This post is inspired by Helen Sparkles’ comment under an earlier post. It raises an issue which, to be honest, I have not given much thought and I was quite struck by the challenge it offered. The comment can be read in a fuller account in a blog post (you can also find the author’s details there). For me the comment raises quite a fundamental issue about clinical communication, one which, I think, is rarely pondered outside, say, psychotherapy. Should we communicate at all?
Whenever you read about communication in clinical settings, you will read about ways in which to improve it. I see it in two ways. One, which I find unhelpful, focuses on the too simple solutions of asking a particular kind of question which is seen as a trigger for my, the patient’s, narrative. The other, which I advocate, focuses on a more contextual ‘opening of the space’ for communication, which can be done by all sorts of means. Both approaches share the same fundamental assumptions. Communication is desirable, it should happen, we should find ways in which to expedite it, make it easier, more comfortable etc. Who wouldn’t agree with that? Indeed, accounts of the ‘wonder-questions’ suggest that patients invariably are liberated by them, finally being able to talk, talk and then talk some more.
And here comes Helen Sparkles’ bombshell – why do you assume that? Why do you assume communication must happen, should happen? Or as she puts it: “I would most like to be asked is would I like to talk”. And, as I said, I didn’t expect that! Surely, talking is good, as 20 years ago we were reminded by Bob Hoskins in a BT advert. It’s good to talk! Or is it? Indeed, even when I wrote about sitting in silence, I didn’t question the basic assumption that talking must happen (still, I am pleased to find post).
I think the assumption comes from the basics of a clinical encounter. Of course, communication must happen. After all, clinicians cannot see into us and we must tell them what we see them about. But after that things get complicated. Do I have to have to share with you what I think, what I experience, my pain, my suffering (I am not even talking about ICEing me)? Could I actually just tell you ‘my symptoms’ and be done with it?
And here comes something that I am almost scared to say. Can the ‘medical model’ be protective of me and save me from needing to tell you a story? Sometimes, I don’t want to navigate through the narrative, so that I will avoid the sharing and the (virtual) hand-holding. I really don’t feel like getting another ‘empathetic look’, I am tired of them. In fact, some time ago I wrote about being ill. I saw a number of doctors (in two countries), not only did they have no clue as to what was wrong with me, but they also disagreed what it might be. To be honest, when I was going to another medical appointment, I mostly dreaded the need to ‘tell the story’ again. To say, yet another time, that I felt anxious, scared, that it was having a significant impact on my life. Basically, if you can’t tell me what is wrong with me, let’s not go through the ‘communication bit’, because the only thing I want to say cannot be said, lest I end up in the zero-tolerance unit.
There is another aspect to the need to communicate. It’s the empathy thing. But before I offer a comment, I’ll tell a story. A couple of years ago I took part in a conference on community psychiatry in Poland. It was the usual stuff, with most doctors feeling good about themselves. So as I was regretting the decision to come along, after one of the papers a patient got up, probably also bored with another load of obviousness.
She spoke about her long-term psychotherapy which came to an end. It had been going nowhere and her therapist (and also a psychiatrist) decided it would be unethical for them to continue, he was unable to help and he should not be paid for it. As she was sinking into the sofa, the therapist got up, sat next to her and said: ‘I am so very very sorry’ and they just sat there for some time. The woman ended saying that these few minutes of silence, when she felt his empathy, his sorrow made all the difference. That actually started recovery (whatever recovery meant). The silence, the presence, not the talking.
Empathy might mean only that you are available to talk. The channel of communication is at the ready and I can, but I don’t have to talk you. Or let me put it in linguistic terms: give me the right to initiate communication. As you ask me questions, speak to me whether I like it or not, expect me to say things, you assume the most important communicative right – right to start (and also probably end) communication. This, in fact, tells me a lot about your power, but I don’t really want to write about power. Still, I suggest that you should share some of this power with me. It’s much more difficult than you might think actually.
I guess, I should now say that communication in a clinical setting doesn’t consist of talking, there are all sorts of other channels of communication and, depending on your theoretical point of view, you might not be able not to communicate. But the point I would like to make is that ‘giving me space’ might not work. Perhaps it’s also worth being mindful of my right to tell you: I don’t want your space. And so, to paraphrase the slogan I quite dislike: It’s OK not to talk!