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Linus Geisler: Doctor and patient - a partnership through dialogue   © Pharma Verlag Frankfurt
Pauses in discussion
Pauses for decision
The pause as a means of contact
Pauses due to blocking
Pauses due to hindrances
The correct technique for pauses
Help for breaks in discussion
Not saying anything with speech
Commonly used "hindrance to communication"
Pauses in discussion
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 conscious effort.

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 reason.

The reasons for pauses in discussion can be as follows:
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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).
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The pause as a means of contact
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".

Usually agreement 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.
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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 communication.

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 excessive 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 link).
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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:
Opportunities to consider, reflect and work on the material
Calming the flood of speech
Promoting the intensity and quantity of the messages
Signaling a change or end of the subject
Opportunity for composure of emotions
Lowering of the level of aggression

Disadvantages of pauses or interruptions are:
Breaks in the thread of discussion
Misunderstandings (misinterpretation as disinterest, lack of approachability, superiority, keeping one's distance)
Feelings of frustration (conversation partner feels he has been abandoned or neglected)
Emotional stress (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:
Analysis of the cause
Ability to accept pauses
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 patiently.
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The correct technique for pauses
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.
1. Pauses which promote discussion 
Decisive pauses: reflection
working through
changing/ending the subject
Communicative pause: understanding approval
Pauses in discussion
2. Pauses which inhibit discussion
Blocking:  Inhibition
(Causes) Refusal
Conflict situation
Overcome by emotions
Unable to cope
Interruptions: External disturbances
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.

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.
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Help for breaks in discussion
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 accepts 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 point now?" 
"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.
For example:
"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 helpless, 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 difficulty".
"The more that you can tell me about the difficulties you are having, the easier it will be to help solve these problems".

Help to offer during pauses due to blocking 
1. Make it obvious that pausing is acceptable
2. Suggest that the pause is an opportunity for decision
3. Recall the subject of the conversation by repetition
4. Use bridge-building where there are signs of helplessness
5. Direct mentioning of blocks (metacommunication)
6. Offer to postpone discussion in threatening breaks in conversation
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.
For example:
"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 discussion 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 recommended:
For example:
"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:
For example:
"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.
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Not saying anything with speech
or: "The Art of Communicative Uncommitment"
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:
Communicative uncommitment
"One can almost take it to mean that..."
Appeal to the impersonal
"Probably one should get more involved there..."
The unquantified limitation
"more or less,... approximately..."
"Overall, however, these tablets are good."
Use of the conditional
"It might be conceivable that..."
The killer phrase
"I really can not see why this is such a problem for you."
The Trojan 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:
Factual 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 applicable" formulations.

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.
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Commonly used "hindrances to communication"
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 himself.

Neutral sentences

"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". Never and always occur frequently in these "killer phrases". They strangle discussion, as they make it impossible to argue fairly.

Undefined limitations

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

"We" expressions have an ambivalent 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...".

Opposing agreement

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" operates.

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:
"Certainly, however..."
"That's right, but.."
"Completely true, nevertheless..."
"Absolutely! On the other hand..."
"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. 
For example:
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 situation".

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Linus Geisler: Doctor and patient - a partnership through dialogue
© Pharma Verlag Frankfurt/Germany, 1991
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