As I analyse the way doctors and patients communicate, I tend to focus on the linguistic form, sometimes on the content. That’s discourse analysis. But today I want to leave all these things. And I want to write about silence.One of the interviews I sat on, when I was an intern, was with a patient who had been admitted to the ward in a crisis, close to a breaking point. She was convinced she was possessed by a spirit. The interview happened as she was coming out of another crisis. She knew who I was and she agreed to my presence at the interview.
The interview was conducted by an experienced psychiatrist. At the moment I cannot remember the exact details of the conversation, but it went something like this. The psychiatrist asked the patient how she was, but she responded with monosyllables. And then came the crucial moment. The doctor asked her about the crisis and silence fell. First seconds, then a minute, then another, then another. I was thinking it was uncomfortable.
I remember thinking that it was getting heavier and heavier. I also remember the calm of the shrink. She was just vaguely smiling. There was no pressure, just silence. And at some point the patient simply started talking. It didn’t feel forced, it felt like she decided it was worth her while and she knew what to say. I was so impressed. Basically, the interview, well, its beginning, consisted of NOT speaking. The success was in the doctor’s waiting. It was probably the best psychiatric interview I have ever heard.
This was the first time I thought about silence in clinical communication. Not only ‘opening the space’, but silence, intentionally used. About using silence in communicating with a patient. After all, silence has so many meanings (as Adam Jaworski in his by now classic “Power of silence” told us). It can mean, for example, that the communication channel is open but, at the same time, it can mean lack of communication. That’s why it can be uncomfortable.
Whenever I talk to clinicians, they seem to be afraid of silence. They see it as meaning they have no idea what to say and so undermining their professionalism, competence. They never see it as giving the patient the time to consider what to say, or even whether to say anything. Rather silence must be filled, as the patient needs a ‘helping hand’ in getting them to talk. It’s, again, this assumption that a clinician’s question is simply a trigger for a response. The patient is to react. Now, now, now.
As I was writing this piece, I did a quick search for studies of silence in clinical communication. I have not found much, mostly on psychotherapy. I’m surprised and I hope it was the fact that the search was rather cursory. For the more I think about silence, the more important it seems to me. As I go into a doctor’s surgery, I always think I need to have the ready-made fully-formed spiel I will recite to the doctor, as they look at me with expectation. Hey, presto, hit me, so I can sort it out for you (and call the next patient). Yes, yes, I understand – you really do have little time for me.
But then silence can accomplish so much. It shows you listen, it shows you wait for me. It also shows you have time for me, as I consider what to say. Because sometimes I don’t know. So, can we sometimes sit in silence, please?