Dheeraj Makkar*

Department of Orthopedics, UIHC, USA

*Corresponding Author: Dheeraj Makkar, Department of Orthopedics, UIHC, USA.

Received: July 29, 2024; Published: September 01, 2024

Citation: Dheeraj Makkar. “Beyond Words: Silence as a Therapeutic Tool”. Acta Scientific Orthopaedics 7.10 (2024): 01-02.

I first met Tim when he arrived at our clinic after a fall, unable to walk. As we delved into the cause of his sudden immobility, our tests uncovered a much graver situation: Tim had thymic cancer that had metastasized to his liver and bones. As we discussed his diagnosis, Tim shared a poignant story that revealed a life marked by resilience and longing.

Tim’s childhood was overshadowed by a lack of affection from parents who, despite their closeness to each other, struggled to show love to their children. Reflecting on this, Tim recognized that his sense of detachment led him to create a fantasy world of imagined love and happiness. This yearning for connection drove him to the United States with his girlfriend. After two years together, his girlfriend left him for someone else, leading Tim to move to Iowa. There, he lived alone, feeling “very unhappy,” while building a successful career. During this period, he described himself as “an injured person” seeking meaningful relationships through social media, travel, meditation, a brief romance, and an increasing interest in Buddhism.

Years later, he faced another loss when his mother passed away from Alzheimer’s disease, leaving him with no chance for reconciliation. Yet, he found solace in M, his current partner, a kindred spirit who had also endured a painful breakup. At age 36, Tim was diagnosed with thymic cancer, with metastases in his liver and bones soon becoming apparent. The newfound happiness in his life was overshadowed by a profound sense of “loss of self,” helplessness, and grief. As the severity of his condition became evident, Tim felt an urgent need to regain control. “I had to get out of that spiral somehow. I had to!” he said. He became more proactive in seeking medical treatment but faced a dire situation.

Without insurance, Tim and I confronted two daunting options: a femur replacement, which might be too risky due to his metastases, or amputation from the hip. As we prepared to deliver this heartwrenching news, I felt the weight of the moment pressing heavily on my chest. How would he react? What words could soften such a devastating blow? The silence before our conversation felt like an endless, tense prelude to the life-altering choices Tim would soon face. In my research on delivering bad news, I found that silence could be a powerful tool in such moments.

As I prepared to speak with Tim, the gravity of our impending discussion seemed almost overwhelming. The profound silence that enveloped us was not merely a pause, but a space of shared humanity and deep emotional resonance. It was in this silence that we would both find the strength to face the difficult path ahead.

Silence can be a powerful tool in maintaining a patient’s calm, allowing them to process information and emotions at their own pace. As Max Picard insightfully noted, “Silence can exist without speech, but speech cannot exist without silence”.

This experience led me to delve into the nuances of silence and its role in challenging conversations. Literature reveals that, when used thoughtfully, silence provides essential space for patients to absorb and reflect on the gravity of their situation, fostering a more compassionate and supportive environment during these critical moments.

Structured approaches for delivering bad news, such as the SPIKES protocol (Setting up the interview, Assessing the Patient’s Perception, Obtaining the Patient’s Invitation, Giving Knowledge and Information, Addressing the Patient’s Emotions with Empathy, Strategy and Summary), the ABCDE protocol (Advance preparation, Build a therapeutic environment/relationship, Communicate well, Deal with patient and family reactions, Encourage and validate emotions), and the BREAKS protocol (Background, Rapport, Explore, Announce, Kindle, Summarize), all emphasize the importance of allowing moments of silence. These protocols recognize that silence is a crucial component of empathy, enabling patients to process information and emotions more effectively.

Processing emotions is vital in building a therapeutic alliance, especially with life-threatening diagnoses like cancer (Safran and Muran, 2000). Linguistic research shows that most silences in everyday conversation last between 0.1 and 0.3 seconds (Heldner and Edlund, 2010; Xiao., et al. 2015; Levinson and Torreira, 2015). Longer pauses, exceeding three seconds, are rare but can be significant depending on language, culture, and conversational norms (Nagaoka., et al. 2013; Holler., et al. 2015). Beneficial silences can reduce distress (Frankel., et al. 2006) and promote self-understanding or insight (Hill., et al. 2018; Levitt, 2001a). Additionally, vocal acoustics play a role in discerning emotions, which enhances effective communication and impacts the quality of social relationships and medical care (Lima, Castro, and Scott, 2013; Laukka., et al. 2008). Research indicates that the duration of silence affects the intensity and variability of emotional expression, and pausing after delivering bad news can alleviate anxiety and improve comprehension (Baile., et al. 2000). In any conversation, silence acts as a profound form of listening.

Pausing during a conversation, especially when delivering difficult news, is crucial. Studies show that pauses allow patients to process information and lessen the immediate emotional impact. A pause should follow key pieces of information or moments of emotional overwhelm to avoid overwhelming the patient with too much information at once. Timing the re-engagement in conversation after a pause is just as important. The speaker should resume when the patient indicates readiness through eye contact, nodding, or verbal cues. Literature suggests that verbal and nonverbal patient cues are essential for determining when to continue the conversation (Back., et al. 2005). The duration of pauses in conversation can vary, but they should generally be long enough to allow the patient to absorb the information without creating discomfort or anxiety. Short pauses, lasting between 3 to 5 seconds, provide brief moments for reflection without interrupting the flow of the discussion. In contrast, longer pauses, extending from 10 to 30 seconds or more, become particularly valuable when the patient is emotionally overwhelmed and requires additional Time to process distressing news. These extended pauses offer a crucial respite, enabling patients to manage their emotional responses and engage more fully with the conversation.

Handling the stress of delays during difficult conversations can be challenging. According to a study by Ptacek and Eberhardt (1996), healthcare providers can manage this stress by preparing mentally for the conversation, using relaxation techniques like deep breathing, and reminding themselves of the importance of giving the patient Time to process the information.

For the speaker, using silence effectively can initially feel uncomfortable but offers significant benefits. Pausing allows the speaker to collect their thoughts, manage their emotions, and respond more thoughtfully. Research shows that silence can help reduce the speaker’s stress by providing a moment to breathe and compose themselves, which is crucial when discussing emotionally charged topics (Narayanan., et al. 2010). Silence enables healthcare providers to regulate their emotions and maintain a calm demeanor, essential for effective communication (Stepanek., et al. 2010). It provides an opportunity to respond with greater empathy and thoughtfulness.

Silence, rather than being a mere by-product of conversation, can serve as a powerful non-verbal tool that enriches dialogue, extending beyond the simple exchange of words. It creates a profound space for reflection, understanding, and deeper connection between participants.

As for Tim, after careful consideration, we decided it would be reasonable to buy Time and start him on chemotherapy before committing to a definitive treatment. We performed intramedullary nailing, and fortunately, Tim is responding well to the treatment. His fracture is healing, and the metastases are disappearing, offering him a renewed sense of hope and improvement in his condition.

Bibliography

Copyright: © 2024 Dheeraj Makkar. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.