lack of critical information,
misinterpretation of information, unclear orders over the telephone, and
overlooked changes in status.
Lack of communication creates situations where medical errors
can occur. These errors have the potential to cause severe injury or
unexpected patient death. Medical errors, especially those caused by a
failure to communicate, are a pervasive problem in today’s health care
organizations.
Effective communications make effective the work of teams;
enhance trust, respect, and collaboration, reduce the risk of medical errors,
increase the parent as well as health professionals satisfaction.
The importance of communication in public health
Public health is the approach to medicine that is concerned with
the health of the community as a whole. Public health is community
health. It has been said that: "Health care is vital to all of us some of the
time, but public health is vital to all of us all of the time."
The three core public health functions are:
1. The assessment and monitoring of the health of communities
and populations at risk to identify health problems and priorities;
2. The formulation of public policies designed to solve
identified local and national health problems and priorities;
3. To assure that all populations have access to appropriate and
cost-effective care, including health promotion and disease prevention
services, and evaluation of the effectiveness of that care.

86
 The efficiency in accomplishment of these tasks is directly related
to efficient communication, but there are some public health arias where
good communication is of special importance.
First one is communication for health education directed to learning
experiences and the voluntary actions people can take, individually or
collectively, for their own health, the health of others, or the common
good of the community. Health education is a systematically planned
activity, and can thus be distinguished from incidental learning
experiences. Further, this construction of health education draws attention
to voluntary behavioral actions taken by an individual, group, or
community with the full understanding and acceptance of the purposes of
the action—either to achieve an intended health effect or to build capacity
for health.
The second aria is communication for health behavior change.
Nowadays there are a lot of people that practice behavior with high health
risk, like smoking, drug abuse, alcohol consuming etc. the individuals with
such types of behavior will be more likely to change their health-related
behavior if they recognize a health risk or condition as important, if they
view themselves as susceptible to the risk or condition and if they regard
the benefits of change as outweighing barriers to making change.
Communication strategies play a key role in influencing these perceptions.
The third aria is communication in condition of health emergency.
Health emergencies include:
significant communicable disease outbreaks, e.g. an influenza pandemic;
chemical, biological or radiological incidents either criminal or accidental;
mass casualty incidents, e.g. an earthquake or transport accident; any
emergency where there are a significant number of people needing
medical treatment which requires a coordinated national approach. In all
this conditions the risk for community, damages, and panic will be low
down as a result of good (well planed) communication.
► Exercises and Discussions:
1.What is communication?
2.How is communication? Give some attributes of communication.
3.What are the elements of communication as a process?
4.Describe the functions of communication.
5.Identify your own reasons for communication.
6.What is health communication?

87
 7.What are the benefits of efficient communication in physician and
patient, and in medical team?
► Recommended Essays
1.Theoretical models of communication
2.E. Bern and transactional analysis
3.Neuro-linguistic programming
4.Communication behavior in a hospital setting
5.Communication in public health emergency/ its importance
► Literature:
1.Dance, Frank E. X., and Larson, Carl E. The Functions of Human
Communication: A Theoretical Approach. New York: Holt,
Rinehart and Winston, 1976.
2.Berry Dianne. Health communication: theory and practice.
McGraw-Hill International, 2006.
3.Brian Williams. Communications. Heinemann Library, 2002.
4.O’Daniel Michelle, Rosenstein Alan H. Professional
Communication and Team Collaboration.
http://www.ahrq.gov/qual/nurseshdbk/docs/O'DanielM_TWC.pdf
5.Samuel YS Wong, Albert Lee. Communication Skills and Doctor
Patient Relationship.
http://www.fmshk.org/database/articles/607.pdf

88
 Chapter 5

Metacommunication and Cultural Differences

Messages we send through our posture,

gestures, facial expression,
and spatial distance account for 55% of what
is perceived and understood by others. In fact,
through our body language we are always
communicating, whether we want to or not!
Albert Mehrabian

5.1. Metacommunication as Interpretation

According to etymological meaning of word Meta-communication
is "communicating about communication”. In the early 1970s, Gregory
Bateson coined the term to describe the underlying messages in what we
say and do. In other words meta-communication can be define as a
process of interpretation and understanding of communication and
consequently as a tool for developing one's interpersonal relationships.
People communicate all the time. It’s not possible to avoid it. We
are always sending out signals that others read, interpret, and respond to
while we are reading, interpreting and responding to theirs. Our
communication occurs not flatly, but on different levels and via various
processes. Could be mentioned conventionally even four levels on which
communication take place:
- Verbal level: communication by words;
- Para-verbal level: loudness of speaking, manner of speaking,
when keeping silent, meaning of interrupting or interfering the
conversation;
- Non-verbal level: body language (facial expression, eye
contact, gestures), messages without words;

89
 - Extra-verbal level: time, place, context, orientation towards
target groups, tactile (feeling by touching) and olfactory
(smelling) aspects.
In condition of the complexity of communication as a process
Meta-communication is an indispensable tool. Because people
communicate on different levels, one may not be aware of all the messages
he is sending. The actual content of what one says is the obvious form of
communication, but there are others: the context in which one says
something, the tone and volume of his voice, the look in his eyes, and
other body language, to name a few. Meta-communication can help one
ensure that his messages are consistent. It can also help him better
understand the messages sent by others.

5.2. Verbal Communication

Verbal communication includes written and oral communication.
Oral communication, is primarily referring to spoken verbal
communication, which typically relies on words. Oral communication may
be face-to-face discussion, interpersonal medicate communication
(telephone discussion) or public presentations.
Written communication involves any type of interaction that
makes use of the written word. Examples of written communication
avenues typically pursued include electronic mail, Internet Web sites,
letters, proposals, telegrams, faxes, postcards, contracts, advertisements,
brochures, and news releases. Indifferently of variety verbal
communication supposed the use of language.
Language is a real power. Our use of language has tremendous
power in the type of atmosphere that is created at the problem-solving
table. Words that are critical, blaming, judgmental or accusatory tend to
create a resistant and defensive mindset that is not conducive to productive
problem solving. On the other hand, we can choose words that normalize
the issues and problems and reduce resistance.
What is the meaning of term Language? Language may refer
either to the specifically human capacity for acquiring and using complex
systems of communication, or to a specific instance of such a system of
complex communication. The scientific study of language in any of its
senses is called linguistics.

90
 The approximately 3000–6000 languages that are spoken by
humans today are the most salient examples, but natural languages can
also be based on visual rather than auditive stimuli, for example in sign
languages and written language. Codes and other kinds of artificially
constructed communication systems such as those used for computer
programming can also be called languages. A language in this sense is a
system of signs for encoding and decoding information. The English word
derives from Latin lingua, "language, tongue." This metaphoric relation
between language and the tongue exists in many languages and testifies to
the historical prominence of spoken languages. When used as a general
concept, "language" refers to the cognitive faculty that enables humans to
learn and use systems of complex communication.
Language is thought to have originated when early hominids first
started cooperating, adapting earlier systems of communication based on
expressive signs to include a theory of other minds and shared
intentionality. This development is thought to have coincided with an
increase in brain volume. Language is processed in many different
locations in the human brain, but especially in Broca’s and Wernicke’s
areas. Humans acquire language through social interaction in early
childhood, and children generally speak fluently when they are around
three years old. The use of language has become deeply entrenched in
human culture and, apart from being used to communicate and share
information, it also has social and cultural uses, such as signifying group
identity, social stratification and for social grooming and entertainment.
Many spoken languages are written. Written communication is
divided into three revolutionary stages called Information Communication
Revolutions. During the 1st stage written communication first emerged
through the use of pictographs. The pictograms were made in stone; hence
written communication was not yet mobile. During the 2nd stage writing
began to appear on paper, papyrus, clay, and wax (etc). Common alphabets
were introduced and allowed for the uniformity of language across large
distances. A leap in technology occurred when the Gutenberg printing-
press was invented in the 15th century. The 3rd stage is characterized by
the transfer of information through controlled waves and electronic
signals.
However, even today, there are many world languages that can be
spoken but have no standard written form. Such languages can be
expressed in writing using the International Phonetic Alphabet. Spoken

91
language is much richer than written language; for example, transcripts of
actual speech show numerous hesitancies which are usually left out of
written forms of 'speech' such as screenplays.
Even from the point of view of syntax, spoken language usually
has its own set of grammatical patterns which sometimes may be quite
different from that in written language. In many languages, the written
form is considered a different language, a situation called diglossia.
Human language is unique in comparison to other forms of
communication, such as those used by other animals, because it allows
humans to produce an infinite set of utterances from a finite set of
elements, and because the symbols and grammatical rules of any particular
language are largely arbitrary, so that the system can only be acquired
through social interaction. The known systems of communication used by
animals, on the other hand, can only express a finite number of utterances
that are mostly genetically transmitted. Human language is also unique in
that its complex structure has evolved to serve a much wider range of
functions than any other kinds of communication system.
Verbal communication can be efficient, inefficient and even
socially inacceptable.
The form of antisocial verbal communication is verbal abuse.
Verbal abuse (also called reviling or verbal attack) is a form of
abusive behavior involving the use of language. It is a form of profanity
that can occur with or without the use of expletives. While oral
communication is its most common form, verbal abuse may be expressed
in the form of written word as well.
Verbal abuse is a pattern of behavior that can seriously interfere
with a person's healthy emotional development. A single exposure to
verbal assault can be enough to significantly affect a person's self-esteem,
emotional well-being, and physical state.
Verbal abuse is best described as an ongoing emotional
environment organized by the abuser for the purposes of control. The
underlying factor in the dynamic of verbal abuse is the abuser’s low regard
for him or herself. The abuser attempts to place their victim in a position
to believe similar things about him or herself, a form of warped projection.
Reports of verbal and emotional abuse indicate that it frequently
occurs in romantic relationships between men and women, where women
are generally reported as the victims. However, verbal abuse may occur to
a person of any gender, race, culture, size, sexual orientation, or age.

92
 Typically, verbal abuse increases in intensity over time and often
escalates into physical abuse as well.
During intense verbal abuse, the victim usually suffers from low
self-worth and low self-esteem. As a result, victims may fall into clinical
depression and post-traumatic stress disorder.
Verbal abuse starting from a young age contributes to inferiority
complex, machismo attitudes, and other negative behaviors that plague
many people into senior age.
People who feel they are being attacked by a verbal abuser on a
regular basis should seek professional counsel and remove themselves
from the negative environment whenever possible. Staying around verbal
abusers is damaging for a person's overall well-being, and all steps to
change the situation should be pursued.
The way to recognize signs of verbal abuse in an unhealthy
relationship is to simply know what a healthy relationship looks like.
Consider the things people value in a healthy and strong relationship.
These could be respect, acceptance, trustworthiness, and honesty with the
freedom and safety to express oneself within healthy boundaries. When we
think about what constitutes a healthy relationship, it becomes easier to
identify when we are in an unhealthy relationship.
Signs of verbal abuse exhibited by the abuser are:
 Actions of ignoring, ridiculing, disrespecting, and criticizing
others consistently.
 A manipulation of words.
 Purposeful humiliation of others.
 Accusing others falsely for the purpose of manipulating a person's
decision making.
 Manipulating people to submit to undesirable behavior.
 Making others feel unwanted and unloved.
 Threatening to leave the family destitute.
 Placing the blame and cause of the abuse onto others.
 Isolating a person from some type of support system, consisting of
friends or family.
 Harassment
 Threatening to do any type of harm to a family member or friend
Once the victim identifies and recognizes the signs of verbal
abuse, the victim can be more proactive in finding help. If left too long in
an abusive relationship, the person will start feeling hopeless.

93
5.3. Para-verbal Communication
Para-verbal communication is communication by the mean of
nonverbal cues of the voice. Various acoustic properties of speech such as
tone, pitch and accent, loudness of speaking, manner of speaking, keeping
silent, meaning of interrupting or interfering the conversation collectively
known as prosody, can all give off nonverbal cues.
Paraverbal communication refers to how we say something, not
what we say. The paraverbal message accounts for approximately 38% of
what is communicated to someone. A sentence can convey entirely
different meanings depending on the emphasis on words and the tone of
voice. For example, the statement, "I didn't say you were stupid" has six
different meanings, depending on which word is emphasized:

Or, if you say the sentence “Cynthia likes you” with a lilting tone
you are probably teasing someone.  However, if you stress the word likes,
“Cynthia likes you”, the message comes out, “Whatever made you think
she didn’t?”  Stress the word you this time, “Cynthia likes you" and you
might be saying, “I wish she liked me”.
The linguist George L. Trager developed a classification system
which consists of the voice set, voice qualities, and vocalization
The voice set is the context in which the speaker is speaking. This
can include the situation, gender, mood, age and a person's culture.
The voice qualities are volume, pitch, tempo, rhythm, articulation,
resonance, nasality, and accent. They give each individual a unique "voice
print".

94
 Vocalization consists of three subsections: characterizers,
qualifiers and segregates. Characterizers are emotions expressed while
speaking, such as laughing, crying, and yawning. A voice qualifier is the
style of delivering a message - for example, yelling "Hey stop that!", as
opposed to whispering "Hey stop that". Vocal segregates such as "uh-huh"
notify the speaker that the listener acceptance.
There are some points to be remembered about our para-verbal
communication:
- When we are angry or excited, our speech tends to become
more rapid and higher pitched.
- When we are bored or feeling down, our speech tends to slow
and take on a monotone quality.
- When we are feeling defensive, our speech is often abrupt.
Vocal characterizers (laugh, cry, yell, moan, whine, belch, yawn)
- send different messages in different cultures (Japan — giggling indicates
embarrassment; India – belch indicates satisfaction).
Vocal qualifiers (volume, pitch, rhythm, tempo, and tone) are
associated with cultural distinctions.  Loudness, for example, indicates:
- Strength and sincerity in Arab culture;
- Confidence and authority to the Germans;
- Impoliteness to the Thais;
- Loss of control to the Japanese;
- Aggressiveness in North America
Gender based as well: women tend to speak higher and more
softly than men.
Vocal segregates (un-huh, shh, uh, oooo, ooh, mmmh, humm, eh,
mah, lah) - indicate formality, acceptance, assent, uncertainty.
Vocal rate deals with the speed at which people talk, another
factor that offers various interpretations.
In the Americas as well as in Arabic countries the pauses between
words are usually not too long, while in India and Japan pauses can give a
contradictory sense to the spoken words. Enduring silence is perceived as
comfortable in India and Japan, while in Europe and North America it may
cause insecurity and embarrassment. Scandinavians, by the standards of
other Western cultures, are more tolerant of silent breaks during
conversations.
5.4. Body Language

95
 Body language is a form of non-verbal communication which
consist in sending and interpreting of non verbal signals almost entirely
subconscious. Body language consists of body posture, gestures, facial
expressions, eye movements etc. Humans send and interpret such signals.
When a person sends a message with conflicting verbal and nonverbal
information, the nonverbal information tends to be believed. Consider the
example of someone, through a clenched jaw, hard eyes, and steely voice,
telling you they're not mad. Which are you likely to believe? What you see
or what you hear?
Argyle (1988) concluded there are five primary functions of
nonverbal bodily behavior in human communication:
 Express emotions;
 Express interpersonal attitudes;
 To accompany speech in managing the cues of interaction
between speakers and listeners;
 Self-presentation of one’s personality;
 Rituals (greetings).
The Facial Expression
The face is perhaps the most important conveyor of emotional
information. A face can light up with enthusiasm, energy, and approval,
express confusion or boredom, and scowl with displeasure. The facial
expession includes:
a)mimics, knit brows (frawn), wrinkle up forehead, corrugate
nose, clench teeth etc.
b) smile, that can be recepted from delight to cinism.
c)the look, it can communicate love, frendship, sadness, guilty,
indiference, hate.

