Shhh!!!…facilitating Silence
An exploration into the therapeutic relationship that may provide a trusted environment where absence of speech can be a useful form of communication
Introduction
This essay is a critical appraisal of the nature of therapeutic relationship. It aims at identifying facilitators to the alliance of practitioner to patient that may assist in the creation of a comfortable union for the patient in the homeopathic consultation. The experience of ‘silence’ in psychoanalytic theory and practice is used to inform of the requirement of a patient/practitioner relation that employs person-centred aspects.
Exposing weakness, such as describing symptoms of illness to a homeopath or other healthcare practitioner has, for me, never been a comfortable issue. Here I am, feeling unwell and there is that other person to whom I have to describe what pains me. In illness I feel vulnerable, and the last thing I want to do is share what weakens me with a person I hardly know.
Out of this personal experience, when I became a homeopath, I looked with great respect at my patients that booked an appointment without knowing who or how I am, and shared their story. I have learnt that my patients, like myself, do not do this readily and that they too, to a more or lesser extent, feel similar to how I do in situations at an appointment with my health care provider.
In this essay therefore, following a critical differentiation of the patient/practitioner alliance in homeopathic practice, psychoanalysis and conventional medicine, the concept of the person-centred approach is introduced as a form of being in the therapeutic relationship. Silence as a form of communication is used to demonstrate the importance of creating a trusted and comfortable alliance of patient and practitioner, whilst an analysis of silence as part of the homeopathic therapeutic relationship demonstrates its value for the homeopathic case-taking process.
The literature search for information relevant for this essay, conducted via open access platforms such as Bing, Yahoo, Google, and the academic search engine Google-scholar was deficient. Search terms such as, homeopathy, homeopathic, silence, silent, non-verbal, psychoanalysis, and communication, rendered no adequate information. The search in German national, organizational and association sources proved equally inadequate. Papers that were found, were mostly ´purchase-on-demand`. Therefore most publications referenced for this essay originated from books, or via publishing sites, databases and online libraries that were accessible via the UCLan subscription. Articles came from Elsevier, Ebscohost and Sciencedirect, but the majority came from the PEP web and Sage journals online databases. The literature search has been conducted in the English and German language; the larger amount of articles was available in English, few of relevance were found in German.
The nature of the therapeutic relationship
In contemporary medicine, where disease is viewed as localized disorder, the patient intentionally spends little time within the therapeutic encounter [1]. The practitioner-patient interaction is seen as one that is practitioner-dominated. It is the practitioner that interrogates the patient, establishes a diagnosis and suggests a course of treatment. The patient is immediately pushed into a passive role that is submissive to the medical expertise and authority of the practitioner [2].
Both psychoanalysis and homeopathy stand quite opposite to this practice in conventional medicine. The emphasis on, and the appreciation of the patients’ individuality stand central to both treatment approaches. Both support the development of awareness and both involve time, the duration of a consultation, as an element of impact within the therapeutic alliance [3]. The consultation frequency too, is in both approaches augmented. In psychoanalysis and in homeopathy [3]; [4 – Aphorism 209], unlike in conventional medicine, the incidence of patient-practitioner reunion, by nature of the treatment approach, is naturally construed for multiple interactions; in psychoanalysis still more than in homeopathy [3].
There are distinct similarities between homeopathy and psychoanalysis, but both have differing interpretations of the human nature and different concepts of therapeutic care [5]. While the psycho-therapeutic approach deals with investigations into the orientation of the mental and emotional states of patients, homeopathy´s exploration is aimed at identifying holistic, inherent expressions of the disequilibrium the patient is presenting with, for the purpose of identifying the curative remedy [5].
Homeopathy is the only scientific discipline in the medical spectrum that considers constitutional, hereditary, mental-emotional and idiosyncratic parameters. It views its patients as a holistic totality and is therefore not restrictive of an ailment or symptom, as is the conventional approach to health [3].
The patient-centred approach
The term `patient-centred´, describes a qualitative presence of the practitioner in the therapeutic encounter. It means facilitating patient development and retrieval of the patients own immanent resources in order to achieve growth and fulfilment of his own needs [6]; [7]. Underlying this concept is the believe that the patient himself has the greatest awareness of his requirements and the practitioner functions solely as a facilitator of the conditions the patient requires to be able to recognize this [8]; [7]. The patient is the expert of his state and not, like in the conventional medical relationship, the practitioner the instructing authority [7] and the patient in dependence on others [8].
