A pause is just as much an essential
component of a discussion as is speech. Luban-Plozza described pauses in
discussion as "affective node points". The pause is a particular
sort of silence. It can be desired and intended or it can appear without
Depending on the reasons
for it, a break in conversation can serve as a constructive element
in guiding the interview or be a sign of difficulties in the course
of the dialogue. Since the pause has this ambivalent character, it
is important to immediately analyze the likely reasons and to learn how
to use it effectively. The productive and perhaps even creative function
of the pause is balanced by its function as a signal of difficulties in
a discussion. In general, a pause can be less of a problem if the reason
for it is recognized by the discussion partners. For example, when the
doctor finds that he is suddenly unsure of the way to proceed with the
conversation, he can tell the patient that he would like to "think for
a moment", and then leave a short pause for reflection. This is better
than sitting dumbly in front of his discussion partner for no apparent
The reasons for pauses
in discussion can be as follows:
Pauses for decision
They allow the patient to think
about what has just been said, to work through it, or to think how he would
like to proceed with the discussion. Not only the person leading the discussion
is allowed to introduce pauses for the constructive course of discussion.
Pauses are not time wasters, but rather save time, as they serve
to build up the structure of the discussion.
Pauses in discussion are
also necessary for the brief consideration of messages. This avoids pressurizing
or overwhelming the patient. It is a mistake to immediately start discussing
therapeutic measures if the patient has only just been informed of a serious
diagnosis. Closing or changing the subject can also be made
clear by the use of a pause.
It is usually body language
that makes the reason for the pause clear. Pauses which serve for taking
stock or reflection are usually preceded by breaking eye-contact. If the
pause serves to conclude a subject, the patient usually starts redirecting
his gaze just before the pause resuming it immediately afterwards. The
gaze is usually indirect while thinking about the way the conversation
has developed, but direct and thereby questioning if he is expecting a
reaction (Dahmer and Dahmer).
The pause as a means
The pause which is introduced
by the partner whose turn it would be to speak, can be an obvious means
of contact. Active listening can be further expressed by the pause,
as a particular sort of decision not to speak. In other words, the pause
can be introduced consciously, as if to express: "I have understood
what you have said" or "I agree with you".
or understanding are accompanied by non-verbal expressions such
as nodding or smiling.
If these non-verbal confirmations
are missing, misunderstanding cannot be excluded, as the conversation partner
quickly becomes uncertain, or gets the feeling that he has not communicated
with his discussion partner. It can be very useful to interject a purely
vocal brief agreement such as "ummm" during the pause, as this shows active
understanding and attention, even though not necessarily agreement. Although
these reactions appear simple, they can be very useful to let a discussion
partner know that there is still real interest during an appropriate pause,
and this motivates him to carry on speaking and go deeper into the subject.
Pauses due to blocking
Looked at closely, these are
not natural breaks in speech, but rather undesired interruptions.
They usually arise from emotional causes and can therefore be very
disturbing, and in turn release emotional reactions. There are a whole
series of reasons for speech blocks:
Inhibition can arise
either because the subject under discussion is very stressful, or because
the patient finds it difficult to express himself, perhaps because as yet
no dependable basis for trust has been developed during conversation. Observing
body-language can be useful for recognizing and decoding inhibition.
A situation can arise where
there is refusal (resistance). The patient is not willing to
talk, either because he would prefer not to talk about the topic that
has been raised, or because he is rejecting the doctor as a discussion
partner. There is not much use in trying to continue the conversation if
there are clear signs of refusal. It is much more advisable to address
the reason for the break in conversation (metacommunication), and to attach
an offer of a further discussion later. For example: "I have the impression
that you are not yet ready to talk about this. I suggest that we talk about
it again, at a time which is best for you".
The pause in conversation
can also be based in the fact that the discussion has reached the point
at which a conflict situation has been revealed. This also applies
to situations in which a discussion has attained its so-called critical
point. In order to avoid an emotional escalation or outburst, the pause
in conversation should be used for stabilization. Here the pause is signaling
the "calm before the storm". In such cases, only the speech appears
calm while the body-language very clearly forewarns the approaching "explosion".