While some say that facial expressions are identical, meaning

attached to them differs.  Majority opinion is that these do have similar
meanings world-wide with respect to smiling, crying, or showing anger,

96
sorrow, or disgust.  However, the intensity varies from culture to culture. 
Note the following:
o Many Asian cultures suppress facial expression as much as
possible.
o Many Mediterranean (Latino / Arabic) cultures exaggerate
grief or sadness while most American men hide grief or sorrow.
o Some see “animated” expressions as a sign of a lack of control.
o Too much smiling is viewed in as a sign of shallowness.
o Women smile more than men.
Eye gaze
Eye contact is an event in which two people look at each other's
eyes at the same time. It is a form of nonverbal communication and is
thought to have a large influence on social behavior. Frequency and
interpretation of eye contact vary between cultures and species. The study
of eye contact is sometimes known as oculesics. Eye contact can indicate
interest, attention, and involvement. Gaze comprises the actions of looking
while talking, looking while listening, amount of gaze, and frequency of
glances, patterns of fixation, pupil dilation, and blink rate.
Eye contact and facial expressions provide important social and
emotional information; people, perhaps without consciously doing so,
probe each other's eyes and faces for positive or negative mood signs. In
some contexts, the meeting of eyes arouses strong emotions. Eye contact is
also an important element in flirting, where it may serve to establish and
gauge the other's interest in some situations.
A 1985 study published in the Journal of Experimental Child
Psychology suggested that "3-month-old infants are comparatively
insensitive to being the object of another's visual regard". A 1996
Canadian study with 3 to 6 month old infants found that smiling in the
infants decreased when adult eye contact was removed. A recent British
study in the Journal of Cognitive Neuroscience found that face recognition
by infants was facilitated by direct gaze. Other recent research has
confirmed the belief that the direct gaze of adults influences the direct
gaze of infants.
A study by University of Stirling psychologists concluded that
children who avoid eye contact while considering their responses to
questions had higher rates of correct answers than children who
maintained eye contact. One researcher theorized that looking at human
faces requires a lot of mental processing, which detracts from the cognitive

97
task at hand. Researchers also noted that a blank stare indicated a lack of
understanding.
In some parts of the world, particularly in East Asia, eye contact
can provoke misunderstandings between people of different nationalities.
Keeping direct eye contact with a work supervisor or elderly people leads
them to assume you are being aggressive and rude.
In Japan, it is more common to look at the throat of the other
person. In China and Indonesia, the practice is to lower the eyes because
direct eye contact is considered bad manners, and in Hispanic culture
direct eye contact is a form of challenge and disrespect. In Mediterranean
society, men often look at women for long periods of time that may be
interpreted as starring by women from other cultures.
In some Western cultures the eye to eye contact is considered as
positive (advise children to look a person in the eyes).  But within USA,
African-Americans use more eye contact when talking and less when
listening with reverse true for Anglo Americans.  This is a possible cause
for some sense of unease between races in US.  A prolonged gaze is often
seen as a sign of sexual interest.
In Arab culture, it is common for both speakers and listeners to
look directly into each others’ eyes for long periods of time, indicating
keen interest in the conversation. The prolonged eye contact shows interest
and helps them understand truthfulness of the other person (a person who
doesn’t reciprocate is seen as untrustworthy).
Movement and body position
Kinesics is the study of body movements, facial expressions, and
gestures. It was developed by anthropologist Ray L. Birdwhistell in the
1950s. Kinesic behaviors include mutual gaze, smiling, facial warmth or
pleasantness, childlike behaviors, direct body orientation, and the like.
The body movements way.
 lateral movements – good communicator.
 forward / backword movements – action man.
 vertical movements – man with strong persuasion power
Posture can be used to determine a participant’s degree of
attention or involvement, the difference in status between communicators,
and the level of fondness a person has for the other communicator. Our
body postures can create a feeling of warm openness or cold rejection.
Studies investigating the impact of posture on interpersonal relationships
suggest that mirror-image congruent postures, where one person’s left side

98
is parallel to the other’s right side, leads to favorable perception of
communicators and positive speech; a person who displays a forward lean
or a decrease in a backwards lean also signify positive sentiment during
communication. Posture is understood through such indicators as direction
of lean, body orientation, arm position, and body openness. For example,
when someone faces us, sitting quietly with hands loosely folded in the
lap, a feeling of anticipation and interest is created. A posture of arms
crossed on the chest portrays a feeling of inflexibility. The action of
gathering up one's materials and reaching for a purse signals a desire to
end the conversation.

The position of the body gives us the information about the

subject’s attitude and emotions. The dominating person will keep the head
up, but the inferior will keep the head down. The inclination of the body
means the interest, anxiety.
Consider the following actions and note cultural differences:
o Bowing (not done, criticized, or affected in US; shows rank in
Japan)
o Slouching (rude in most Northern European areas)
o Hands in pocket (disrespectful in Turkey)
o Sitting with legs crossed (offensive in Ghana, Turkey)

99
 o Showing soles of feet. (Offensive in Thailand, Saudi Arabia
Gesture is a non-vocal bodily movement intended to express
meaning. They may be articulated with the hands, arms or body, and also
include movements of the head, face and eyes, such as winking, nodding,
or rolling one's eyes. The boundary between language and gesture, or
verbal and nonverbal communication, can be hard to identify.
According to Ottenheimer (2007), psychologists Paul Ekman and
Wallace Friesen suggested that gestures could be categorized into five
types: emblems, illustrators, affect displays, regulators, and adaptors
 emblems are gestures with direct verbal translations, such as a
goodbye wave;
 illustrators are gestures that depict what is said verbally, such as
turning an imaginary steering wheel while talking about driving
 an affect display is a gesture that conveys emotions, like a smile;
 regulators are gestures that control interaction;
 and finally, an adaptor is a gesture that facilitates the release of
bodily tension, such as quickly moving one's leg.
Some emblems seem to be universal, while others are cultural,
with different interpretations in various cultures, or perhaps with different
uses by men and women. An example of a universal emblem is the
uplifted shoulders and upturned hands that indicate “I don’t know”
virtually everywhere in the world. An example of a culture-bound emblem
is the encircled thumb and forefinger "O". "Everything ok" is shown in
western European countries, especially between pilots and divers. This
sign, especially when fingers are curled, means in Korea and Japan "now
we may talk about money", in southern France the contrary ("nothing,
without any value"). In Brazil, it is considered rude, especially if
performed with the three extended figures shown horizontally to the floor
while the other two fingers form an O.
Gestures can be also categorized as either speech-independent or
speech-related. Speech-independent gestures are dependent upon
culturally accepted interpretation and have a direct verbal translation. A
wave hello or a peace sign are examples of speech-independent gestures.
Speech related gestures are used in parallel with verbal speech; this form
of nonverbal communication is used to emphasize the message that is
being communicated.

100
 Speech related gestures are intended to provide supplemental
information to a verbal message such as pointing to an object of discussion
There are some cultural differences regarding the interpretation of
a certain gesture, an acceptable in one’s own culture may be offensive in
another.  Amount of gesturing varies from culture to culture. Even simple
things like using hands to point and count differ.
For example – to point (show direction using the finger) is
unpolite in Europe, offence in Thailand and usual in the US. But, pointing:
in US with index finger; Germany with little finger; Japanese with entire
hand (in fact most Asians consider pointing with index finger to be rude).
Another example is putting foot on the table in America.
Dance is a form of nonverbal communication that requires the
same underlying faculty in the brain for conceptualization, creativity and
memory as does verbal language in speaking and writing. Means of self-
expression, both forms have vocabulary (steps and gestures in dance),
grammar (rules for putting the vocabulary together) and meaning. Dance,
however, assembles (choreographs) these elements in a manner that more
often resembles poetry, with its ambiguity and multiple, symbolic and
elusive meanings
The tactile communication
Touches can be defined as communication include handshakes,
holding hands, kissing (cheek, lips, hand), back slapping, high fives, a pat
on the shoulder, hugging, taping on the shoulder and brushing an arm.
Touching of oneself during communication may include licking, picking,
holding, and scratching. These behaviors are referred to as "adaptor" and
may send messages that reveal the intentions or feelings of a
communicator. The meaning conveyed from touch is highly dependent
upon the context of the situation, the relationship between communicators,
and the manner of touch. It depends on age, relation and cultutre.
Touch is culturally determined. But each culture has a clear
concept of what parts of the body one may not touch.  Basic message of
touch is to affect or control — protect, support, disapprove (i.e. hug, kiss,
hit, kick).
Example: An African-American male goes into a convenience
store recently taken over by new Korean immigrants.  He gives a $20 bill
for his purchase to Mrs. Cho, who is cashier, and waits for his change. 
He is upset when his change is put down on the counter in front of him.
What is the problem?  Traditional Korean (and many other Asian

101
countries) doesn’t touch strangers, especially between members of the
opposite sex. But the African-American sees this as another example of
discrimination (not touching him because he is black).
Cultures (English, German, Scandinavian, Chinese, and Japanese)
with high emotional restraint concepts have little public touch; those
which encourage emotion (Latino, Middle-East, Jewish) accept frequent
touches. It has been noted, for example, that Mediterranean, Middle
Eastern and Latin American cultures employ much social touching in
conversation, including embraces and hand-holding; these are called high-
contact (or high-touch) cultures. In moderate-touch cultures such as North
America and Northern Europe, touching is used only occasionally, such as
in handshakes and sporadic shoulder touching or back slapping. In low
contact cultures such as in Northern Asian cultures, meanwhile, social
touching is rarely used at all. But the geography is by no means that
simple. People in the Asian nation of the Philippines, for example, use a
large amount of social touching in conversation and personal interaction.
In USA the handshake is common (even for strangers), hugs, and
kisses for those of opposite gender or of family (usually) on an
increasingly more intimate basis. Note differences between African-
Americans and Anglos in USA.  Most African Americans touch on
greeting but are annoyed if touched on the head (good boy, good girl
overtones).
In Islamic and Hindu cultures people typically don’t touch with
the left hand.  To do so is a social insult.  Left hand is for toilet functions. 
Mannerly, in India to break your bread is permitted only with your right
hand, sometimes is difficult for non-Indians.
Islamic cultures generally don’t approve of any touching between
genders (even handshakes).  But consider such touching (including hand
holding, hugs) between same-sex to be appropriate.
Many Asians don’t touch the head - head houses the soul and a
touch puts it in jeopardy.
5.5. Extraverbal Communication
Extraverbal Communication is a form of communication
which includes receiving and sending of information by mean of time,
place, context, orientation towards target groups aspects.
Physical environment

102
 Environmental factors such as furniture, architectural style,
interior decorating, lighting conditions, colors, temperature, noise, and
music affect the behavior of communicators during interaction.
Environmental conditions can alter the choices of words or actions that
communicators use to accomplish their communicative objective.
The space language.
Proxemics is the study of how people use and perceive the
physical space around them. The space between the sender and the
receiver of a message influences the way the message is interpreted.
Proxemics was first developed by Edward T. Hall during the 1950s and
60s. Hall's studies were inspired by earlier studies of how animals
demonstrate territoriality. The term territoriality is still used in the study of
proxemics to explain human behavior regarding personal space. There are
identified 4 such territories:
1. Primary territory: this refers to an area that is associated with
someone who has exclusive use of it. For example, a house that
others cannot enter without the owner’s permission.
2. Secondary territory: unlike the previous type, there is no “right” to
occupancy, but people may still feel some degree of ownership of a
particular space. For example, someone may sit in the same seat on
train every day and feel aggrieved if someone else sits there.
3. Public territory: this refers to an area that is available to all, but only
for a set period, such as a parking space or a seat in a library.
Although people have only a limited claim over that space, they
often exceed that claim. For example, it was found that people take
longer to leave a parking space when someone is waiting to take that
space.
4. Interaction territory: this is space created by others when they are
interacting. For example, when a group is talking to each other on a
footpath, others will walk around the group rather than disturb it.
Consequently space in nonverbal communication was devided into
four main categories: intimate, social, personal, and public space.
Intimate space (Distance: Touching to 11/2 feet). This is the
distance of lovemaking, wrestling, comforting, and protecting.
Personal Distance (Distance: 11/2 feet to 4 feet). This distance is
reserved for more than just a casual friend or fleeting encounter; however,
it is a no-contact distance. Where people stand in relation to each other
signals their relationship, or how they feel toward each other, or both. A

103
wife can stay inside the circle of her husband's close personal zone with
impunity. For another woman to do so is an entirely different story.
Social Distance (Distance: 4 to 12 feet). Impersonal business or
casual conversations can be carried on in this space. People are very much
aware of the presence of one another, but they neither interfere with each
other nor are they oppressively near;
Public Distance (Distance: 12 to 25 feet, or farther). A person at
this distance is outside the circle of involvement. This is the distance
reserved for public speakers and/or public officials or for anyone on public
occasions.
Note that this distance can vary significantly. Extraverts, for
example, may have smaller distances whilst introverts may prefer to keep
their distance. People who live in towns and cities are used to squeezing
closer to people so have smaller spaces, whilst country people stand so far
apart they have to lean forwards to shake hands. Also the distance varies
greatly across cultures and different settings within cultures.
The distance between communicators will also depend on sex,
status, and social role.
The time language
Chronemics is the study of the use of time in nonverbal
communication. The way we perceive time, structure our time and react to
time is a powerful communication tool, and helps set the stage for
communication. Time perceptions include punctuality and willingness to
wait, the speed of speech and how long people are willing to listen. The
timing and frequency of an action as well as the tempo and rhythm of
communications within an interaction contributes to the interpretation of
nonverbal messages. Gudykunst & Ting-Toomey (1988) identified 2
dominant time patterns.
Monochronic time schedule (M-time): Time is seen as being very
important and it is characterized by a linear pattern where the emphasis is
on the use of time schedules and appointments. Time is viewed as
something that can be controlled or wasted by individuals, and people tend
to do one thing at a time.
Polychronic time schedule (P-time): Personal involvement is more
important than schedules where the emphasis lies on personal relationships
rather than keeping appointments on time.
Studies show that the monochronemic conversation (talking about
one thing at a time) is common in Northern Europe and North America.

104
Meanwhile, Latin American, Asian, Middle Eastern and Mediterranean
cultures are more likely to use polychronemic conversation (multiple
conversations at the same time, and frequent interruption by other speaker-
listeners).
The way of using the time language is correlated with:
- time precision
The time is something precious and personal and when somebody
tries to organize out time it shows the status difference. To come in time or
not to meeting shows the attitude of the interlocutor in regards of the
speaker or the subject, perception of the status and power, the respect and
importance paid. The more people are made to wait, the more they feel
humble and disrespected.
In different cultures the punctuality means different times to come
to a meeting or appointment. In some countries like China and Japan,
punctuality is considered important and being late would be considered as
an insult. However, in countries such as those of South America and the
Middle East, being on time does not carry the same sense of urgency.
Americans come earlier in order to accommodate themselves to
the space and prepare for the discussion. British and Swedish come exactly
in time in order to prove efficient time management, French come a little
later in order to make the interlocutor a little nervous to be easier to
manipulate.
Thus the time language can be used consciously or not to control
and subdue or to communicate respect and interest.
- time lack
The time is perceived as a personal scarce recourse therefore the
way how the person allocates it to another person who requires a part of
this recourse shows the attitude of the subject regarding the demander.
Miss-allocation of time for communication with a person is considered as
miss- allocation of importance. Some sociological researches proved that a
positive communication relation is built in direct proportion with the
frequency.
- time as symbol
This aspect is related to certain usuality, like rhythm (for example
we eat three times a day at a certain hour). Similarly seasons impose some
certain activities and a certain life style. Holydays and rituals also are
marked in time. Thus businessmen know that in the period of winter
holidays people spend more money and work less.