This person-centred approach to the therapeutic interaction, as postulated by Carl Rogers, knows six conditions that the practitioner may communicate to the patient in order to create circumstances in which the patient finds mutual trust, unconditional acceptance, positive appreciation, empathic comprehension and genuineness on part of the practitioner [9].
The concept of silence
Silence, according to a dictionary definition is “forbearance from speech or noise, an absence of sound or noise, and an absence of mention” [10].
In the historic apprehension of silence, linguists initially perceived it as meaningless and refused it a purpose [11]. It was described as `no-speech´ in opposition to `speech´ and was viewed as the absence, the negative, the passive. Only in very recent times, around the 1990´s, has silence been described as an element with impact and was acknowledged as an active, expressive part of communication [11], as a constituent and a type of speech [12].
Within the therapeutic relationship silence was initially understood and recognized by Sigmund Freud as an element of the patient-practitioner interaction [13]; [14]. Freud placed his focus on silence being an expression of “resistance towards anal-erotic wishes” [13 – p.2], blockage to recollection, or opposition to transference from the practitioner [14]. Therapists of his time followed this or similar interpretations of silence up until the 1960´s [13]; [14]. It was only then that first considerations were made toward a communicative expression of silence within the therapeutic encounter [14].
Silence versus verbalization
In the psychoanalytic patient-practitioner alliance, as much as in the homeopathic consultation, and for that matter most other therapeutic interventions, the major tool of communication is the spoken word. In fact these approaches are reliant on verbal expression [12]; [14]; [15].
The patient is narrator of his story and is responsible for conveying necessary information to the practitioner, whilst the latter functions as auditor to the patient [12]; [13]; [16]. Patients are required to express their experiences in the spoken word which is seen as a form of unloading their disagreeable and unamenable experiences, remembrances and conflicts [14].
But where such revelations are held back and are difficult for the patient to share in a verbal form, silence may become an escape from the reiteration or reminiscence of past conflicts and traumatic experiences [12].
Whilst earlier notions in the range of psychoanalytic interaction, were to transcend such silent states of the patient [14]; [17], such that a verbal expression of the inherent conflicts could be exposed, it was later recognized that silence in itself was expression in non-verbal form [14] and had a meaningful significance [13]; [18].
It has become indispensable to view silence in the therapeutic encounter as a form of communicative interaction [12]; [18]; [19]. “Silence of the patient, is a part or form of speech” [12 – p.549]. Even in silence are patients´ inner struggles communicated to the attentive therapist [20]; [21]. These messages may complement the perception of the patient and the progression of the therapy [14]; [16]. The behaviour of the patient in such silent phases, the cause of his speechlessness and the instance when this occurs may deliver valuable information to the therapist [15].
Communication in silence
According to Kulkarni [22] 35% of communication is verbal and 65% is expressed in the absence of vocal language. Such unspoken communication employs the physical plane to reflect expression on the outside of what is happening within. This language of the body conveys more than the spoken word [22]. Therefore non-verbal behaviours and unconscious, instinctual expressions may be of utmost importance to the therapeutic interaction.
A patient may reveal his/her state of emotion by alteration of mimic, in composure, variance of respiration, by lip-biting, rubbing hands, erecting the body etc [3]; [12]; [21]; [23]. Freud is quoted in Elson, [17] and the notes to Kurtz [19] as such: “He that has eyes to see and ears to hear may convince himself that no mortal can keep a secret. If his lips are silent, he chatters with his fingertips…” (p.244). Freshwater and Stickley [24] state that “therapeutic listening hears the sigh developed over a lifetime…or despair in a facial expression” (p.15).
The function of silence
Within the therapeutic alliance the practitioner holds the position of the listener, that is, his silence is one destined to attentiveness towards his patients’ vocal and non-verbal expressions [12]; [13]; [16]. According to a study by Ladany, Hill, Thompson and O´Brien [25], the therapists´ silence is intended to permit a patients investigation into his own state of being, his memories, past experiences and connected emotions.
At the same time, the practitioners silence has the purpose of conveying presence, support and empathic understanding to the patient [13]; [25]. Yet it may also function as a means of provoking or encouraging a response from the patient, or may serve the purpose of self-reflection of the practitioner on aspects of the therapeutic interaction [25].