This is a typical example of inconsistent (incongruous) verbal and non-verbal
Finally the doctor himself
can produce pauses in speech, when the patient does not understand him
or, better said, the doctor has expected too much of him. Incomprehension
can be at the purely factual level, but also at the emotional level. Even
expectation can affect the cognitive functions as well as the emotional
ability to cope.
The pauses due to emotion
causing blocks often lead to breaking off of eye-contact as well
as turning away of the face. Turning away is usually a sign of rejection,
inhibition or conflict, while inability to cope and incomprehension are
more often associated with visual expressions requesting help.
There are a number of conversation
technique options which can be used to resolve these types of blocks
(see table page 98 ).
Pauses due to hindrances
These can have a multitude of
causes. Difficulties in remembering or with though processing
are a frequent cause of breaking the flow of conversation, especially in
old people. Body language suggests the internal unrest and tension.
Particularly unwelcome interruptions
result from purely unfavourable external circumstances, such as
external noise, telephones ringing and interruptions by other people. As
individuals have different levels at which they are disturbed, it
can be that a disturbance is more obvious to one conversation partner than
the other. It is usually the person with a particularly urgent request
who is disturbed less by these external factors than the person who is
trying to listen actively.
For example, during the ward
round, patients may be unaware of the radio which continues to play, whereas
the doctor clearly feels disturbed.
In conversation with sick
people, there are of course pauses which are due to tiredness, exhaustion
or pain, which have to be respected.
The saying: "A conversation
lives from its pauses" (Weisbach) is just as true as the statement: "Pauses
can kill conversation". The significance of a pause depends upon
the reason for it.
The advantages of
the pause in conversation which is consciously introduced lies in:
to consider, reflect and work on the material
|Calming the flood
intensity and quantity of the messages
|Signaling a change
or end of the subject
composure of emotions
|Lowering of the
level of aggression
Disadvantages of pauses
or interruptions are:
in the thread of discussion
(misinterpretation as disinterest, lack of approachability, superiority,
keeping one's distance)
|Feelings of frustration
(conversation partner feels he has been abandoned or neglected)
(especially where the pauses are long, and the conversation partner is
unsure of reasons for pauses)
|Anxiety if the
reason for the pause remains unclear.
The response to the
pause in conversation is of great importance for the continuation of the
discussion. It is most important to differentiate whether this is a natural
break (decisive pause, communicative pause) or if it is due to blocking
or an undesired interruption.
Observing the non-verbal
messages of the conversation partner makes it easier to differentiate
between natural pauses and blocks in discussion. The conversation really
does "live from" natural pauses in speech, whereas blocks and interruptions
can have an agonizing effect, signaled by body-language, on one conversation
partner. The successful resolution of blocks and interruptions in speech
can result in an exceptional relief and freedom for the conversation partner.
For this reason, "holes" in the discussion do not have to be filled. In
fact, a very small amount of practice sharpens the ability to recognize
the advantages of pauses and to consciously introduce them as part of dialogue
technique. Ignoring them, continuing to talk or repeating oneself are usually
of little use in starting the conversation again or in keeping it up.
The pauses in speech require
an appropriate reaction:
of the cause
|Ability to accept
|To offer help
|Respect for the
need for pauses
The ability to introduce
pauses at the correct point in time is bound up with the ability to listen
The correct technique
R. Lay recommends that the correct
pause technique can be trained initially when: "You first speak, if
the other has been quiet for at least 3 seconds". (This should not be practiced
on patients). Lay explains that it is easier to practices tolerating a
pause of at least 3 seconds when one knows how long 3 seconds is. Many
experiments have shown that pauses of 1.8 to 2.2 seconds are hardly tolerable
emotionally (even by the person who was just speaking) so that the partner
(who is under pressure to speak) ends the pause prematurely.