105
5.6. Interaction Between Verbal and Nonverbal Communication

Non-verbal communication consists of all the messages other than

words that are used in communication. Humans use consciously or
unconsciously nonverbal communication for many reasons:
 To create impressions beyond the verbal element of communication
(kinesics, chronemics, vocalics, environment).
 To repeat and reinforce what is said verbally (occulesics, kinesics).
 To manage and regulate the interaction among participants in the
communication exchange (kinesics, occulesics, proxemics, synchrony).
 To express emotion beyond the verbal element (kinesics, occulesics,
haptics, vocalics, proxemics).
 To convey relational messages of affection, power, dominance,
respect, and so on (proxemics, occulesics, haptics).
 To promote honest communication by detecting deception or
conveying suspicion (kinesics, occulesics, vocalics).
 To provide group or social leadership by sending messages of power
and persuasion (kinesics, vocalics, chronemics).
Nonverbal communication is a part of communication process.
That mean it is in continuous interaction with verbal communication.
When communicating, nonverbal messages can interact with verbal
messages in six ways: repeating, conflicting, complementing, substituting,
regulating and accenting/moderating.
Repeating - consists of using gestures to strengthen a verbal
message, such as pointing to the object of discussion.
Conflicting - verbal and nonverbal messages within the same
interaction can sometimes send opposing or conflicting messages. A
person verbally expressing a statement of truth while simultaneously
fidgeting or avoiding eye contact may convey a mixed message to the
receiver in the interaction. Conflicting messages may occur for a variety of
reasons often stemming from feelings of uncertainty, ambivalence, or
frustration. When mixed messages occur, nonverbal communication
becomes the primary tool people use to attain additional information to
clarify the situation; great attention is placed on bodily movements and
positioning when people perceive mixed messages during interactions

106
 Complementing - accurate interpretation of messages is made
easier when nonverbal and verbal communication complement each other.
Nonverbal cues can be used to elaborate on verbal messages to reinforce
the information sent when trying to achieve communicative goals;
messages have been shown to be remembered better when nonverbal
signals affirm the verbal exchange
Substituting - nonverbal behavior is sometimes used as the sole
channel for communication of a message. People learn to identify facial
expressions, body movements, and body positioning as corresponding with
specific feelings and intentions. Nonverbal signals can be used without
verbal communication to convey messages; when nonverbal behavior
does not effectively communicate a message, verbal methods are used to
enhance understanding.
Regulating - nonverbal behavior also regulates our conversations.
For example, touching someone's arm can signal that you want to talk next
or interrupt.
Accenting/Moderating - nonverbal signals are used to alter the
interpretation of verbal messages. Touch, voice pitch, and gestures are
some of the tools people use to accent or amplify the message that is sent;
nonverbal behavior can also be used to moderate or tone down aspects of
verbal messages as well. For example, a person who is verbally expressing
anger may accent the verbal message by shaking a fist.
5.7. Appearance of Medical Students and Doctors. The Dress Code.
Appearance refers to the communication role played by a person’s
look or physical appearance. It deals with physical aspects of body shape,
hair color and skin tone, as well as grooming, dress (both clothing and
jewelry) and use of appearance enhancements such as body piercings,
brandings and tattoos. Appearance is an important aspect of personal as
well professional image. Having a professional image is important for any
practice and especially for medical practice. If patients see
professionalism, in addition to receiving courteous treatment and quick
service, they will be impressed. Patient satisfaction with health care,
compliance with medication and treatment outcome is related to the
physician’s interpersonal skills including his/her sensitivity to nonverbal
behavior and appearance.
You may think that setting guidelines for professional appearance
is more difficult today than in years past, but women's skirt lengths and

107
men's long hair used to challenge human resources managers. Now it's
body piercing, tattoos and skimpy clothing. Whether it's the 1970s or the
2010s, these issues have a common source – people declaring themselves
as individuals or maybe not knowing what's considered "professional."
Either way, today's medical practice administrators and human resources
managers must know where to draw the line so the group practice projects
a competent, professional image.
As students/physicians will encounter patients from diverse
groups, their personal appearance becomes an important part in
establishing rapport with each patient. Therefore, the therapeutic alliance
must be secured before initial verbal interaction has occurred.
Student/physicians should place the patient’s needs first even if this
necessitates curtailing some aspects of one’s individual expression.
Because of the responsibility to inspire confidence in our professionalism
and high quality of care, physicians are expected to wear appropriate dress
as defined herein; in a manner which reflects positively on the department,
hospital and their profession. Each student/physician is expected to reflect
the organization’s high standards through professional dress, grooming,
conduct, language, and decorum.
Standards for dress, grooming, and personal cleanliness contribute
to the morale of all staff members and affect the image of the Medicine as
a Practice. During business hours, student/physicians are expected to
present an appearance and dress according to the requirements of their
positions. Clothing worn to work should reflect professional status,
provide for mechanical safety of student/physicians and patients, allow for
full performance of all duties and provide easy identification of
student/physicians.
Dress codes for a job at a hospital, medical office or any other
medical institution require conservative styles. The dress code is not
simply a matter of professionalism, but also a matter of safety.
Students/physicians come into contact with patients and medical
equipment. They must be prepared for a number of situations, such as
excessive bleeding, vomiting, chemical spills and other accidents.
Appropriate dress for all medical personnel is as follows:
 Dress of medical students in routine class in the first two years could
be informal.
 All medical students are required to wear a clean, short white coat.

108
  Hair (including facial hair) should be clean, neatly trimmed, and
contained so that it does not come in contact with patients. Men’s beards
are acceptable when neatly trimmed. Hair colored green, blue, pink, etc., is
not acceptable
 Anything that is exaggerated or overdone, whether it is jewelry,
make-up, hairstyle, perfume, or clothing, is inappropriate. A minimum of
jewelry such as wedding rings or class rings are acceptable, it must be
small and simple. It cannot obstruct his or her work, and should be visible
on the ear only (that means no facial jewelry such as nose, eyebrow, lip,
etc., piercings). Multiple rings, i.e., one on each finger, are unacceptable.
Earrings, necklaces, bracelets and other piercings may impede the
employee's work or catch on a patient or equipment.
 Student/physicians are required to maintain a clean, odor-free
personal hygiene. Strong-smelling perfume, aftershave, scented lotions,
and cologne are not permitted, as some patients may be allergic.
 Button-down shirts should not be open below the second button
(sterno-manubrial junction). Ties are required for men.

 Shoes should be polished, neat and clean, and always with closed
toes. Do not wear sandals in patient care areas because dropped needles
may pierce your feet.

 Student/physicians are required to maintain fingernails clean,

well-manicured, and moderate in length. Nail color will be in keeping with
the professional image.

 Tattoos and other body art must be covered at all times while on
duty.

 Clothing should fully cover the mid-back, lower-back, and

stomach. Undergarments should not be visible. Bare legs, if applicable,
must be neat and presentable.
 Women should wear professional blouses or sweaters. Low cut or
clinging shirts, sweaters or blouses are inappropriate.

 Skirts should be at least three inches below the white coat and
below the knee if no stockings are worn. Shorter skirts are acceptable with
tights or stockings. No clam-digger or Capri pants, jeans, cargo pants or

109
leggings without skirts. Minimize excessively bright, dark or creatively-
colorful polish.

 Blue scrub suits are permitted in direct patient care areas and in
the Operating Room
In the Operating Room
 Women who wear scrub suits with a deep V-neck should wear the
V-neck behind so as to prevent gapping in the front.
 Jewelry must come off before scrubbing. Earrings are
unacceptable in the Operating Room because they may fall into the field.
Short necklaces are acceptable as they are covered by O.R. gowns.
Inappropriate dress for all medical personnel is as follows:
 Soiled, tattered, torn, frayed, or ripped clothing
 Shorts of any kind
 See-through garments, or those with plunging or revealing
necklines
 Garments exposing midriff or undergarments
 Tube-tops, tank tops, or tight, form-fitting shirts
 Spaghetti straps, and low-cut or off-the-shoulder shirts or dresses
 Sweatshirts
 Stirrups, leggings, or exercise attire
 Tight or transparent clothing (including tight-fitting T-shirts)
 Any clothing with slogans, advertising, or questionable or
suggestive logos or emblems
 Any clothing that promotes alcohol or tobacco
 Belly shirts
 Baseball caps or hats
 Low-rise jeans
Other
 Do not chew gum.
 No eating or drinking in front of patients or in patient care areas.
 Speak softly in the hospital.
 Never discuss one’s own or friends’ personal issues in public
areas.
 Never discuss patient care issues in public areas, such as cafeterias
and elevators.
 Do not criticize pedagogy, faculty, staff, others or institutions in
public areas.

110
  Do not carry patient charts or X-ray folders with the name
exposed.
 Keep beepers on vibrator-silent mode so as not to interrupt
attendings and patients.
► Exercises and Discussions:
1. What is metacommunication?
2. What are verbal communication forms and types?
3. Describe the elements of paraverbal communication.
4. Describe the elements of body language. What are your
preferable gesture, body posture, face expression etc?
5. What is extra verbal communication? Do you have a
monochronemic or polychronemic perception of time?
6. Learn the elements of professional dress code.
7. Identify three of the seven uses of nonverbal communication.
8. Explain from personal experience an example of misunderstood
communication caused by differing interpretations of nonverbal
communication techniques.
► Recommended Essays
1. The therapeutic miracle of words
2. Language of colors
3. Language of flowers
4. Dress code in the intercultural contexts
5. How to make a good first impression?
6. Smile and its significance
► Literature:
1. Burgoon Judee K., Buller David B., Woodall William Gill.
Nonverbal communication: the unspoken dialogue. Harper & Row,
1989.
2. Esposito Anna. Fundamentals of verbal and nonverbal
communication and the biometric issue. IOS Press, 2007.
3. Keidar Daniela Classroom Communication. Use of Emotional
Intelegence and Non-Verbal Communication in Ethics Education at
Medical Schools. UNESCO Chair Office, Haifa, 2005. – 116 p.

4. Krueger Juliane. GRIN Verlag, 2008.

5. Kendon Adam. Gesture: visible action as utterance. Cambridge

University Press, 2004.

111
 6. Wood Julia T.. Communication in Our Lives. Cengage Learning,
2008.

Chapter 6

Barriers and Cleavages in Communication

A barrier to communication is something that keeps
meanings from meeting. Meaning barriers exist between all
people, making communication much more difficult than
most people seem to realize. It is false to assume that if one
can talk he can communicate. Because so much of our
education misleads people into thinking that communication
is easier than it is, they become discouraged and give up
when they run into difficulty. Because they do not
understand the nature of the problem, they do not know what
to do. The wonder is not that communicating is as difficult
as it is, but that it occurs as much as it does."
Reuel Howe, theologian and educator

6.1 Communication Distorting Factors

Every time people inject voluntary or involuntary barriers into
their communication. These barriers can exist in any of the three
components of communication (verbal, paraverbal, and nonverbal). Any
one of the components of the communication model (sender, message,
receiver, context, code, channel etc) can become a barrier to
communication. For this reason, it is worthwhile to describe some of the
common responses that will, inevitably, have a negative effect on
communications. The most common of them are listed and analyzed
below.

112
a. Barrier of communication on the level of message Muddled
messages
Muddled messages are a barrier to communication because the
sender leaves the receiver unclear about the intent of the sender. Contrast
these two messages: "Please be here about 7:00 tomorrow morning."
"Please be here at 7:00 tomorrow morning." The one word difference
makes the first message muddled and the second message clear. Muddled
messages have many causes. The sender may be confused in his or her
thinking. The message may be little more than a vague idea. The problem
may be semantics, e.g., note this muddled newspaper ad: "Dog for sale.
Will eat anything. Especially likes children. Call 888-3599 for more
information."
Clarifying muddled messages is the responsibility of the sender.
The sender hoping the receiver will figure out the message does little to
remove this barrier to communication.
Effective communication starts with a clear message. Making
messages when intend an efficient communication sender should also take
in account the receiver’s interests and abilities of decoding.
Verbal Message can be a serious impediment of communication
when:
1. Attacking, interrogating, criticizing, blaming, and shaming:
"If you were doing your job and supervising Susie in the lunch line
we probably wouldn't be in this situation, would we?"
"Have you followed through with the counseling we asked you to
do? Have you gotten Ben to the doctor's for his medical checkup? Did you
call and arrange for a Big Brother? Have you found out if you're eligible
for food stamps?"
"From what I can see, you don't have the training to teach a child
with ADHD. Obviously if you did you would be using different strategies
that wouldn't make her feel like she's a bad person."
2. Moralizing, preaching, advising, and diagnosing:
"You don't seem to understand how important it is for your child
to get this help. Don't you see that he's well on his way to becoming a
sociopath?"
"You obviously don't realize that if you were following the same
steps we do at home you wouldn't be having this problem. You don't seem
to care about whatís going on in this child's life outside of school."
3. Ordering, threatening, commanding, and directing:

113
 "If you don't voluntarily agree to this evaluation we can take you
to due process. Go ahead and file a complaint if you want to."
"I'm going to write a letter of complaint to the superintendent and
have this in your file if you don't stop humiliating my son in front of his
classmates. I know my rights."
4. Shouting, name calling, refusing to speak.
Some Nonverbal messages which could be Communication
Barriers are:
1. Flashing or rolling eyes,
2. Quick or slow movements,
3. Arms crossed, legs crossed,
4. Gestures made with exasperation,
5. Slouching, hunching over,
6. Poor personal care,
7. Doodling,
8. Staring at people or avoiding eye contact,
9. Excessive fidgeting with materials.
b. Barrier of communication on the receiver’s level
Listening is difficult. A typical speaker says about 125 words per
minute. The typical listener can receive 400-600 words per minute. Thus,
about 75 percent of listening time is free time. The free time often
sidetracks the listener. Letting your attention drift away you put
deliberately a barrier in commutation.
Others impediments of communication related to poor listening
skills are:
- Automating listening.
- Selective listening.
Automatic listening happens when a person listening just long
enough to find a word that he knows something about. Then shut off the
rest of what is being said, particularly the emotional content. Then starts
talking about the word he knows something about. This blocks real
communications by not hearing the total content. This is the most used
form of blocking true communication.
Selective listening is when a person hears another but selects to
not hear what is being said by choice or desire to hear some other
message. This can take several forms and result in acting out in destructive
ways. An example is to become passive aggressive by pretending to hear
and agree to what was said when actually your intent is to NOT act on the

114
message, but make the other person think you will. Another form is to act
on what you wanted to hear instead of what was said. Continued selective
listening is one of the best ways to destroy a relationship.
c. Barriers on the channel’s level
In order to avoid misunderstanding, in choice of a channel, the
sender needs to be sensitive to such things as the complexity of the
message (good morning versus a construction contract); the consequences
of a misunderstanding (medication for a sick animal versus a guess about
tomorrow's weather); knowledge, skills and abilities of the receiver (a new
employee versus a partner in the business); and immediacy of action to be
taken from the message (instructions for this morning's work versus a plan
of work for 1994). Variation of channels helps the receiver understand the
nature and importance of a message.
For instance an oral channel is highly appropriate for such a
message as “Good morning". Writing "GOOD MORNING!" on a
chalkboard in the machine shed is less effective than a warm oral greeting.
On the other hand, a detailed request to a contractor for construction of a
far rowing house should be in writing, i.e., non-oral.
d. Barriers on the context’s level
Barriers on the context level refer to all condition in which
communication occurs. These may be:
 Physical (for instance spatial barriers);
 Biological (physiological and gender barriers);
 Psychological (emotional, perceptual, cognitive barriers etc)
 Social.
Physical barriers:
Physical distractions are the physical things that get in the way of
communication. Examples of such things include the telephone, a pick-up
truck door, a desk, an uncomfortable meeting place, and noise.
A supervisor may give instructions from the driver's seat of a pick-
up truck. Talking through an open window and down to an employee
makes the truck door a barrier. A person sitting behind a desk, especially if
sitting in a large chair, talking across the desk is talking from behind a
physical barrier. Two people talking facing each other without a desk or
truck-door between them have a much more open and personal sense of
communication. Uncomfortable meeting places may include a place on the
farm that is too hot or too cold. Another example is a meeting room with
uncomfortable chairs that soon cause people to want to stand even if it

