Silence and being silenced

Mellor and Webster offer a useful typology of silences (see table 1). They base this on whether someone’s locus of control is internal (choosing to be silent) or external (being silenced), and if the silence helps communication or hinders it. Some of their examples are taken from communal contexts, like the silences required in libraries or imposed by censorship, but the categories also apply to one-to-one encounters. They can help us to identify how we each employ silence to evoke closeness or protect ourselves from it, and to obstruct or ease others in their self-expression.

Drawing on ideas from the book, I suggest there are three key aspects of silence that clinicians and medical educators need be aware of (see box 1). First, it is possible that some assertive forms of communication used nowadays may have the opposite effects to the ones intended – and effectively silence patients. Conversations that are ostensibly aimed at gathering information or exploring views may be so rapid and forceful that they negate both. This risk may be compounded by the wider context, including the lack of privacy, and continual interruptions by third parties. Restoring more silence to medical conversations, both in our speech and in the environment, might allow patients to think at their own natural pace, with potential benefits like being able to give fuller histories or to manage their own conditions better.

Next, silence and exchanging information need to complement each other, especially when serious illness is present. Much of the literature on cancer treatment and breaking bad news, for example, suggests that clinicians are often not very good either at imparting complex and distressing facts, or at creating the right conditions for patients to absorb these4–6 Doing both competently means knowing how to balance speech and silence, so that patients can take in distressing information properly and respond in their own time. Clinicians also need to learn how to calibrate their conversations in response to the cognitive and emotional requirements of each situation, and to the individual patient.

Compassionate silence

We also need to ask the question: what is silence meant to express? In a paper in the Journal of Palliative Medicine, Anthony Back and his colleagues identify three different kinds of silence in clinical consultations. They call these ‘awkward’, ‘invitational’ and ‘compassionate’ silences.7 Well-meaning physicians, they point out, may sometimes think they are using silence as an effective behavioural technique, while the patient only feels a sense of awkwardness, and interprets the silence as judgement, ambivalence, disapproval or withholding. Invitational silence, by contrast, conveys more empathy. It allows both patient and doctor to digest everything that has been discussed so far and decide where to take the conversation next. Back et al relate this kind of silence to mindfulness practice, where practitioners consciously foster their capacity for attention, curiosity and presence in the moment.8

Beyond this, the authors of the paper invite doctors to regard silence as simply one expression of a compassionate state of mind. Referring to Eastern contemplative traditions, they explain how silence is inseparable from awareness of breath and body, careful speech, and an attitude of respect, and stillness. ‘The ability to actualize mindful, compassionate silence’ they write “can enable a clinician to shift from using silence, to making space for silence to emerge as a way to affirm mutual respect and understanding.’ According to this view, silence is not merely something we should learn to apply in order to attain particular objectives. It is a spontaneous expression of ‘being with’ other people, in every sense.