Williams et al and through actions and gestures of positive nonverbal feedback. The idea of empathy in medicine is based largely on the biopsychosocial model of integrative care, which states that medicine should be approached from a biological, psychological, and social perspective, and involves cognitive, behavioral and emotional components, all of which are centered on the patient (Brody 1999). Empathy can increase feelings of relatedness, reduce patients’ experience of alienation from others, and can be expressed through both verbal and nonverbal channels (Sleath et al 2000). Verbal expressions of empathy may involve words of supportiveness, expressions of understanding, or invitations to the patient to tell his or her story of the experience of illness or pain. Nonverbal expressions of empathy may involve eye contact during discussion of difﬁcult topics, leaning toward the patient, or having a closer interactional distance than in more formal interaction (Hall et al 1995). Tone-of-voice can express affective feelings and empathy. In research, the content-ﬁltering of speech allows empathy in voice tone to be evaluated without its semantic content. Results suggest that empathic voice tone is associated with better outcomes including fewer malpractice claims (Ambady et al 2002) and more successful referral of alcoholic patients for further treatment (Milmoe et al 1967). Recognition that there is also affective or socio- emotional meaning in task- oriented behaviors, such as information exchange, is critical. A physician can provide much information to a patient and do so through voice tone, body posture, and facial expressions reﬂecting empathy (Roter and Hall 1989). There are documented disparities in the empathic care of patients. Fewer empathic responses tend to be offered to patients who are of minority ethnicity status and who are not proficient in English than to those who are or majority and language-proﬁcient (Ferguson and Candib 2002). Empathy requires openness to cultural differences, including understanding folk beliefs, the role played by the patient’s family in his or her life, listening with attentiveness (including when a patient has an interpreter), and exploring how patients use alternative medical treatments or home remedies (Mull 1993). A systematic review has found that patients of lower socioeconomic status received less empathic comments from their physicians than did those of higher income (Willems et al 2005a). These researchers also found that patients’ own communication styles inﬂuenced the communication directed toward them. Speciﬁcally, lower income patients asked fewer questions and appeared to prefer less decision-making power than did higher income patients. Their physicians reciprocated with a less participatory style 458 and fewer attempts to involve patients in the process of care (Willems et al 2005a). The value of therapeutic relationships to patient health The physician-patient relationship can have an important, and sometimes lasting, effect on patients’ treatment regimen adherence and ultimately on their health outcomes (Stewart 1984, 1995). When patients face barriers to their adherence such as economic challenges, lack of insurance, and logistical problems (eg, limited mobility and transportation), the therapeutic relationship can serve as a guide or additional source of support for patients (Greene et al 1996). Such patient challenges may seem to be tangential to the treatment experience; however, without practical and emotional support, patient nonadherence may severely limit the process of treatment and affect health outcomes (DiMatteo 2004a). The therapeutic relationship is essential for the physician to understand the patient’s unique situational challenges and subsequently to offer solutions. Adherence challenges are likely to occur in the manage- ment of chronic illness; their resolution is strongly dependent upon communication process. Nonadherence in asthma, for example, can result when patients are uncomfortable describing their struggles with treatment, when they feel constrained in talking about their medication side effects, and when they have difﬁculty expressing their personal experience of the severe periods of their illness (Apter et al 1998). Dealing with nonadherence among hypertensive patients requires a number of communication strategies in which physicians must assess how patients understand their illness, determine their knowledge and beliefs about the medication and regimen, and explore how their practical, emotional, and ﬁnancial concerns might affect their adherence (Betancourt et al 1999). Empathic therapeutic communication can help to reduce the economic costs of health care. Greater levels of patient-centered communication, for example, are associated with lower diagnostic testing costs and with more efﬁcient and effective medical visits (Epstein et al 2005). Developing a therapeutic relationship can be difﬁcult in the face of social barriers and impediments, however. American women of minority ethnic backgrounds for whom English is a second language, for example, receive fewer screening tests, such as breast and cervical cancer screening (Jacobs et al 2005). Similar disparities have also been found with French-speaking women in Canada (Woloshin et al Clinical Interventions in Aging 2007:2(3)