115
means cutting short the discussion. Noise is a physical distraction simply
because it is hard to concentrate on a conversation if hearing is difficult.
Biological barriers:
Gender barriers
There are distinct differences between the speech patterns in a
man and those in a woman. A woman speaks between 22,000 and 25,000
words a day whereas a man speaks between 7,000 and 10,000. In
childhood, girls speak earlier than boys and at the age of three, have a
vocabulary twice that of boys.
The reason for this lies in the wiring of a man's and woman's
brains. When a man talks, his speech is located in the left side of the brain
but in no specific area. When a woman talks, the speech is located in both
hemispheres and in two specific locations.
This means that a man talks in a linear, logical and
compartmentalized way, features of left-brain thinking; whereas a woman
talks more freely mixing logic and emotion, features of both sides of the brain.
It also explains why women talk for much longer than men each day.
Physiological barriers:
They may result from individuals' personal discomfort, caused, for
example, by ill health, poor eye sight or hearing difficulties.
Psychological barriers:
Perceptual barriers
The problem with communicating with others is that we all see the
world differently. If we didn't, we would have no need to communicate:
something like extrasensory perception would take its place.
The following anecdote is a reminder of how our thoughts,
assumptions and perceptions shape our own realities:
A traveller was walking down a road when he met a man from the
next town. "Excuse me," he said. "I am hoping to stay in the next town
tonight. Can you tell me what the townspeople are like?"
"Well," said the townsman, "how did you find the people in the
last town you visited?"
"Oh, they were an irascible bunch. Kept to themselves. Took me
for a fool. Over-charged me for what I got. Gave me very poor service."
"Well, then," said the townsman, "you'll find them pretty much the
same here."
Emotional barriers

116
 One of the chief barriers to open and free communications is the
emotional barrier. It is comprised mainly of fear, mistrust and suspicion.
The roots of our emotional mistrust of others lie in our childhood and
infancy when we were taught to be careful what we said to others.
"Mind your P's and Q's"; "Don't speak until you're spoken to";
"Children should be seen and not heard". As a result many people hold
back from communicating their thoughts and feelings to others.
They feel vulnerable. While some caution may be wise in certain
relationships, excessive fear of what others might think of us can stunt our
development as effective communicators and our ability to form
meaningful relationships.
Cognitive barriers:
One of the most frequent cognitive barriers is stereotypes.
Stereotyping causes us to typify a person, a group, an event or a
thing on oversimplified conceptions, beliefs, or opinions. Thus, basketball
players can be stereotyped as tall, green equipment as better than red
equipment, football linemen as dumb, Ford as better than Chevrolet,
Vikings as handsome, and people raised on dairy farms as interested in
animals. Stereotyping can substitute for thinking, analysis and open
mindedness to a new situation.
Stereotyping is a barrier to communication when it causes people
to act as if they already know the message that is coming from the sender
or worse, as if no message is necessary because "everybody already
knows." Both senders and listeners should continuously look for and
address thinking, conclusions and actions based on stereotypes.
Social barriers
When we join a group and wish to remain in it, sooner or later we
need to adopt the behavior patterns of the group. These are the behaviors
that the group accepts as signs of belonging.
The group rewards such behavior through acts of recognition,
approval and inclusion. In groups which are happy to accept you and
where you are happy to conform, there is a mutuality of interest and a high
level of win-win contact.
Where, however, there are barriers to your membership of a group,
a high level of game-playing replaces good communication.
e. Barriers on the level of code
When is spoken about barriers on the level of code is meant most
commonly language barriers. Language that describes what we want to

117
say in our terms may present barriers to others who are not familiar with
our expressions, buzz-words and jargon. When we couch our
communication in such language, it is a way of excluding others.
Different languages represent a national barrier which is
particularly important for organizations involved in overseas business. In a
global market place the greatest compliment we can pay another person is
to talk in their language
Individual linguistic ability is also important. The use of
difficult or inappropriate words in communication can prevent people
from understanding the message.
Poorly explained or misunderstood messages can also result in
confusion. We can all think of situations where we have listened to
something explained which we just could not grasp.

6.2. Stereotypes, Stigma and Discrimination

Stereotypes
The term stereotype derives from the Greek words stereos - "firm,
solid" and typos "impression" hence "solid impression". The term, in its
modern psychology sense, was first used by Walter Lippmann in his 1922
work Public Opinion .
A stereotype is a fixed, commonly held notion or image of a
person or group; a generalization based on an oversimplification of some
observed or imagined trait of behavior or appearance. We develop
stereotypes when we are unable or unwilling to obtain all of the
information we would need to make fair judgments about people or
situations. In the absence of the "total picture", stereotypes in many cases
allow us to "fill in the blanks."
Stereotypes can be either positive (black men are good at
basketball) or negative (women are bad drivers). But most stereotypes
tend to make us feel superior in some way to the person or group being
stereotyped. Stereotypes ignore the uniqueness of individuals by painting
all members of a group with the same brush. It is easier to create
stereotypes when there is a clearly visible and consistent attribute that can
easily be recognized. This is why people of color, police and women are
so easily stereotyped.
People from stereotyped groups can find this very disturbing as they
experience an apprehension (stereotype threat) of being treated unfairly.

118
 For example, if we are walking through a park late at night and
encounter three senior citizens wearing fur coats and walking with canes,
we may not feel as threatened as if we were met by three high school-aged
boys wearing leather jackets. Why is this so? We have made a
generalization in each case. These generalizations have their roots in
experiences we have had ourselves, read about in books and magazines,
seen in movies or television, or have had related to us by friends and
family. In many cases, these stereotypical generalizations are reasonably
accurate. Yet, in virtually every case, we are resorting to prejudice by
ascribing characteristics about a person based on a stereotype, without
knowledge of the total facts. By stereotyping, we assume that a person or
group has certain characteristics. Quite often, we have stereotypes about
persons who are members of groups with which we have not had firsthand
contact.
A stereotype can be embedded in single word or phrase (such as,
"jock" or "nerd"), an image, or a combination of words and images. The
image evoked is easily recognized and understood by others who share the
same views.
Stereotyping can be subconscious, where it subtly biases our
decisions and actions, even in people who consciously do not want to be
biased. Stereotyping often happens not so much because of aggressive or
unkind thoughts. It is more often a simplification to speed conversation on
what is not considered to be an important topic.
Stereotyping can go around in circles. Men stereotype women and
women stereotype men. In certain societies this is intensified as the
stereotyping of women pushes them together more and they create men as
more of an out-group. The same thing happens with different racial
groups, such as white/black (an artificial system of opposites, which in
origin seems to be more like European/non-European).
Television, books, comic strips, and movies are all abundant
sources of stereotyped characters. For much of its history, the movie
industry portrayed African-Americans as being unintelligent, lazy, or
violence-prone. As a result of viewing these stereotyped pictures of
African-Americans, for example, prejudice against African-Americans has
been encouraged. In the same way, physically attractive women have been
and continue to be portrayed as unintelligent or unintellectual and sexually
promiscuous.

119
 We change our stereotypes infrequently. Even in the face of
disconfirming evidence, we often cling to our obviously-wrong beliefs.
When we do change the stereotypes, we do so in one of three ways:
 Bookkeeping model: As we learn new contradictory
information, we incrementally adjust the stereotype to adapt to the new
information. We usually need quite a lot of repeated information for each
incremental change. Individual evidence is taken as the exception that
proves the rule.
 Conversion model: We throw away the old stereotype and start
again. This is often used when there is significant disconfirming evidence.
 Subtyping model: We create a new stereotype that is a sub-
classification of the existing stereotype, particularly when we can draw a
boundary around the sub-class. Thus if we have a stereotype for
Americans, a visit to New York may result in us having a ‘New Yorkers
are different’ sub-type.
Our society often innocently creates and perpetuates stereotypes,
but these stereotypes often lead to unfair discrimination and persecution
when the stereotype is unfavorable. When we judge people and groups
based on our prejudices and stereotypes and treat them differently, we are
engaging in stigmatization and discrimination.
Stigmatization
Stigma is a Greek word that in its origins referred to a kind of
tattoo mark that was cut or burned into the skin of criminals, slaves, or
traitors in order to visibly identify them as blemished or morally polluted
persons. These individuals were to be avoided or shunned, particularly in
public places. Modern American usage of the words stigma and
stigmatization refers to an invisible sign of disapproval which permits
"insiders" to draw a line around the "outsiders" in order to demarcate the
limits of inclusion in any group. The demarcation permits "insiders to
know who is "in" and who is "out" and allows the group to maintain its
solidarity by demonstrating what happen to those who deviate from
accepted norms of conduct. Stigmatization is an issue of disempowerment
and social injustice. In this context, stigma is considered to be a powerful
social control tool applied through the marginalization, exclusion, and
exercise of power over individuals who present particular characteristics.
Stigma exists when four specific components converge:
1. Individuals differentiate and label human variations.

120
 2. Prevailing cultural beliefs tie those labeled to adverse
attributes.
3. Labeled individuals are placed in distinguished groups that
serve to establish a sense of disconnection between "us" and "them".
4. Labeled individuals experience "status loss and discrimination"
that leads to unequal circumstances.
Stigma and health
Stigma is typically a social process, experienced or anticipated,
characterized by exclusion, rejection, blame or devaluation that results
from experience, perception or reasonable anticipation of an adverse social
judgment about a person or group. This judgment is based on an enduring
feature of identity conferred by a health problem or health-related
condition, and the judgment is in some essential way medically
unwarranted. In addition to its application to persons or a group, the
discriminatory social judgment may also be applied to the disease or
designated health problem itself with repercussions in social and health
policy. Many conditions and symptoms from nervous ticks and stuttering
to tuberculosis and leprosy carry stigmatizing connotations. It is more
expedient to focus here on several illnesses in some details.
Patients with HIV
Stereotypes about HIV that are commonplace among the general
public are also evident in a surprising number of clinical staff. More than
25 years after its discovery, HIV still has the power to generate a broad
array of stigmatizing behavior. People infected with HIV have previously
labeled dealing with stigma as the most significant social and
psychological challenge of the HIV experience. Sufferers' experiences
were categorized by the type of stigmatizing behavior that they
experienced most often in the presence of health-care personnel. These
categories were: lack of eye contact; assuming physical distance; using
disdainful voice tone or inflection; asking confrontational questions;
showing irritation, anger, nervousness, fear or panic; taking excessive
precautions; scaring, mocking, blaming or ignoring patients; providing
substandard care or denying care, and being generally abusive.
Patients with mental illnesses
Patients with mental illnesses are stigmatized and suffer adverse
consequences such as increased social isolation, limited life chances, and
decreased access to treatment. In addition to poorer social functioning as
assessed by housing and employment status, those with the stigma of

121
mental illness also encounter a significant barrier to obtaining general
medical care and to recovery from mental illness. Stigma also affects
family members of persons with mental illness.
Obese persons
Negative attitudes toward obese persons are pervasive in
contemporary society. Numerous studies have documented harmful
weightbased stereotypes that overweight and obese individuals are lazy,
weak-willed, unsuccessful, unintelligent, lack self-discipline, have poor
willpower, and are noncompliant with weightloss treatment. These
stereotypes give way to stigma, prejudice, and discrimination against
obese persons in multiple domains of living, including the workplace,
health care facilities, educational institutions, the mass media, and even in
close interpersonal relationships. Perhaps because weight stigma remains a
socially acceptable form of bias, negative attitudes and stereotypes toward
obese persons have been frequently reported by employers, coworkers,
teachers, physicians, nurses, medical students, dietitians, psychologists,
peers, friends, family members,1–4 and even among children aged as
young as 3 years.
Discrimination
Discrimination is the prejudicial treatment of an individual based
solely on their membership in a certain group or category. Discrimination
is the actual behavior towards members of another group. It involves
excluding or restricting members of one group from opportunities that are
available to other groups.
There are two types of discrimination: direct discrimination and
indirect discrimination.
Direct discrimination is pretty straightforward in most cases. It
happens when a person is dealt with unfairly on the basis of one of the
grounds (compared with someone who doesn’t have that ground) and in
one of the areas covered by the act.
Examples:
 Somebody is asked at a job interview whether he/she has
children. When he/she told the interviewer that has four children, she
makes a remark about he/she needing a lot of time off work if they’re sick,
and says he/she won’t be suitable for the position.
 An Aboriginal woman wanting to rent a house. When she
arrives to inspect a house she is told it’s already been taken. The woman
arranges for a non-Aboriginal friend to enquire about the house. She

122
rings, is told it’s still available, looks at the house and is offered a lease.
This is the third time this woman tried to rent a house through this agency.
In spite of the fact she has a good tenancy record, each time she phone,
she is told a house is available, and each time she meet one of the agents,
she is told it’s been rented already.
 When a woman advises her employer that she is pregnant, she
was moved to a lower-paying job out of the public view, because clients
„don’t want to look at people in her condition”.
Indirect discrimination is often less obvious. Sometimes, a policy,
rule or practice seems fair because it applies to everyone equally, but a
closer look shows that some people are being treated unfairly. This is
because some people or groups of people are unable or less able to comply
with the rule or are disadvantaged because of it.
Examples:
 An employer has a policy of not letting any staff work part-time.
(People with children or family responsibilities could be disadvantaged.)
 A public building, while fitted with lifts, has a set of six steps at
the front entrance. Entry for those needing to use the lift is through the
back entrance near the industrial bins. Those using a wheelchair can’t get
into the building from the front entrance.)
 Minimum height requirements apply for jobs in a resort, for no
apparent reason. (People from an Asian background, or women, may not
be able to meet the requirement.)
 All information about workplace health and safety in a factory, is
printed in English. (Those whose first language isn’t English may be at
risk.).
Unlike direct discrimination, indirect discrimination is not always
intentionally perpetrated.
In addition, direct discrimination proceeds from an individualistic,
personal complaint to the situation faced, whereas indirect discrimination
is concerned with group disadvantage and group rights.
Now regulations and laws are in place in most Western countries
to outlaw both direct and indirect discrimination. However, cases continue
to arise which prove that discrimination still occurs.
Discrimination behaviors can take many forms:
Racial and ethnic discrimination - differentiates between
individuals on the basis of real and perceived racial differences, and has
been official government policy in several countries, such as South Africa