The patients’ silence on the other hand, has mainly a different purpose. He too is a listener, when addressed by the therapist, but may also seek silence when, due to an inner impulse which may arise out of the therapeutic encounter, he is inhibited in the verbal communication [18]. The latter form of silence of the patient is primarily viewed as a protection mechanism [16].
However, there may also be forms of silence in the therapeutic alliance that are exercised with intent; when for example the patient chooses to consider or reflect. These do not distinctly have therapeutic relevance. But, there may be phases of intent in which the patient utilizes silence, for the purpose of challenging the practitioner [15]; [16]. The intention of this may evolve out of the precise observation by the patient, who is weighing the analysts’ reaction to the imposed silence [16]. Silence may therefore be an intention to provoke a reaction from the practitioner [21]; [26].
The practitioner may also be the cause of silence of the patient. The therapist may, unknowingly, with his reaction to the patients’ story, arouse sensations of past experiences in the patient [27]; [28]. This form of transference is largely unintentional. But with his silence, the patient may attempt to object to these recollections the therapist arouses in him [13].
Likewise a counter-transference, from the patients narration, may arouse unconscious perceptions in the therapist [27], which can be disruptive to the relationship of practitioner and patient [19].
Experiencing silence
It is false to assume that only the practitioner studies notions of silence in the therapeutic encounter. The practitioners’ presence in silence is conversely noticed by the patient [16]; [26]. Both participants of the therapeutic alliance therefore experience their own silence and that of their counterpart. Their judgement of such silent phases differs.
Silent phases can be experienced as being “empathic attunement” [17 – p.358] between practitioner and patient, where in the speech-free moments the patient finds unrestricted acceptance and warm comprehension and may experience the therapeutic alliance as a safe environment [14]; [17]. In such phases growth can be encouraged and the perceived self-worth in the patient can be reinforced [17].
On the other hand, silence can be disturbing to the patient. The silence of the therapist deprives the patient of the reaction to his/her story. It leaves the patient ignorant of the acknowledgement or resonance of the therapist and consequently raises discomfort and feelings of trepidation [14]; [17].
Fuller and Crowther [26] describe patient experiences of silence as being interpreted as “punishing, deliberate and merciless” or as “neglectful and withholding” (p.528). At the same time the practitioner, when attempting to break the silence, may be apprehended as “intrusive and demanding” [26 – p.528]. In Zeligs [21] a practitioners silence is described as inducing “unconscious inhibitory resentment” (p.18).
The patients silence too impacts on the therapist as the cognizant and incognizant perceptions received from the patient [19]; [21], for the therapist too, may be discomforting and oppressive [26].
The question that arises in the narrations of Blos [18], Nacht [15] and Ladany et al. [25] is whether silence is “help or hindrance” [18 – p.350], taking into account the multiple aspects it exposes and the experiences it may arouse in the patient. Blos [18] describes the impact of silent phases as having been efficient for his therapeutic interactions with patients. Nacht [15] points out that there is “the productive character to some forms of silence” (p.336), and development can evolve out of silent encounters. In Ladany et al. [25], it is pointed out that silence may be a gain for the therapeutic process and at times may be destructive to it.
What can be extracted from these three statements is that silence works for some but not all therapeutic relationships. This makes clear that the therapeutic relationship does play a crucial role if silence is to be an active element of a patient/practitioner interaction.
The important role of the therapeutic relationship – requirements for silence
“For silence to be beneficial it must be made tolerable to the patient; in fact, he can only bear silence if he feels perfectly at ease in the analytic situation…”[15 – p.336]. Nacht [15] goes on to say that this state in the therapeutic alliance may be achieved “…if fear and tension have been eliminated or at least attenuated” (p.336). In Olinick [20] the perception of such analytic encounter is described as “comfortable” (p.462). In Nacht [15 – p.336] this is termed as “safe”, and is described as the element sought by a patient in the analytic interaction.
In order to achieve this safe and comfortable dynamic in the therapeutic alliance, it requires facilitators to the relationship that the therapist should provide, in order to achieve the desired depth to the patient-practitioner union.
Providing a “quality of presence” [15 – p.337], or “being with” [14 – p.1097]; [24 – p.14] the patient, is created by expressing gentleness and empathic comprehension, towards him/her in the therapeutic encounter [15]. Waldhorn [12] postulates the need of “appropriate and benevolent listening” (p.557).