Exercises like these soon
reveal just how often we are likely to interrupt our conversation partner
and how infrequently we introduce necessary breaks in conversation. Interruption,
or not allowing the other to talk as much as he would like, is the antithesis
of conscious introduction of pauses in discussion. The one who speaks most
(the "continual talker") is most likely to provoke an interruption. However
interrupting is usually not worthwhile, as it is only by allowing
the other to speak as much as he requires that it is possible to find out
his real requirements.
Introducing pauses is strongly
recommended at times when the conversation partner is "overcome by
emotions". The technique is also appropriate when conflicts arising from
the conversation are gradually leading to "emotional escalation" in the
conversation partner. The level of aggression can be markedly lowered by
allowing him to carry on speaking and allowing pauses.
which promote discussion
which inhibit discussion
|Overcome by emotions
|Unable to cope
The most effective pause-length
has to be judged intuitively, as too long a pause can be equally frustrating
as a short one, leading to misunderstandings and anxiety, both of which
can in turn encourage aggression.
Help for breaks in
Pauses or interruptions which
have a distressing emotional effect, which are excessively inhibitory or
threaten to completely end any discussion, can be overcome by various offers
of help from the person leading the conversation.
The conversation partner
should never be given the impression that the pause which he has introduced
is in any way disturbing to the other, or his blocks will be even more
accentuated. Therefore the doctor must show the patient that he
the pause, that it does not worry him, and that he is still prepared to
continue the conversation. He can encourage the patient to carry on whilst
he does this, for example, with:
"Consider it for a bit."
"You have plenty of time
to think about it."
"It doesn't matter if you
want to collect your thoughts."
"Of course we can talk about
it again, when you have thought about it more."
This last sentence not only
gives the patient the opportunity to reflect, but also the stimulus to
continue the conversation. This can also be expressed as:
"Should we talk about this
"You can talk about it,
if you think that this is important".
If we are not clear what
it is that has led the conversation partner to break off, we can offer
him, by repeating, to pick up the former subject again.
"You were just now talking
about the problems you are having with your son."
"You had just told me that
you were concerned about a feeling of coldness in your leg. What are you
particularly concerned about?"
If it appears from what has
been already said and from the non-verbal messages that the patient is
a bridge can be constructed so that dialogue can be recommenced.
"I can see that it is all
getting you down, understandably. Tell me what you see as the greatest
"The more that you can tell
me about the difficulties you are having, the easier it will be to help
solve these problems".
One can seek to remove blocks
by addressing them directly, in the sense of metacommunication.
This frees the other from the pressure of the undesired pause, and gives
him the opportunity to continue the conversation without losing face.
to offer during pauses due to blocking
it obvious that pausing is acceptable
the pause is an opportunity for decision
|Recall the subject
of the conversation by repetition
where there are signs of helplessness
of blocks (metacommunication)
|Offer to postpone
discussion in threatening breaks in conversation
"It is difficult for you
to talk about it."
"Is it taking effort to
discuss this point?"
"I can well understand that
you are unwilling to carry on."
The patient who is about
to cry or is overcome by emotions is almost always blocked and unable to
continue to talk. In these cases, words must be chosen very carefully not
to tip the situation emotionally or to accentuate it. Injunctions such
as: "Do cry if you want to", or observations such as: "You are still greatly
affected by your husband's death" will certainly lead to an increase in
emotional pressure and to tears.
This means that when the
is about to cease, it has to be ascertained from the climate of the
discussion whether or not a pause or a delay in the discussion should be
"Perhaps you need a little
time to calm down; we can carry on talking afterwards".
"Perhaps it would help if
we had a short break, and tried to talk about it a bit later on".
If it is obvious that the
patient is not in a position to carry on, it is the doctor who should
suggest that the discussion is put off, in order that the patient is not
stressed even more. It is best if the offer is made quite openly:
"I have the impression that
it would be better that we talk about this subject at your next visit."
"We shouldn't talk about
this any more today, but we can talk about it calmly when we see each other
again next week."
This subject must of course
be approached at the next visit.