123
in the apartheid era, and the USA. It is direct race discrimination to treat
someone less favorably than someone else would be treated in the same
circumstances, because of race. Racist abuse and harassment are forms of
direct discrimination. Genocide is the last step in a continuum of actions
taken by those who are prejudiced. The first step of this continuum is
discrimination and treating certain groups of people differently. The
second step is isolation, such as the physical segregation of minorities in
ghettos or setting up separate schools. The third step is persecution,
followed by dehumanization and violence. As example is the Holocaust
tragedy, which was the destruction of European Jewry by the Nazis
through an officially sanctioned, government-ordered, systematic plan of
mass annihilation. As many as six million Jews died, almost two-thirds of
the Jews of Europe.
Linguistic discrimination is discrimination based on native
language, usually in the language policy especially in education of a state
that has one or several linguistic minorities. People are sometimes
subjected to different treatment because their preferred language is
associated with a particular group, class or category. Commonly, the
preferred language is just another attribute of separate ethnic groups.
Discrimination exists if there is prejudicial treatment against a person or a
group of people who speak a particular language or dialect. Language
discrimination is suggested to be labeled linguicism or logocism. Anti-
discriminatory and inclusive efforts to accommodate persons who speak
different languages or cannot have fluency in the country's predominant or
"official" language, is bilingualism such as official documents in two
languages, and multiculturalism in more than two languages.
Examples:
 The Coptic language: At the turn of the 8th century,
Caliph Abd al-Malik ibn Marwan decreed that Arabic replace Koine Greek
and Coptic as the sole administrative language. Literary Coptic gradually
declined such that within a few hundred years, and suffered violent
persecutions especially under the Mamluks, leading to its virtual extinction
by the 17th century.
 Language policy of the British Empire in Ireland, Wales
and Scotland: Cromwell's conquest, the long English colonization and
Great Irish Famine made Irish a minority language by the end of 19th
century. It had not official status until the establishment of Republic of
Ireland. In Wales speaking of the Welsh language in schools was

124
prohibited. Scottish Gaelic also had not official status until the end of 20th
century. Scots was often treated as a mere dialect of English.
 Basque: Public usage of Basque was prohibited in Spain
under Franco, 1939 to 1965. Galician and Catalan have similar histories.
 Kurdish: Kurdish remains banned in Syria. Until August
2002, the Turkish government placed severe restrictions on the use of
Kurdish, prohibiting the language in education and broadcast media.
 Russification: Under the Russian Empire there were some
attempts in 1899-1917 to make Russian the only official language of
Finland. In the Soviet Union, following the phase of Korenizatsiya
("indigenization") and before Perestroika (late 1930s to late 1980s),
Russian was termed as "the language of friendship of nations", to the
disadvantage of other languages of the Soviet Union.
Age discrimination - is discrimination on the grounds of age; can
refer to the discrimination against any age group, usually comes in one of
three forms: discrimination against youth (also called adultism),
discrimination against those 40 years old or older, and discrimination
against elderly people.
Sex, Gender and Gender Identity discrimination - refers to
beliefs and attitudes in relation to the gender of a person, such beliefs and
attitudes are of a social nature and do not, normally, carry any legal
consequences.
Caste discrimination - currently, there are an estimated 160
million Dalits or Scheduled Castes (formerly known as "untouchables") in
India. Dalit people face severe problems, such as segregation and violence
against them.
Religious discrimination - Religious discrimination is valuing or
treating a person or group differently because of what they do or do not
believe. It is discrimination to treat you unfairly compared to someone
else, because of your religion or belief. This is called direct discrimination
and is illegal. Examples include: refusing a bank loan because the person
is Jewish; refusing to allow into a restaurant because the person is
Muslim ; dismissing from work because the person is Rastafarian.
Disability discrimination - against people with disabilities in favor
of people who are not, is called ableism or disablism. Disability
discrimination, which treats non-disabled individuals as the standard of
‘normal living’, results in public and private places and services,

125
education, and social work that are built to serve 'standard' people, thereby
excluding those with various disabilities.
Example of direct discrimination because of disability: a pub
allows a family with a child who has cerebral palsy to drink in their beer
garden but not in their family room. The family with the disabled child is
not given the same choices that other families have.
Example of indirect discrimination: A local authority produces an
information leaflet about its services for local people. It does not produce
an easy-to-read version of the leaflet in order to save money. This would
make it more difficult for someone with a learning disability to access the
services and could amount to indirect discrimination.
It is not count as a disability:
 Addiction to alcohol, nicotine or any other substance not
prescribed by a doctor. However, damage to health caused by the addiction
may be considered a disability.
 High fever.
 Certain personality disorders (for example exhibitionism,
voyeurism or a tendency to steal, set fires, or physically or sexually abuse
other people).
 Tattoos and body piercing.

6.3. Active Listening

Effective communication is vital for people. If humans wish to
construct good personal or professional relationships, to satisfy their
needs, to accomplish their tasks, goals, desire they must know how to
communicate efficiently. What mean to communicate efficiently? There
are many and different rules of efficient communication in different
settings. But indifferently is communication occurring in personal or
professional, interpersonal or collective setting it has to involve among
other rules active listening in order to be efficient.
The key to receiving messages effectively is listening. Active
listening is an intent to "listen for meaning", and requires more than
hearing words. It requires a desire to understand another human being,
interpret, and evaluate what he or she heard; an attitude of respect and
acceptance, and a willingness to open one's mind to try and see things
from another's point of view.

126
 The ability to listen actively can improve personal relationships
through reducing conflicts, strengthening cooperation and fostering
understanding. True listening requires that we suspend judgment,
evaluation, and approval in an attempt to understand another frame of
reference, emotions, and attitudes. Listening to understand is, indeed, a
difficult task!
When interacting, people often are not listening attentively to one
another. They may be distracted, thinking about other things, or thinking
about what they are going to say next (the latter case is particularly true in
conflict situations or disagreements).
Active listening is a structured way of listening and responding to
others. It focuses attention on the speaker. Suspending one’s own frame of
reference and suspending judgment are important in order to fully attend
to the speaker.
When we listen effectively we gain information that is valuable to
understanding the problem as the other person sees it. We gain a greater
understanding of the other person's perception. After all, the truth is
subjective and a matter of perception. When we have a deeper
understanding of another's perception, whether we agree with it or not, we
hold the key to understanding that person's motivation, attitude, and
behavior. We have a deeper understanding of the problem and the
potential paths for reaching agreement.
Active listening involves and an effective attending which is a
careful balance of alertness and relaxation that includes appropriate body
movement, eye contact, and "posture of involvement". Fully attending
says to the speaker, "What you are saying is very important. I am totally
present and intent on understanding you". We create a posture of
involvement by:
- Leaning gently towards the speaker;
- Facing the other person squarely;
- Maintaining an open posture with arms and legs uncrossed;
- Maintaining an appropriate distance between us and the speaker;
- Moving our bodies in response to the speaker, i.e., appropriate
head nodding, facial expressions.
When we pay attention to a speaker's body language we gain insight
into how that person is feeling as well as the intensity of the feeling.
Through careful attention to body language and paraverbal messages, we
are able to develop hunches about what the speaker (or listener) is

127
communicating. We can then, through our reflective listening skills, check
the accuracy of those hunches by expressing in our own words, our
impression of what is being communicated.
Providing feedback is the most important active listening skill.
Ask questions. Nod in agreement. Look the person straight in the eye.
Lean forward. Be an animated listener. Focus on what the other person is
saying. Repeat key points. Active listening is particularly important in
dealing with an angry person. Encouraging the person to speak, i.e., to
vent feelings, is essential to establishing communication with an angry
person. Repeat what the person has said. Ask questions to encourage the
person to say again what he or she seemed most anxious to say in the first
place. An angry person will not start listening until they have "cooled"
down. Telling an angry person to "cool" down often has the opposite
effect. Getting angry with an angry person only assures that there are now
two people not listening to what the other is saying.
Reflective listening or responding is the process of restating, in
our words, the feeling and/or content that is being expressed and is part of
the verbal component of sending and receiving messages. By reflecting
back to the speaker what we believe we understand, we validate that
person by giving them the experience of being heard and acknowledged.
We also provide an opportunity for the speaker to give us feedback about
the accuracy of our perceptions, thereby increasing the effectiveness of our
overall communication. Responses can take different forms. Some of the
them are as followed.
Paraphrasing
This is a concise statement of the content of the speaker's message.
A paraphrase should be brief, succinct, and focus on the facts or ideas of
the message rather than the feeling. The paraphrase should be in the
listener's own words rather than "parroting back", using the speaker's
words.
"You believe that Jane needs an instructional assistant because
she isn't capable of working independently."
"You would like Bob to remain in first grade because you think the
activities would be more developmentally appropriate."
"You do not want Beth to receive special education services
because you think it would be humiliating for her to leave the classroom at
any time."

128
 "You want to evaluate my child because you think he may have an
emotional disability."
Reflecting Feeling
The listener concentrates on the feeling words and asks herself,
"How would I be feeling if I was having that experience?" She then
restates or paraphrases the feeling of what she has heard in a manner that
conveys understanding.
"You are very worried about the impact that an evaluation might
have on Lisa's self esteem".
"You are frustrated because dealing with Ben has taken up so
much of your time, you feel like you've ignored your other students."
"You feel extremely angry about the lack of communication you
have had in regards to Joe's failing grades."
"You're upset because you haven't been able to get in touch with
me when I'm at work."
Summarizing
The listener pulls together the main ideas and feelings of the
speaker to show understanding. This skill is used after a considerable
amount of information sharing has gone on and shows that the listener
grasps the total meaning of the message. It also helps the speaker gain an
integrated picture of what she has been saying.
"You're frustrated and angry that the assessment has taken so long and
confused about why the referral wasn't made earlier since that is what you
thought had happened. You are also willing to consider additional evaluation
if you can choose the provider and the school district will pay for it".
"You're worried that my son won't make adequate progress in
reading if he doesn't receive special services. And you feel that he needs to
be getting those services in the resource room for at least 30 minutes each
day because the reading groups in the classroom are bigger and wouldn't
provide the type of instruction you think he needs."
Questioning
The listener asks open ended questions (questions which can't be
answered with a "yes" or a "no") to get information and clarification. This
helps focus the speaker on the topic, encourages the speaker to talk, and
provides the speaker the opportunity to give feedback.
"Can you tell us more about Johnny's experience when he's in the
regular classroom?"

129
 "How was it for Susie when she rode the special ed. bus for those
two weeks?"
"Tell us more about the afterschool tutoring sessions."
"What kinds of skills do you think are important for Jim to learn in
a social skills class?"
"Could you explain why you think itís difficult for Ben to be on the
playground for an hour?"
"I'm confused - are you worried that the testing may mean time
out of the classroom for Jim or is there something else?"

6.4. Barriers and Solutions for Effective Medical Communication

In the first paragraph of this chapter we make the general approach
to the topic of communication barriers. The barriers discussed can be met
in any professional setting. And they are met in medical context also but
with some peculiarities proper to medical profession.
Barriers and solution for effective communication between
physician and patient
While the majority of doctors seek to encourage open and
informative dialogue with patients, it is recognized that episodes of poor
communication occur. There are a number of barriers to communication
ranging from personal traits to organizational:
 A lack of skill and understanding of the structures of
conversational interaction. For example, the importance of providing
accessible information in a language that is tailored to the patient, giving
structured explanations and listening to patients’ views, thereby
encouraging two-way communication.
 Inadequate knowledge of, or training in, other communication
skills including body language and speed of speech. Problems may be
caused by insufficient personal insight into communication difficulties. In
some cases communication will be hampered by factors as straightforward
as poorly laid out furniture.
 Doctors undervaluing the importance of communicating. For
example, not appreciating the importance of keeping patients adequately
informed. In some cases this will stem from a wider imbalance in the
relationship between doctor and patient.
 Negative attitudes of doctors towards communication. For
example, giving it a low priority due to a concern primarily to treat illness

130
rather than focusing on the patient’s holistic needs such as psychological
and social wellbeing. This is often an artificial distinction since health and
ill health tend to be composed of physical, psychological and social
components. A lack of inclination to communicate with patients can be
due to lack of time, uncomfortable topics, lack of confidence and concerns
relating to confidentiality lack of knowledge about the illness/condition or
treatment. The last need not be a barrier to effective communication so
long as doctors are honest about the limitations of their knowledge.
Doctors should recognize that in many cases patients may be as
knowledgeable or insightful about their own conditions as the doctor
human failings, such as tiredness and stress inconsistency in providing
information language barriers.
Identifying the specific factors inhibiting good communication
should be mentioned that these are overcoming by the mean of
communication skills training and reflection.
Good communication skills expected of healthcare workers
include the ability to:
o talk to patients, carers and colleagues effectively and clearly,
conveying and receiving the intended message;
o providing patients and others with adequate information;
o handling complaints appropriately;
o enable patients and their carers to communicate effectively;
o listen effectively especially when time is pressured;
o identify potential communication difficulties and work through
solutions;
o understand the differing methods of communication used by
individuals;
o understand that there are differences in communication signals
between cultures;
o cope in specific difficult circumstances;
o understand how to use and receive non verbal messages given by body
language;
o utilize spoken, written and electronic methods of communication;
o know when the information received needs to be passed on to another
person/professional for action;

131
 o know and interpret the information needed to be recorded on patients
records, writing discharge letters, copying letters to patients and
gaining informed consent;
o recognize the need for further development to acquire specialist skills.
Barriers and solution for effective communication in medical team
Health professionals tend to work autonomously, even though they
may speak of being part of a team. Efforts to improve health care safety
and quality are often jeopardized by the communication and collaboration
barriers that exist between clinical staff. Although every organization is
unique, the barriers to effective communication that organizations face
have some common themes. There are some common barriers to inter-
professional communication and collaboration:
 Personal values and expectations,
 Personality differences,
 Hierarchy ,
 Disruptive behavior,
 Culture and ethnicity,
 Gender,
 Historical interprofessional and intraprofessional rivalries,
 Differences in schedules and professional routines,
 Varying levels of preparation, qualifications, and status,
 Differences in requirements, regulations, and norms of
professional education,
 Fears of diluted professional identity,
 Differences in accountability, payment, and rewards,
 Concerns regarding clinical responsibility,
 Emphasis on rapid decision making.
The indicated barriers can occur within disciplines, most notably
between physicians and residents, surgeons and anesthesiologists, and
nurses and nurse managers etc. However, most often the barriers manifest
between nurses and physicians. Even though doctors and nurses interact
numerous times a day, they often have different perceptions of their roles
and responsibilities as to patient needs, and thus different goals for patient
care. One barrier compounding this issue is that because many clinicians
come from a variety of cultural backgrounds. In all interactions, cultural
differences can exacerbate communication problems. For example, in
some cultures, individuals refrain from being assertive or challenging
opinions openly. As a result, it is very difficult for nurses from such

132
cultures to speak up if they see something wrong. In cultures such as these,
nurses may communicate their concern in very indirect ways. Culture
barriers can also hinder nonverbal communication. For example, some
cultures ascribe specific meaning to eye contact, certain facial expressions,
touch, tone of voice, and nods of the head.
Issues around gender differences in communication styles, values,
and expectations are common in all workplace situations. In the health
care industry, where most physicians are male and most nurses are female,
communication problems are further accentuated by gender differences.
A review of the organizational communication literature shows
that a common barrier to effective communication and collaboration is
hierarchies. The communication failures in the medical setting arise from
vertical hierarchical differences, concerns with upward influence, role
conflict, and ambiguity and struggles with interpersonal power and
conflict. Communication is likely to be distorted or withheld in situations
where there are hierarchical differences between two communicators,
particularly when one person is concerned about appearing incompetent,
does not want to offend the other, or perceives that the other is not open to
communication.
In health care environments characterized by a hierarchical culture,
physicians are at the top of that hierarchy. Consequently, they may feel that
the environment is collaborative and that communication is open while nurses
and other direct care staff perceive communication problems. Hierarchy
differences can come into play and diminish the collaborative interactions
necessary to ensure that the proper treatments are delivered appropriately.
When hierarchy differences exist, people on the lower end of the hierarchy
tend to be uncomfortable speaking up about problems or concerns.
Intimidating behavior by individuals at the top of a hierarchy can hinder
communication and give the impression that the individual is unapproachable.
Staff who witness poor performance in their peers may be hesitant
to speak up because of fear of retaliation or the impression that speaking
up will not do any good. Relationships between the individuals providing
patient care can have a powerful influence on how and even if important
information is communicated. Research has shown that delays in patient
care and recurring problems from unresolved disputes are often the by-
product of physician-nurse disagreement. Nurses are either reluctant or
refuse to call physicians, even in the face of a deteriorating status in
patient care. Reasons for this include intimidation, fear of getting into a

133
confrontational or antagonistic discussion, lack of confidentiality, fear of
retaliation, and the fact that nothing ever seems to change. Many of these
issues have to deal more with personality and communication style.
The major concern about disruptive behaviors is the potential
negative impact they can have on patient care. In condition of the high rate
fervency of such behavior the high responsibility lay on the shoulders of
heath managers. Leaders in both medicine and nursing are obliged to issue
initiatives for the development of a cooperative rather than a competitive
agenda to benefit patient care. A powerful incentive for greater teamwork
among professionals is created by directing attention to the areas where
changes are likely to result in measurable improvements for the patients
they serve together, rather than concentrating on what, on the surface,
seem to be irreconcilable professional differences. The fact that most
health professionals have at least one characteristic in common, a personal
desire to learn, and that they have at least one shared value, to meet the
needs of their patients or clients, is a good place to start.
► Exercises and Discussions:
1.What are the barriers in communication?
2.Give the definition of terms “stereotype”, “stigmatization”, “and
discrimination”. Describe the effects of discrimination in health care.
3.What involve and active listening? Find the other rules besides active
listening for an efficient communication.
4.What are the barriers in communication between physician and
patient? How can be they overcome?
5.What the communication skills need physicians?
6.What are the impediments of good collaboration in medical team?
7.How to construct good team collaboration in medical setting?
8.What communication skills need a manager in health area?
► Recommended Essays
1. Genocide, from history to solutions
2. Stigma and Discrimination in Health Care Service
3. Causes and consequences of HIV patients stigmatization
4. Good management of medical team
► Literature:
1. Aggleton Peter, Wood Kate, Malcolm Anne. HIV - Related Stigma,
Discrimination and Human Rights Violations. WHO Library Cataloguing-
in-Publication Data. UNAIDS. Geneva, 2005.