In Lane et al. [14] is mentioned the requirement for the practitioner to refrain from appraising the expressions of the patient or bringing reprimand towards the latter.
The experiences described by Fuller and Crowther [26] of silence on their attitude in the patient-practitioner consultation, suggest a need for practitioners to be more expressive with their own emotions. The authors describe the use of “mutual conversations” and “mutual support” (p.537).
Trust and security are mentioned in Kurtz [19] and Nacht [15] as being necessary for the creation of a comfortable therapeutic relationship where fear is absent and a connection of practitioner to patient and vice versa is established.
In application of the person centred theory the above indicate the requirement of empathic understanding of the patient and his story. “The empathic interaction stimulates the person who feels understood in this way, to attend to their own experiencing and to represent him- or her-self more acutely from their experiential source”(p.29), this is how Brodley [29] describes the effect of empathic understanding in the person centred alliance.
Another requisite from the practitioner is that of holding a non-judgemental position. Tolan [30] describes acceptance and being non-judgemental, the so called unconditional positive regard, as a universal trust in the fact, that every individual has good reasons for all actions they undertake.
Congruence describes the therapists’ self-awareness of his emotions in the presence of the patient and his/her story [6]. This state of being authentic is achieved through avoiding self-disclosure before the patient and as Mearns and Thorne [31] define it “giving expression to responses which he/she has, which are relevant to the client and which are relatively persistent or striking” (p.92).
In application of Rogers´ core conditions to the person-centred approach therefore, a comfort-zone may be facilitated in a therapeutic encounter, in which the patient experiences safety, trust, empathy, and is met by a practitioner who is without judgement and genuine towards him/her.
The above states clearly that a constructive silence, one that is beneficial, is more readily found, if a patient-centred approach is taken on the therapeutic union of patient and practitioner, and the therapeutic environment is experienced as a comfortable encounter.
Silence in the homeopathic consultation
Frankland and Sanders [32] brought back a memory of the first time in my career, when a patient had chosen silence over speech and withdrew from the realms of spoken discourse with me, the practitioner, into the absence of vocal expression. I had not assumed the homeopathic consultation to be an encounter that would see much silence in the therapeutic relationship, it being reliant on the explanations and descriptions of the patient, but I have learnt otherwise.
Frankland and Sanders [32] pose an interesting question, “What do you fear might happen or might be happening during a silence?” (p.174). I remember being irritated and very uncomfortable that first time a patient retreated into himself and left me in silence. Why had I felt that way? Was I afraid, and what was I afraid of? I remember questioning if I could have been the cause of my patients’ silence. Had I been too demanding in my case-taking? Was I behaving such as doctors did when I felt uncomfortable in their consultation? Here I noticed how very important my behaviour and attitude in the therapeutic encounter is and how much I could do wrong in this patient/practitioner space.
That day I endured this speech-free episode for a while, but had a restless urge to break it and eventually did interrupt, by asking questions aimed at encouraging a response. When that response came, I almost directly regretted my disruption. The dynamic that had been established in this consultation, between my patient and I, instantly changed. Something was then and there lost, and I sensed my patient had been on the brink of sharing something with me that he had previously not had felt confident or safe enough to share [33].
This realization of the impact my comportment could have on the consultation, and the dynamic that could evolve in this space between patient and practitioner, had never been that clear to me. This experience made me recognize that silence, even in the homeopathic consultation, does happen and that my attitude and behaviour can influence the patient/practitioner dynamic, if I can facilitate its creation in the therapeutic relationship.
I have since experienced quite a number of silent encounters and none have been disturbing or irritating to me. I have learnt to endure silence and to feel comfortable in it. I have become conscious of, and sensitized for, the expressions my patients make in verbal and in non-verbal form, as my observations and perceptions in silent phases with the patient, have convinced me that there is communication in silence. Silence as much as speech may be revealing, and I, as practitioner have to sharpen my awareness for what is, and for what is not said.
Listening to silence in homeopathy
Owen [23] makes an interesting point in that he mentions the homeopathic practitioner to be “receiving a case” rather than “taking a case”(pp.163-164). This stresses the practitioners need of “being receptive” (p.164) to all expressions of a patient, those the patient chooses to neglect and those that he may be unaware of [23]. Silence therefore is considered by Owen [23] as a “most powerful tool” (p.171) and as “listening involves all senses, not just the ears” [24 – p.14], “a patients silence should be given as much attention as his words” [18 – p.349].