Natural pauses in conversation
are unavoidable. They serve to allow working out of messages received
during the course of the conversation, they encourage the flow of conversation,
modulate disturbing emotional factors, and are a non-verbal complement
of the conversation. The dialogue "lives from its pauses", as they determine
the natural character of its dynamics. It is certainly untrue that "nothing
happens" during a pause; in fact, on the contrary, in certain situations,
the pauses in conversation can be more effective and more expressive than
the words which have been spoken.
Not saying anything with speech
or: "The Art of Communicative
Silence can be golden and full
of meaning but words can be empty of content. Put another way, often less
is said with words than by silence. This loquacity is widely used in daily
life. These are the techniques:
"One can almost take it
to mean that..."
"Probably one should get
more involved there..."
"more or less,... approximately..."
"Overall, however, these
tablets are good."
|Use of the conditional
"It might be conceivable
"I really can not see
why this is such a problem for you."
horse in discussion i. e. pseudo-information, which actually contains
a cry for help, self-revelation or attack.
All of these perfidious forms
of speech are widely used communication techniques, but should be taboo
for the doctor's way of speaking. All show the following characteristics:
statements are avoided
|Speech is used
(or misused) to cover the true content of the information
|Shying away from
personal identification with the statement, leading to evasion into "generally
This speech bristles with
terms such as "to a certain extent", "so to say", "actually", "perhaps",
"probably" etc. The perfidious nature of these techniques of language lies
in the fact that they make it possible for the person leading the discussion
to remain unchallenged, as the course of the discussion is superficially
smooth and tidy. The truth is that the dialogue never moves forward. This
uncommitment is one of the major hindrances to communication.
Commonly used "hindrances
Use of the impersonal
Impersonal expressions are
the preferred speech technique of those who appear to deprecate themselves.
Everyday speech if full of examples: "One should think carefully what one
gets for one's money." (instead of "I suggest that you should think about
what you do with your money"), "One can't have everything" (instead of
"You are asking too much, in my opinion".).
These expressions using "one
should", "one must", "one could" are half-hearted appeals. Their power
of conviction is correspondingly low, as the person giving the advice chooses
to use the camouflage of the "one.." expression in order not to expose
"It" sentences also afford
a method of self-protection: they make a truly personal meaning anonymous,
and attempt to give it a general character:
"It is clear that the present
government is incompetent."
"It is to be expected that
this play will hardly survive from a literary point of view."
The "it" technique is also
used to criticize without expressing a personal point of view:
"It is stiff-necked, never
to change an opinion" (instead of "I think you are being stiff-necked").
"It" expressions are also
used when the person who is speaking is contradicting another's (spouse,
parent, society) opinion, meaning or judgement, without actually identifying
himself with his statement. These are often opinions which are "spoon-fed"
rather than "digested". The patient is usually not affected by these terms
if the doctor uses them, not only because they appear to be generalizations,
but also because they have an uncommitted impersonal character. These sorts
of statements belong to the class of "freely circulating information" and
their effect on motivation is very low.
Exaggeration and generalization
Such a sentence is a typical
example in clinical practice: "You will always have your stomach
problem, if you never take your tablets regularly."
Exaggerations and generalizations
count as some of the classical "hindrances to dialogue" as the statement
is usually both incorrect and powerless to convince. The argument is given
weight which it really does not deserve. On hearing it the discussion partner
feels under pressure or reacts with excessive defensiveness.
Generalization is one of
the typical discussion techniques which leads to asymmetry, as it
creates an authoritarian situation. It is a favourite form of speech in
conflict situations between parents and children or in legal "discussions".
and always occur frequently in these "killer phrases". They strangle
discussion, as they make it impossible to argue fairly.
It is worthwhile watching
how often undefined limitations are used in daily speech: "if all goes
well", "to a certain extent", "all in all", "up to a point", "somehow",
"probably", "and so on".