134
2. Burnard Ph. Effective communication skills for health professionals.
Nelson Thornes, 1997.
3. Hogan K, Stubbs R. Can't Get Through: 8 Barriers to Communication.
Pelican Publishing, 2003.
4. Macrae Neil C., Stangor Charles, Hewstone Miles. Stereotypes and
stereotyping. Guilford Press, 1996.
5. Fishbein Harold D. Peer prejudice and discrimination: the origins of
prejudice. Routledge, 2002.
6. Ray Berlin Eileen, Donohew Lewis. Communication and health:
systems and applications. Routledge, 1989.
7. Ray Berlin Eileen. Case studies in health communication. Routledge,
1993.
8. Thompson Teresa L.. Handbook of health communication. Routledge,
2003.
Chapter 7

Behavior and Cultural Contexts

Culture is the sum of all the forms of art, of love,
and of thought, which, in the course or centuries,
have enabled man to be less enslaved
Andre Malraux

7.1. The Concept of Culture

The concept of culture has a long and complicated story.
Nowadays is accounted more than one hundred meaning or definition of it.
The word culture comes from the Latin root colere (to inhabit, to cultivate,
or to honor). So the firstly this concept connoted a process of cultivation or
improvement, as in agriculture. Cicero, the roman ancient philosopher
used an agricultural metaphor to describe the development of a
philosophical soul, which was understood teleologically as the one natural
highest possible ideal for human development. In other words Cicero
defines culture as development or improvement of the mind by education.
In the nineteenth century, humanists such as English poet and essayist
Matthew Arnold used the word "culture" to refer to an ideal of individual

135
human refinement, of "the best that has been thought and said in the
world." Thus culture is the quality in a person or society that arises from a
concern for what is regarded as excellent in arts, letters, manners,
scholarly pursuits, etc.
Sir Edward B. Tylor in 1871 gave the very cited especially by
anthropologist definition of culture. He said "culture or civilization, is that
complex whole which includes knowledge, belief, art, morals, law,
custom, and any other capabilities and habits acquired by man as a
member of society". In the 20th century "culture" emerged as the central
and unifying concept of American anthropology, where it most commonly
refers to the universal human capacity to classify and encode their
experiences symbolically, and communicate symbolically encoded
experiences socially. In 2002 United Nations agency UNESCO states that
culture is the "set of distinctive spiritual, material, intellectual and
emotional features of society or a social group and that it encompasses, in
addition to art and literature, lifestyles, ways of living together, value
systems, traditions and beliefs".
Analyzing the mentioned definitions it is possible to conclude that
culture is a quality of an individual, social organization, social group (i.e.
ethnic, or age group) or society as a hole to share the systems of symbols,
beliefs, attitudes, values, expectations, and norms of behavior. Culture is a
quality acquired by the means of education and it is a quality which makes
the difference between humans and animals, between individuals of one
community, between organization, social groups and societies (of the same
or different epochs).
7.2. Etiquette and Cultural Differences
Etiquette is French word that literally means ticket of admission.
Etiquette is a code of behavior that delineates expectations for social
behavior according to conventional norms within a society, social class, or
group. Rules of etiquette encompass most aspects of social interaction in
any society, though the term itself is not commonly used. A rule of
etiquette may reflect an underlying ethical code, or it may reflect a
person's fashion or status. Rules of etiquette are usually unwritten, but
aspects of etiquette have been codified from time to time.
Etiquette evolves within culture. Thus etiquette is a component
part of culture. It is dependent on culture. What is excellent etiquette in
one society may shock another. The Dutch painter Andries Both shows

136
that the hunt for head lice (illustration, right), which had been a civilized
grooming occupation in the early Middle Ages, a bonding experience that
reinforced the comparative rank of two people, one groomed, one
groomer, had become a peasant occupation by 1630. The painter portrays
the familiar operation matter-of-factly, without the disdain this subject
would have received in a nineteenth-century representation.
Etiquette could vary widely between different cultures and
nations. In China, a person who takes the last item of food from a common
plate or bowl without first offering it to others at the table may be seen as a
glutton and insulting the generosity of the host. In America a guest is
expected to eat all of the food given to them, as a compliment to the
quality of the cooking.
The term etiquette is used interchangeable with word manners
which is define as the unenforced standards of conduct which show the
actor that you are proper, polite, and refined. They are like laws in that
they codify or set a standard for human behavior, but they are unlike laws
in that there is no formal system for punishing transgressions, other than
social disapproval. They are a kind of norm. What is considered
"mannerly" is highly susceptible to change with time, geographical
location, social stratum, occasion, and other factors. That manners matter
is evidenced by the fact that large books have been written on the subject,
advice columns frequently deal with questions of mannerly behavior, and
that schools have existed for the sole purpose of teaching manners. A lady
is a term frequently used for a woman who follows proper manners; the
term gentleman is used as a male counterpart; though these terms are also
often used for members of a particular social class.
Politeness is best expressed as the practical application of good
manners or etiquette. It is a culturally defined phenomenon, and therefore
what is considered polite in one culture can sometimes be quite rude or
simply strange in another cultural context.
While the goal of politeness is to make all of the parties relaxed
and comfortable with one another, these culturally defined standards at
times may be manipulated to inflict shame on a designated party.
The British social anthropologists Penelope Brown and Stephen
Levinson identified two kinds of politeness:
 Negative politeness: Making a request less infringing, such as
"If you don't mind..." or "If it isn't too much trouble..."; respects a person's

137
right to act freely. In other words, deference. There is a greater use of
indirect speech acts.
 Positive politeness: Seeks to establish a positive relationship
between parties; respects a person's need to be liked and understood.
Direct speech acts, swearing and flouting maxims can be considered
aspects of positive politeness because:
o they show an awareness that the relationship is strong enough
to cope with what would normally be considered impolite (in the popular
understanding of the term);
o they articulate an awareness of the other person's values,
which fulfills the person's desire to be accepted.
Some cultures seem to prefer one of these kinds of politeness over
the other. To be polite in one culture or society mean to know and to
follow the etiquette accepted in them.
Examples of etiquette:
 If invited to dinner, in some Asian countries it is well-
mannered to leave right after the dinner: the ones who don’t leave may
indicate they have not eaten enough. In the Indian sub-continent, Europe,
South America, and North American countries this is considered rude,
indicating that the guest only wanted to eat but wouldn’t enjoy the
company with the hosts.
 In Mediterranean European countries, Latin America, and
Sub-Saharan Africa, it is normal, or at least widely tolerated, to arrive half
an hour late for a dinner invitation, whereas in Germany and in the United
States this would be considered very rude.
 Showing the thumb held upwards in certain parts of the world
means "everything's ok", while it is understood in some Islamic countries
(as well as Sardinia) as a rude sexual sign. Additionally, the thumb is held
up to signify "one" in France and certain other European countries, where
the index finger is used to signify "one" in other cultures.
 In Africa, Arab cultures, and certain countries in South
America (not in Brazil), saying to a female friend one has not seen for a
while that she has put on weight means she is physically healthier than
before, whereas this would be considered an insult in India, Europe, North
America, Australia, and Brazil.
 In Africa and Asian countries, avoiding eye contact or
looking at the ground when talking to one's parents, an elder, or someone
of higher social status is a sign of respect. In contrast, these same actions

138
are signals of deception or shame (on the part of the doer) in North
America and most of Europe.
 In African, South American and Mediterranean cultures,
talking and laughing loudly in the streets and public places is widely
accepted, whereas in some Asian cultures it is considered rude and may be
seen as a mark of self-centeredness or attention-seeking.
In this context is opportune to ask the question: how is possible the
communication between communicators belonging to different cultures?
With such an interrogation is dealing discipline called cross-cultural
communication.
7.3. The Conflict – Definition and Resolution
In first paragraph of this chapter is said that culture as system of
values, attitudes, beliefs, expectations, norms and principles of behavior
make the difference between us as humans and as representatives of
diverse communities. The differences can be source of tension and finally
the source of conflict. In what will follow we will try to clarify the nature
of conflict.
What is a conflict? The term "conflict" has been defined as
"intense interpersonal and/or intrapersonal dissonance (tension or
antagonism) between two or more parties based on incompatible goals,
needs, desires, values, beliefs, and/or attitudes. Conflict can appear as
Racial and Cross Cultural Issues - Interracial conflict, Cross-racial
confrontations, Religious conflict. Nevertheless it is present in such areas
as: Neighborhood – Noise, Pets, Shared common areas, Disturbances
(except for domestic violence); Housing - Landlord/Tenant,
Roommate/Roommate, Mobile Home Parks; Family - Parent/Teen, Youth,
Peer Relations; Organization - Private Nonprofit Agencies, Community
Groups, Home Owner Associations, Neighborhood Groups.
The conflict response styles
People may appreciate the same situation in different ways, and so
respond differently to the conflict situation. According to Turner and
Weed (1983), there are several response styles to conflict and classified
them as follows:
1. Style of addressers. Addressers are the people who are willing to
take initiatives and risk to resolve conflicts by getting their opponents to
agree with them on some issues. Addressers can either be first-steppers or
confronters: A) First-steppers are those who believe that some trust has to

139
be established to settle conflicts. They offer to make a gesture of affability,
agreeableness or sympathy with the other person's views in exchange for a
similar response. B) Confronters think that things are so bad that they
have nothing to lose by a confrontation. They might be confronting
because they have authority and a safe position, which reduces their
vulnerability to any loss.
2. Style of concealers. Concealers take no risk and so say nothing.
They conceal their views and feelings. Concealers can be of three kinds: a)
Feeling-swallowers swallow their feelings. They smile even if the
situation is causing them pain and distress. They behave thus because they
consider the approval of other people important and feel that it would be
dangerous to affront them by revealing their true feelings. B) Subject-
changers find the real issue too difficult to handle. They change the topic
by finding something on which there can be some agreement with the
conflicting party. This response style usually does not solve the problem.
Instead, it can create problems for the people who use this and for the
organization in which such people are working. C) Avoiders often go out
of their way to avoid conflicts.
3. Style of attackers. Attackers cannot keep their feelings to
themselves. They are angry for one or another reason, even though it may
not be anyone's fault. They express their feelings by attacking whatever
they can even, though that may not be the cause of their distress. Attackers
may be up-front or behind-the-back: a) Up-front attackers are the angry
people who attack openly; they make work more pleasant for the person
who is the target, since their attack usually generates sympathy, support
and agreement for the target. B) Behind-the-back attackers are difficult to
handle because the target person is not sure of the source of any criticism,
nor even always sure that there is criticism.
Types of conflict management
Out of conflict styles response there are also studied the style of
conflict management. Conflict management is a process in which conflict
is used as a deliberate personal, social, or organizational tool. Reg Adkins
considers that there are at least four such styles, no one superior than
other, but all depend on the people, environment and the context:
Competing; Avoiding; Harmonizing; Compromising.
The avoiding style of conflict management is a non-
confrontational approach to problems. It involves passive behaviors such
as withdrawing or side stepping issues of contention in order to avoid

140
issues which might be harmful to relationships involved. This approach is
best used when disagreements develop from minor unimportant issues.
This is a useful technique when time is needed in order to gather
additional information for informed decision making. Unfortunately,
sometimes the problems that are not quickly addressed tend to grow over
time. Relationships can be damaged by unresolved issues. Overuse of this
style can lead us into giving up too many of our personal goals and enable
others to take advantage of us.
The competing style of conflict management is an authoritarian
approach to problems and involves only one side getting their say. It is
goal oriented and quick. It is most effective in conflict which involves
personal differences that are unlikely to change. It is valuable as a counter
measure in situations where others are likely to take advantage of those
who display a non-competitive nature. It is also valuable in circumstances
which require a quick decision. Finally, one of its greatest values is in
making unpopular decisions which need to be implemented. The down
side of the model is the hostility it has a tendency to breed in those on the
losing side. This is especially true when it is the only style of conflict
management being utilized.
The harmonizing style of conflict management puts the
relationship of the interacting parties before the conflict at hand. When
utilizing this technique you may find yourself giving in to the other person
for the sake of the relationship. There are two situations in which this
technique is particularly useful. One is when we are caught off guard by
the conflict and the other party is well prepared. In these circumstances
when we find ourselves situationally outmatched the technique allows us
to save face and move forward. As second instance in which this technique
is valuable is in the client service model. It is nearly always more
important to maintain a positive relationship with a client than it is to be
victorious in a confrontation. This is especially true if you are goal
oriented toward repeat business. On the other hand, when this technique is
over used it can manifest some negative results. If you find yourself over
utilizing this strategy and always putting the needs of other before your
own you will find yourself with a buildup of feelings of resentment.
Another negative result occurs when dealing with the unscrupulous. Those
persons who perceive this technique as a weakness will always put their
own interest in the self before the good of the many.

141
 Compromise is a technique often known as the "middle ground"
approach. It supposes a negotiation process in which both parties give up
something they want. Whatever one side gets, the other side loses. Neither
side gets what they want but both sides make concessions in order to reach
a conclusion that is equally acceptable to both. It is most useful when both
parties are of equal stature and there is no simple solution. Unfortunately,
no one is ever really satisfied with the results of this technique. But, at
least both parties are equally dissatisfied.
Ways of Conflict resolution
The term "conflict resolution" refers to a range of processes
aimed at alleviating or eliminating sources of conflict. Conflict resolution
aims to end conflicts before they start or before they lead to verbal,
physical, or legal fighting. This is different from conflict management, in
which conflict is used as a deliberate personal, social, or organizational
tool. Though conflict management is the more common road, it is not
popular with practitioners of conflict resolution; it is better to avoid the
conflict at the start. As pioneering self-help author Napoleon Hill said:
“The most important job is that of learning how to negotiate with others
without friction.”
Duke Ellington had it right when he said, “A problem is a chance
for you to do your best.” To deal with conflict successfully, be concerned
about your own outcomes and also the outcomes for the other party.
Processes of conflict resolution generally include negotiation,
mediation, collaborative law, and arbitration.
The salient features of each type are as follows:
1. In negotiation, participation is voluntary and there is no third
party who facilitates the resolution process or imposes a
resolution.
2. In mediation, there is a third party, a mediator, who facilitates the
resolution process (and may even suggest a resolution, typically
known as a "mediator's proposal"), but does not impose a
resolution on the parties.
3. In collaborative law, each party has an attorney who facilitates
the resolution process within specifically contracted terms. The
parties reach agreement with support of the attorneys (who are
trained in the process) and mutually-agreed experts. No one
imposes a resolution on the parties.