Hahnemann [4] in Aphorism 84 of the Organon stresses that “the practitioner listens and observes with all remaining senses, what is altered and exceptional of the patient…where possible he maintains silent and does not disrupt the patient, unless he digresses to other things”, and in Aphorism 90 Hahnemann [4] stresses the importance of the practitioner taking note of his own perceptions of the patient.
Non-verbal expressions in the homeopathic consultation are of outstanding value to the practitioner. Homeopathy is a holistic treatment approach taking into account symptoms that comprise the totality of the individual. The mental, the physical and the emotional plane are connected and the patient communicates from and with all planes at all times. Thus, in illness “the essence of the sick individual can be understood through the cluster of gestures and postures, being represented consistently” [22]. The information gained from attentive observation of the patient may permit a better comprehension of the patients´ story and may consequently permit a more precise prescription [34].
Kulkarni [22] also stresses another point. The non-verbal expressions sent out by the practitioner are in the consultation also of major importance. The perception of the practitioner by the patient is of great significance to the outcome of the therapeutic interaction. “All movements of the body have meaning. None is accidental” [22]. This indicates that the practitioner too, communicates without speech, unconsciously sending, with his/her postures and gestures, a message to his/her patient. The patients’ interpretation of these messages is influential on how the patient perceives his position in the therapeutic relationship. Therefore, the extent to which the practitioner is able to create a comfortable encounter in the patient/practitioner alliance, also relies on how well he/she is able to specify and control his/her own non-verbal language. In terms of silence, this means that the practitioners’ comportment is essential in the facilitation of the framework that may host silence as a helping element of the therapeutic relationship.
Homeopathy and the person-centred approach
In my homeopathic practice, awareness of the need of a person-centred attitude has been in application, without so being labelled, since before I was introduced to the Rogerian approach. I have learnt that it is necessary to create a ´comfort-zone` in the therapeutic encounter. Descriptions of expressions of individuality and illness or disease I see as a vulnerability that is exposed in the consultation. It is only when there is mutual trust between patient and practitioner, and the patient feels safe, understood and accepted that he/she readily shares personal and specific details. There is no guarantee that this union can always be established. But I have recognized in practice that if this alliance can be found, the dynamic that develops may be revealing of details that in absence of such a relationship would possibly remain concealed.
Hahnemann [4], in the footnote to Aphorism 104 of the Organon (p.200), vehemently criticizes the practitioner-centred approach, the impersonalized methodology and restrictive appraisal of information from the patient, and makes first suggestions to a humanistic, patient-centred interaction in Aphorism 83.
Therefore, communicating patient-centeredness is considered a fundamental aspect of the homeopathic interaction [2], whether expressed in silence or in speech.
Conclusion
What becomes evident from the above is that specifically in silence, but also generally within a homeopathic consultation, certain conditions have to be facilitated in order for a therapeutic synthesis between patient and practitioner to be established. As can be seen in the example of silence, in the therapeutic union, beyond the spoken word, observed and perceived expressions by the patient and the practitioner may deliver information that can be of value to the alliance and the homeopathic case-taking.
The nature of the therapeutic environment is fundamental to the creation of a safe and trusted union. The extent of comfort found within the alliance of patient to practitioner can decide on the depth of information conveyed to the practitioner and consequently, in the homeopathic consultation, on the precision of the remedy prescription.
In order to be able to create a comfort-zone, a therapeutic relationship is needed that focuses on the patient and his/her needs. The person-centred approach delivers the conditions that facilitate these requirements. Homeopathy by its nature, and the laws laid out by Hahnemann in the Organon [4] employs a patient-focused attitude, within the homeopathic consultation [2].
My respect for the power that may lie in a therapeutic relationship and for the dynamic that may evolve in a comfort-zone has increased immensely. The trust a patient places into the therapeutic union, and myself as practitioner, has refined my own behaviour and attitude.
I aim to express toward my patient, an empathic presence in which I am respectful and genuine, acceptant and non-judgemental.
Whether it is in silence or active vocal speech that a patient communicates in the homeopathic consultation, a healing dynamic is best facilitated for the patient, in a patient-centred union.
Acknowledgements:
I would like to express my gratitude to Ian Townsend, University of Central Lancashire, U.K. for his assistance with this assignment (Jan., 2011)!
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