We use these phrases when
we are unable or unwilling to say something definite. To that extent, undefined
limitations are an unavoidable part of our speech. However when they are
used constantly, they open up bolt-holes and flights of speech which always
avoid clearly defined statements. It is as if these words are used to shunt
one's self with one's own uncertainty into the sidings rather than travelling
forward giving clear statements, decisions, and judgements.
Uncertain limitations which
are acceptable in common usage and have a certain protective function there,
create a major source of misunderstanding, uncertainty and anxiety when
used in conversations between doctors and patients. A patient who hears
that his operation was successful "all in all", can easily be led to think
that it was not completely successful. A patient who hears that there will
"probably" not be another epileptic seizure, will hardly be reassured,
as this use of words does not completely exclude the possibility of another
seizure. And when an investigation has to be repeated "under certain conditions"
the patient will worry ("Under which conditions?").
Indefinite limitations also
conflict with the basic rules of successful and comprehensible speech,
which is simple, brief, transparent and orderly. Of course this does not
mean that uncertain limitations should be done away with completely in
discussions between doctor and patient.
If targeted and used economically,
they can be of help to bridge situations which are truly unclear and not
yet decided one way or the other. What is paramount is that the doctor
notices how these ill-defined statements are received by the patient. If
they result in the patient accepting that a point which is part of an ongoing
situation can be put off, no further explanation is necessary. If the patient
is not satisfied or becomes anxious, or misunderstandings arise, a further
explanation must be given.
"We" expressions have an
character, as they can be used in various situations for various reasons.
A politician who says in a speech: "We are convinced that we are moving
into a time when more jobs will be available" is using the "we" to strengthen
his own personal opinion. The father who says to the son: "We are upset
by your poor school report" is exerting pressure by speaking on behalf
of somebody else (here the mother). If "We should not ignore the fact that
the way on which immigrant workers do their jobs leaves much to be desired"
arises in conversation, a personal opinion is being hidden by the undefined
"we". The nurse who says to the patient: "Let's take this tablet, so that
we can sleep better tonight" is using the We-expression in an attempt to
communicate a feeling of companionship and understanding.
"We" expressions can remove
a person from the front line and allow him to say unpleasant things, speaking
on behalf of an indemnified but probable majority; this technique is particularly
commonly used in political television interviews, election campaigns and
official announcements. "We" statements can also be used as a method of
unconsciously strengthening one's own opinions and wishes by means of an
anonymous authority figure, and to protect one's self from opposition.
However "we" expressions
can also have a harmonizing function as can be demonstrated briefly.
This speech technique can
be usefully introduced into conversation when aimed to create harmony,
and to encourage or emphasize community spirit. The "we" can however also
to be used to try to give the appearance of harmony when in fact an opposing
view is hidden behind a protective wall of speech: "We should not be too
dramatic about it...".
Is there really such a thing
as "opposing agreement"? Certainly not! Nevertheless it is remarkable how
often in formal discussion the technique of "opposition with agreement"
This can be illustrated by
the anecdote of a neurosurgeon, who when asked if subarachnoid hemorrhage
should be immediately treated by operation, replied: "Yes, but not on weekends".
The most frequent way of expressing agreement even though one is of the
opposite opinion, is the "Yes, but.." formula. There is a whole range of
terms used in this technique:
"That's right, but.."
"Completely true, nevertheless..."
"Absolutely! On the
"I agree, but..."
"Correct. Now if you want
to know my opinion..."
A "Yes, but" is allowed when
there is a basic agreement between the discussion partners, but one wishes
to express a relevant limitation or would like to make it clear there are
other reasonable points of view.
Question: "Do you think
that there should be speed limits?" Answer: "Yes, but more for safety on
the roads rather than from an environmental point of view".
"Yes, but" however is used
far more frequently to "calm" or "quieten down" the discussion partner,
or to emphasize a contrary opinion by avoiding an "argumentative clinch
Geisler: Doctor and patient - a partnership through dialogue
Pharma Verlag Frankfurt/Germany, 1991
of this page: http://www.linus-geisler.de/dp/dp09_pauses.html