142
 4. In arbitration, participation is typically voluntary, and there is a
third party who, as a private judge, imposes a resolution.
Arbitrations often occur because parties to contracts agree that any
future dispute concerning the agreement will be resolved by
arbitration.
Beyond the peculiarities of each form of conflict resolution there
are some common used strategies for conflict solving. Among success
strategies for conflict resolution are following directives:
 Have a high concern for both your own and the other party’s
outcomes, and attempt to identify mutually beneficial solutions.
 Know and take care of yourself.
o Understand your perceptual filters, biases, and triggers.
o Create a personally-affirming environment for yourself before
addressing the conflict (sleep, eat, seek counsel, etc.).
 Clarify personal needs threatened by the conflict.
o Know your substantive, procedural, and psychological needs.
o Determine your “desired outcomes” from a negotiated process.
 Identify a safe place to meet and negotiate.
o Arrange an appropriate space for the discussion that is private and
neutral.
o Gain mutual consent to negotiate and ensure the time is
convenient for all parties.
o Consider if support people would be beneficial (for example,
facilitators, mediators, advocates, etc.).
o Agree to ground rules.
 Take a listening stance.
o “Seek first to understand, then to be understood.”
o Use active listening skills, and listen loudly.
 Assert your needs clearly and specifically.
o Use “I-messages” as tools for clarification.
o Build from what you have heard; continue to listen loudly and
actively.
 Approach the interaction with flexibility.
o Identify issues clearly and concisely.
o Participate in generating options (brainstorming), while deferring
judgment.

143
 o Be open and don’t get distracted by “tangents” and other problem
definitions.
o Clarify criteria for decision-making.
 Manage impasses with calm, patience, and respectful behavior.
o Clarify feelings.
o Focus on underlying needs, interests, and concerns.
o Take a structured break if needed.
 Build an agreement that works.
o Review “hallmarks” of a good agreement.
o Implement and evaluate—live and learn.
Using these techniques can improve the outcome of a conflict
resolution process for everyone concerned.
7.4. Intercultural Communication
We live in multicultural world, in which cultural differences could
be and are the source of deep interpersonal, institutional, group and social
conflicts. The ways of conflict resolution mentioned above imply
communication. How must be the communication process between
cultures is a complex question address by Cross-cultural communication
(also frequently referred to as intercultural communication) - a field of
study that looks at how people from differing cultural backgrounds
endeavor to communication. Beside that the significant objective of this
discipline is to produce intercultural communication principles designed
to guide the process of exchanging meaningful and unambiguous
information across cultural boundaries, in a way that preserves mutual
respect and minimizes antagonism.
Rules of efficient Intercultural Communication
1. The key to effective cross-cultural communication is knowledge.
It is essential that people research the cultures and communication
conventions of those whom they propose to meet. This will minimize the
risk of making the elementary mistakes.
2. When language skills are not high or unequal, clarifying one’s
meaning in five ways will improve communication:
 avoid using slang and idioms, choosing words that will convey
only the most specific denotative meaning;

144
  listen carefully and, if in doubt, ask for confirmation of
understanding (particularly important if local accents and
pronunciation are a problem);
 recognize that accenting and intonation can cause meaning to vary
significantly;
 respect the local communication formalities and styles, and watch
for any changes in body language;
 Investigate their culture's perception of your culture by reading
literature about your culture through their eyes before entering into
communication with them. This will allow you to prepare yourself
for projected views of your culture you will be bearing as a visitor
in their culture.
3. If it is not possible to learn the other's language, it is expedient to
show some respect by learning a few words. In all important exchanges, a
translator can convey the message.
4. It is essential that people understand the potential problems of
cross-cultural communication, and makes a conscious effort to overcome
these problems. It is important to assume that one’s efforts will not always
be successful, and adjust one’s behavior appropriately. For example, one
should always assume that there is a significant possibility that cultural
differences are causing communication problems, and be willing to be
patient and forgiving, rather than hostile and aggressive, if problems
develop. One should respond slowly and carefully in cross-cultural
exchanges, not jumping to the conclusion that you know what is being
thought and said.
5. Suggestion for heated conflicts is to stop, listen, and think, that
means withdraw from the situation, step back, and reflect on what is going
on before you act. Ask yourself: What could be going on here? Is it
possible I misinterpreted what they said, or they misinterpreted me? Often
misinterpretation is the source of the problem. Active listening can
sometimes be used to check this out – by repeating what one thinks he or
she heard, one can confirm that one understands the communication
accurately. If words are used differently between languages or cultural
groups, however, even active listening can overlook misunderstandings.
6. Often intermediaries who are familiar with both cultures can be
helpful in cross-cultural communication situations. They can translate both
the substance and the manner of what is said.

145
 7. Do put aside defensiveness. When accused of not understanding,
admit that it’s probably true. Ask for help in understanding your partner’s
code.
8. Try continuously to improve your intercultural competence. That
means to be intercultural sensitive (to capture and understand, in
interaction with people from foreign cultures, their specific concepts in
perception, thinking, feeling and acting, while being free from prejudices);
and to be self-confident (to know what you want, your strengths and
weaknesses, to be emotional stabile in order to express your own point of
view in a transparent way with the aim to be understood and respected by
staying flexible where this is possible, and being clear where this is
necessary).
► Exercises and Discussions:
1. What is culture? Give some alternative definition to the term
“culture”?
2. What is the meaning of term “etiquette”? What is the relation
between etiquette, politeness and culture? Give some examples
cultural differences in etiquette.
3. What is conflict? Describe the styles of conflict responses and
types of conflict management.
4. Describe the ways of conflict resolution and strategies of
success conflict solving.
5. What is intercultural communication? Learn the rules of
successful intercultural communication.
► Recommended Essays
1. Ethno medicine/Global health
2. Health, food and culture
3. Conflict in health system
4. Etiquette: norms of behavior in public place, at the
business lunch, in the formal meeting, a family lunch etc.
► Literature:
1. Bartos Otomar J., Wehr Paul Ernest. Using conflict theory.
Cambridge University Press, 2002.
2. Engender Health. (2004) Reducing Stigma and Discrimination
Related to HIV and AIDS: Training for Health Care Workers,
Trainer's Manual and Participant's Handbook.
http://www.popline.org/docs/273667

146
 3. MacLachlan Malcolm. Culture and health: a critical perspective
towards global health. John Wiley and Sons, 2006.
4. Pagano Michael P., Michael Pagano. Interactive Case Studies
in Health Communication. Jones & Bartlett Learning, 2010.
5. Storey John. Cultural theory and popular culture: a reader.
Pearson Education, 2006. – 657 p.
6. Winkelman Michael. Culture and health: applying medical
anthropology. John Wiley and Sons, 2008.

Chapter 8

Health Risk Behaviors and Communication in Risk Conditions

Every human being is the author of his

own health or disease.
Buddha

8.1. Dangerous Factors Determining Appearance of Illness

The World Health Organization (WHO) defined health as "a state of
complete physical, mental, and social well-being and not merely the
absence of disease or infirmity." When these conditions of well – being are
not fulfilled, then one can be considered to have an illness or be ill. Illness

147
sometimes referred to as ill-health or a state of poor health. Taking in
account the broad definition of health given by WHO, it is possible to
resume that human health is influenced at least by three factors: physical,
mental and social. And consequently the state of poor health is determined
by the same factors.
Physical factors strongly influence health status and health
practices. Among them can be listed: genetic make-up, age, developmental
level, race and sex etc. For instance the young woman who has a family
history of breast cancer and diabetes is at a higher risk to develop these
conditions.
Mental factor include some dimensions: emotional, intellectual and
spiritual. It is proved that emotion affect body function and consequently
influences health. For instance long term stress affects the body systems
and anxiety affects health habits; conversely, calm acceptance and
relaxation can actually change body responses to illness. Or a relevant
example is a student that prior to a test always has diarrhea.
The intellectual dimension encompasses cognitive abilities,
educational background and past experiences. These influence a client’s
responses to teaching about health and reactions to health care during
illness. They also play a major role in health behaviors. For instance a
young person with diabetes who follows a diabetic diet but continues to
drink beer and eat pizza with friends several times a week is at risk
because did not realize the danger of such a behavior.
Spiritual dimension refers to spiritual and religious beliefs. These
two are important components of the way the person behaves in health and
illness. For instance Jehovah Witnesses’ are opposed to blood transfusions
which could make a banal illness lethal one
Social factors imply usually to dimensions: environmental and
Socio-cultural.
Housing, sanitation, climate and pollution of air, food and water are
aspects of environmental dimension which have many influences on health
and illness. For instance in large cities with smog are increased incidence
of asthma and respiratory problems.
Socio-cultural dimension includes a person’s economic level,
lifestyle, family and culture. Low-income groups are less likely to seek
health care to prevent or treat illness; high-income groups are more prone
to stress-related habits and illness. The family and the culture to which the
person belongs determine patterns of livings and values, about health and

148
illness that are often unalterable. For instance the adolescent whose
parents smoke and drink will see nothing wrong with smoking or drinking.
Or for instance the person of Asian descent is more likely to use herbal
remedies and acupuncture to treat an illness then results of conventional
medicine.

8.2. Risky Health Lifestyles

Lifestyle is a term to describe the way a person lives. It is the
style of living that reflects the attitudes and values of a person. A lifestyle
is a characteristic bundle of behaviors (patterns of behavior) including
social relations, consumption, entertainment, and dress. The behaviors and
practices within lifestyles are a mixture of habits, conventional ways of
doing things, and reasoned actions.
In public health, "lifestyle" generally means a pattern of individual
practices and personal behavioral choices that are related to elevated or
reduced health risk. Since the mid-1970s, there has been a growing
recognition of the significant contribution of personal behavior choices to
health risk—in the United States thirty-eight percent of deaths in 1990
were attributed to tobacco, diet and activity patterns, and alcohol. Equally
important, illnesses attributable to lifestyle choices play a role in reducing
health-related quality of life and in creating health disparities among
different segments of the population.
In what will follow are unfolded the most heath risky lifestyle.
Smoking
Smoking is a major cause of heart and blood vessel disease. The
American Heart Association has named cigarette smoking as the most
dangerous of the modifiable risk factors. Overall, smokers experience a
70% greater death rate from heart and blood vessel disease than
nonsmokers; and heavy smokers (two or more packs per day) have a death
rate two to three times greater than nonsmokers. Inhaling cigarette smoke
produces temporary effects on the heart and blood vessels. The nicotine in
the smoke increases blood pressure, heart rate, and the amount of blood
pumped by the heart and the blood flow in the vessels in the heart. Other
effects include narrowing of the vessels in the arms and legs. Nicotine is
not the only bad element in cigarette smoke. Carbon monoxide gets in the
blood which reduces the amount of oxygen available to the heart and all
other parts of the body. Cigarette smoking also causes the platelets in the

149
blood to become sticky and cluster which can harm the heart and blood
vessels. No cigarettes are considered safe. Many smokers who have
switched to low tar and low nicotine cigarettes smoke more or inhale more
deeply to make up for the decreased nicotine. By inhaling more deeply,
smokers may increase their risk of disease. Regardless of how much or
how long you have smoked, when you quit smoking your risk of heart and
blood vessel disease gradually decreases.
Finnish researchers report that men who smoke not only die
younger but they have a poorer quality of life than those who never
smoked. "An especially large negative effect was seen for heavy smokers
[more than 20 cigarettes daily], who lost about 10 years of their life
expectancy, and those who survived experienced a significant decline in
their quality of life," said lead researcher Dr. Arto Y. Strandberg, from the
University of Helsinki. The report was published in the Oct. 13 issue of
the Archives of Internal Medicine. For the study, Strandberg's team
collected data on 1,658 men born between 1919 and 1934 and interviewed
in 1974. Over 26 years of follow-up, 372 men had died. Men who had
never smoked lived an average of 10 years longer than men who smoked
more than 20 cigarettes a day, the researchers found. Non-smokers also
scored better on quality-of-life measures, compared with smokers.
"Especially significant differences were seen in physical functioning,
general health, vitality and bodily pain," Strandberg said. "The impairment
of the physical functioning score of smokers was equal to a 10-year age
difference in the general population." Quality of life was worse even
among men who stopped smoking. "On the individual level, the bad news
is that while beneficial compared to continued smoking, cessation of
smoking after midlife could not fully recover the higher risk in mortality
and poorer health-related quality of life seen in smokers," Strandberg said.
Alcohol consuming
Each time someone has a drink, whether it is beer, wine, or liquor,
he or she is consuming alcohol. Alcohol is a drug that is absorbed into the
bloodstream from the stomach and small intestine. It is broken down by
the liver and then eliminated from the body. There are limits to how fast
the liver can break down alcohol and this process cannot be sped up. Until
the liver has time to break down all of the alcohol, the alcohol continues to
circulate in the bloodstream, affecting all of the body's organs, including
the brain. In general, the liver can break down the equivalent of about one
drink per hour and nothing can speed this up--including black coffee.

150
 As alcohol reaches the brain, the person begins to "feel" drunk. The
exact nature of this feeling can vary considerably from individual to
individual and even within the same individual from situation to situation.
What is common to all individuals and all situations is that alcohol
depresses the brain and slows down its ability to control the body and the
mind. This is one reason why alcohol is so dangerous. Alcohol acts like a
sedative and slows down muscle coordination, reflexes, movement, and
speech. If an individual drinks too much alcohol, his or her breathing or
heart rate can reach dangerously low levels or even stop.
Drugs abuse and addiction
People experiment with drugs for many different reasons. Many first
try drugs out of curiosity, to have a good time, because friends are doing
it, or in an effort to improve athletic performance or ease another problem,
such as stress, anxiety, or depression. Use doesn’t automatically lead to
abuse (addiction), and there is no specific level at which drug use moves
from casual to problematic. It varies by individual. But in many case if left
unchecked, the drug is going to win, becoming a disease. Drug abuse is a
disease of the brain, and the drugs change brain chemistry, which results in
a change in behavior. While each drug produces different physical effects,
all abused substances share one thing in common: repeated use can alter
the way the brain looks and functions.
1. Taking a recreational drug causes a surge in levels of dopamine
in brain, which trigger feelings of pleasure. Brain remembers these
feelings and wants them repeated.
2. If person becomes addicted, the substance takes on the same
significance as other survival behaviors, such as eating and drinking.
3. Changes in brain interfere with ability to think clearly, exercise
good judgment, control behavior, and feel normal without drugs.
4. Whether one is addicted to inhalants, heroin, Xanax, speed, or
Vicodin, the uncontrollable craving to use grows more important than
anything else, including family, friends, career, and even your own health
and happiness.
5. The urge to use is so strong that one mind finds many ways to
deny or rationalize the addiction. A person may drastically underestimate
the quantity of drugs taken, how much it impacts his life, and the level of
control he have over his drug use.
Aside from the obvious behavioral consequences of addiction, the
negative effects on a person’s health are potentially devastating. People

151
who use drugs experience a wide array of physical effects other than those
expected. The excitement of a cocaine effect, for instance, is followed by a
"crash": a period of anxiety, fatigue, depression, and an strong desire to
use more cocaine to alleviate the feelings of the crash.
Marijuana and alcohol interfere with motor control and are factors
in many automobile accidents. Users of marijuana and hallucinogenic
drugs may experience flashbacks, unwanted recurrences of the drug's
effects weeks or months after use. Abrupt abstinence from certain drugs
result in withdrawal symptoms. For example, heroin withdrawal symptoms
cause vomiting, muscle cramps, convulsions, and delirium. With the
continued use of a physically addictive drug, tolerance develops; i.e.,
constantly increasing amounts of the drug are needed to duplicate the
initial effect. Sharing hypodermic needles used to inject some drugs
dramatically increases the risk of contracting AIDS and some types of
hepatitis. In addition, increased sexual activity among drug users, both in
prostitution and from the disinhibiting effect of some drugs, also puts them
at a higher risk of AIDS and other sexually transmitted diseases. Because
the purity and dosage of illegal drugs such as heroin are uncontrolled,
Drug Overdose is a constant risk. There are over 10,000 deaths directly
attributable to drug use in the United States every year. Many drug users
engage in criminal activity, such as burglary and prostitution, to raise the
money to buy drugs, and some drugs, especially alcohol, are associated
with violent behavior.

Sedentary lifestyle
A sedentary lifestyle is a mode of living in which a person, an adult
or child, does not engage in sufficient physical activity or exercise for
what is generally considered healthy living. The term is often used by
doctors or professionals within the medical community to describe a
lifestyle among many people in highly developed countries that does not
afford them opportunities for physical activity. This type of living has
been heavily influenced by the propagation of passive forms of
entertainment such as television, video games, and computer use. Along
with such inactive types of entertainment, shifting of large numbers of
adult workers from physical labor to office jobs has also increased the
tendency for many people, especially in technologically developed
nations, toward a sedentary lifestyle. Numerous studies conducted by
doctors and researchers have indicated a variety of negative impacts on a

152
person’s life due to living a sedentary lifestyle. Some of the negative
effects mentioned by researches are as follows:
 The major effect of a sedentary lifestyle is increased weight gain
and obesity. Ingesting a lot of calories and not really burning any of them,
body deposit them as excess fat. Obesity is a big problem of contemporary
society because it causes many difficult health problems such as heart
disease, diabetes, and increased chances of certain types of cancer.
 Lack of physical exercise increased risk of heart diseases. Heart
in order to keep functioning efficiently must get a proper supply of blood
from the blood vessels (coronary arteries). Leading a sedentary lifestyle
can slow the blood circulation and blood vessels can get stiff and blocked.
In serious cases, this can lead to arteriosclerosis and cardiac arrest.
According to a study, lack of physical activity in middle age can increase
risk of dying from heart disease by 52 percent in men and 28 percent in
women.
 Sedentary lifestyle increased risk of diabetes. According to study
conducted by researchers at Duke University Medical Center, regular
exercise helps in regulating the blood glucose levels. The lack of exercise
results in increased blood sugar levels putting excess stress on your
pancreas (which secretes the hormone Insulin), which increases chances of
diabetes.
 Decreased activity increases the risk of developing certain types
of cancers such as breast cancer, colon cancer, and other types of
malignant tumors. According to a study carried out by the University of
Hong Kong, physical inactivity can increase the risk of dying from cancer
by 45 percent in men and 28 percent in women.
 Increased risk of osteoporosis: The prolonged inactivity causes
your bones to lose their strength as they are no longer challenged to
support your body structure, which can result in Arthritis and
Osteoporosis.
 Sedentary lifestyle lead to muscles tone loose: The more
sedentary lifestyle one has the lesser muscles one is likely to posses. The
less muscles one possesses the lesser is one ability to carry out the day-to-
day tasks.
 Sleeping difficulties: A sedentary lifestyle doesn't put any
physical pressure on the body. Thus the body doesn't feel like taking a rest

153
often which leads to sleeping difficulties and in severe cases can also lead
to insomnia.
 Headaches: Researchers in Norway found that that people who
did not exercise were 14 percent more likely to develop non-migraine
headaches than those who did exercise.
 Faster aging process: Telomeres are repeat sequences of DNA
that sit on the ends of chromosomes, protecting them from damage. As we
get older, the telomeres get shorter, and their deterioration is associated
with the physical signs of middle and old age. A research study found that
in inactive people the telomeres shortened more quickly than in active
people. The faster is the rate of shortening, the faster is the ageing process.
The faster is ageing process, the higher is the mortality rate.
Unhealthy eating habits
Many genetic, environmental, behavioral and cultural factors can
affect a person's health. Understanding family history of disease or risk
factors, such as body weight and fat distribution, blood pressure and blood
cholesterol, can help people make more informed decisions about how to
improve health. Making good food choices is among the most pleasurable
and effective ways of improving health. People require energy and certain
essential nutrients. These nutrients are essential because the body cannot
make these nutrients on its own and must obtain them from food. Essential
nutrients include vitamins, minerals, certain amino acids and certain fatty
acids. Foods also contain fiber and other components that are important for
health. Each of these food components has a specific function in the body
and they are all required for overall health. For example, people need
calcium for strong bones, for example, but many other nutrients also take
part in building and maintaining bones. The carbohydrates, fats and
proteins in food supply energy, which is measured in calories.
Carbohydrates and proteins provide 4 calories per gram. Fat contributes
more than twice as much -- 9 calories per gram -- and foods that are high
in fat are also high in calories.
Healthy nutrition is a diet of balanced nutrients. Healthful nutrition
help children grow develop and perform well in school. A healthy diet
allows adults to work productively and feel their best. Good food choices
also can help to prevent chronic diseases, such as heart disease, certain
cancers, diabetes, stroke and osteoporosis, which are leading causes of
death and disability. A proper diet can also reduce major risk factors for
chronic diseases, such as obesity, high blood pressure and high blood

154
cholesterol. In opposition unhealthy nutrition can cause all mentioned
above health problems. Unhealthy nutrition is not only imbalanced
nutritionist diet but also unhealthy eating habits. Bad eating habits include:
skipping breakfast, eating before bed, excessive consuming of fast food,
starvation, eating while doing something, eating too fast, lake of water.
 Healthy breakfast is very important because give boost of energy
and help clear the fog out of brain.
 Eating before bed could result in bad sleep and exacerbating
indigestion.
 Fatty snack foods like chips, pizza or cookies can lead to weight
gain and dissatisfaction..
 Contrary to what many may think, the body’s first reaction to
starvation is weight gain via the storage of fat. Well, when one doesn’t eat
for long periods of time, one’s body thinks it needs to store calories as fat
because it doesn’t know when the chance to eat will come again. And then,
the fat remains with person.
 Eating while doing something lead to overeating, and
subsequently, weight gain. Plus, once begin eating while doing something
else, one often can’t stop it and becomes a mechanical act.
 Eating too quickly also encourages weight gain and indigestion as
well.
 Water is necessary for the optimal functioning of all life forms,
humans included. What’s surprising is that not drinking adequate amounts
of water throughout the day can actually slow down metabolism, making
weight gain a likely possibility, since water is necessary for all metabolic
functions, including calorie burning.
Concluding it is possible to say that bad food habit is a serious cause
of obesity and all associated health problems.
Stress
Stress, as defined by Dr. Hans Selye, is "the nonspecific response of
the body to any demand made upon it." More specifically, stress is defined
by perception. If a person finds a job situation, or another personality
particularly stressful, the feeling often will trigger a physiological
response. On the other hand, studies have shown that when a job situation
or another personality stimulate feelings of challenge or a positive
reaction, these same physiological reactions do not occur. Therefore, when
we talk about stress in relation to disease, we are looking at the more

155
negative stress. Physiological responses to stress include an increase in
heart rate, an increase in blood pressure, and an increased rate of
breathing. These symptoms are caused by the release of adrenaline, which
also narrows your arteries, and results in a greater workload on the heart.
If you are unable to control your stress, you may be at risk for high blood
pressure and possibly injury to your artery walls which sets the stage for
plaque deposits. Negative stress is a risk factor for the development of
coronary artery disease.
Stress management is a learning process. First, you need to identify
the particular cause of your stress. Second, you need to take steps to
change those circumstances that are stressful whenever possible. Third,
you need to relearn ways to cope with stress in your everyday life. The
following are a few suggestions for coping with stress:
- Do not waste energy being upset over little things. Remember that
stress is our reaction to situations, not the situation itself. Often it helps to
talk it out and get a different perspective of the situation while at the same
time venting your concerns.
- Escape from the stress for a period of time. Exercise, taking a walk
before lunch to get rid of the morning's frustrations or taking a walk after
work to help unwind, can be very helpful to reduce your stress.
- Beware of the super-person urges. Set priorities, establish realistic
goals and stop trying to do too much.
- Take time to relax daily whether you learn relaxation techniques
or just take time out for a favorite hobby.
- Take it easy with criticism or arguments. Stand your ground on
what you believe is right, but make allowances for the other party. Search
for the "positives" of an argument, of a critical person, as well as your own
positive qualities.
- Finally, if stress seems out of control, discuss it further with your
doctor or health care professional. They may be able to direct you to other
sources for help such as support groups or professionals trained in stress
management.
8.3. Behavior Change Communication
Lifestyles are directly related to the health state. More over studies
say that behavioral factors play a role in each of the twelve leading causes
of death, including chronic diseases such as heart disease, cancer, and
stroke. In United States and other developed countries the most common

156
behavioral contributors to mortality, or death, in 1990 included the use of
alcohol, tobacco, firearms, and motor vehicles; diet and activity patterns;
sexual behavior; and illicit use of drugs. Behaviors such as these are
thought to contribute to almost half of the deaths in the United States, and,
according to J. McGinnis and W. Foege (1993), they were responsible for
nearly 1 million deaths in the United States in the year of 1992 alone.
The last two decades of the twentieth century saw a rising interest in
preventing disability and death through changes in health-related
behaviors. Behavior change is not understood as an even but a complex
process that occurs in stages. It is not a question of someone deciding one
day to stop smoking and the next day becoming a nonsmoker for life.
Likewise, most people won't be able to dramatically change their eating
patterns all at once. Even where there is good initial compliance to a
health-related behavior change, a relapse to previous behavior patterns is
very common.
Positive health-related changes come about when people learn about
risks and ways of enhancing health, and when they develop positive
attitudes, social support, self-efficacy, and behavioral skills. The main tool
for acquiring this objective is communication.
Communication has long been an important tool in health
promotion. Although its roots date back hundreds of years (to Cotton
Mather's smallpox vaccination campaign during Colonial American
times), if not thousands of years (to Aristotle's theories of persuasion), the
field of public health communication is very much an outgrowth of
contemporary social conditions. Demographic, social, and technological
trends that developed over the second half of the twentieth century
fostered conditions in which the value of good health information, and
thus the value of effective health communication, became increasingly
clear. Public health communication includes a continuum of activities that
span from research to interventions. Communication interventions are
effectively used in order to change risky behavior and to improve health
outcomes. For example, the National Institutes of Health of USA recently
(in partnership with health professional associations, voluntary health
agencies, and pharmaceutical companies) has conducted a communication
campaign that has contributed to more than a 60 percent reduction in the
death rate from stroke. Sudden infant death syndrome (SIDS) campaigns
conducted around the globe during the 1990s led to rapid and dramatic
(50–80%) reductions in death rates from SIDS.

157
 More over communication for behavior change is also economically
efficient. Treatment of behavior-related diseases like cancer is expensive,
while the cost of behavior change interventions is low. For example each
Quality Adjusted Life Year (QALY), say one England journal, gained via
a brief smoking cessation intervention costs £500 compared with £30,000-
£40,000 per QALY for treating patients with advanced cancer.
Many distinctions can be made between the various types of health
communication activities. The most important of them are the activities
that seek to influence the actions of individuals and small groups or the
actions of larger groups such as workplaces, communities, states, or
nations. The objectives of communication interventions at the larger levels
are focused on bringing about changes in policies. Example includes
improved safety a policy is the law prohibiting the driving under the
influence of alcohol. At the individual (or small group) level there are two
forms of activities. The first one is informed decision-making
interventions that seek to inform people for the purpose of enabling them
to make better health decisions. The second is persuasion-oriented
interventions seek to persuade people to change their behaviors or beliefs.
Situational factors determine which of these two approaches is most
appropriate.
Persuasion-oriented interventions are appropriate when there is clear
evidence that the behavior change is likely to benefit the individual, and
when society is able to reach consensus about the worthiness of the
behavior as a societal goal. Examples include promotion of teen
substance-abuse prevention. Informed decision-making interventions are
indicated in situations when persuasion would be inappropriate, when an
individual's values must be taken into consideration to determine the
optimal behavior (e.g., prevention of sexual assault), and when society has
been unable to reach consensus about the optimal recommended behavior
(e.g., prevention of teen pregnancy).
But indifferently of forms of communication interventions, they do
share some underlying principles of effectiveness:
 The first and most important step in communication planning is to
gain as much insight as possible into the target audience. This is done
primarily by conducting original audience research (e.g., focus groups,
surveys), assessing the results of previous communication efforts, and
drawing from theories of communication and behavior change.

158
  The strategies and tactics of a communication intervention will
differ depending on the stated objective (e.g., informed decision-making,
persuasion, policy change). A clear statement of objectives focuses and
enhances all other elements of the communication planning process.
 A critical step in communication planning is to determine what
information has the greatest value in helping to achieve the stated
objective of the campaign. The ideal (albeit rare) scenario is when a single
powerful idea is sufficient to motivate and enable members of the target
audience to embrace the campaign's objective.
 After the information with the greatest value has been identified,
communication planners must determine how to convey that information
simply and clearly, often, and by many trusted sources. Message repetition
is an important element of program success. Audiences tend to process
information incrementally over time. When the message is stated simply
and clearly, when it is repeated often enough, and when it is stated by
many trusted sources, audience members are more likely to learn and
embrace the message.
► Exercises and Discussions:
1. What is health and illness?
2. What are the factors which determine appearance of illness? Share
your oven experience.
3. What is lifestyle? Describe the elements of unhealthy life style.
4. What are the effects of alcohol consuming, of the drug abuse,
smoking, sedentary life, unhealthy nutrition? Analyze each of
them.
5. Sketch a list of healthy lifestyle rules.
6. How do you think what are the effects of unhealthy lifestyle on
family and society?
7. How can be communication used to change the health related
behavior? Give exemples.
► Recommended Essays
1. Distress as a factor influencing appearance of illness.
2. Environmental illnesses
3. Occupation and illness.
4. Grieving and depression
► Literature:
1. Blaxter Mildred. Health and lifestyles. Routledge, 1990 .

159
2. Communication for health http://www.answers.com/topic/health-
promotion
3. Bury Michael. Health and illness. Polity, 2005.
4. Bury Michael. Health and illness in a changing society. Routledge,
1997.
5. Nettleton Sarah. The sociology of health and illness. Polity, 2006.
6. Kafle KK et al. Training intervention to improve the use of
medicines in the communitz through school teachers and women]s
groups. Pharmaceutical Horiyon of Nepal. INRUD Newa, 2001,
Oct; 11 (1):5
http://www.inrud.org/news_pdf/vol11no1_nopics.pdf
7. Sally A. Shumaker, Ockene Judith K., Riekert Kristin A.. The
handbook of health behavior change. Springer Publishing
Company, 2009.
8. Selection and rational use of medicine. World Health
Organization, Geneva, 2006,
http//www.who.int/medicines/areas/rational_use/en/index.html
9. The Role of Education in the Rational Use of Medicine. World
Health Organization, Regional Office for South-East Asia,
Technical Publication Series no.45, April, 2007.

160