February 2018 Article of the Month
This month's article selection is highlighted by John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.
Bassett, L., Bingley, A. F. and Brearley, S. G. "Silence as an element of care: a meta-ethnographic review of professional caregivers' experience in clinical and pastoral settings." Palliative Medicine 32, no. 1 (January 2018): 185-194.
SUMMARY and COMMENT: "This paper provides a novel synthesis of professional caregivers' experience of silence in interdisciplinary settings" [p. 185], though for chaplain readers this review may be less about its aim of synthesis than about its many points along the way that should resonate and -- especially for those in training -- provoke thought. The authors analyze 18 systematically identified articles, only four of which present empirical research (--the paucity highlighting the need for more study), but it would be fair to say that the overall approach is highly research-minded. Principal author Lynn Bassett is a retired healthcare chaplain with a PhD in palliative care.
The methodology for the article selection involved literature database searches in March 2015, augmented by individual searches of spiritual and pastoral care discipline-specific journals, including the Journal of Health Care Chaplaincy, and by citation tracking. Of the final 18, two are from Pastoral Care [--see Related Items of Interest, §I, below], six are from Nursing, and ten are from Psychotherapy and Counseling (one of which is an unpublished Master's thesis). All are conveniently lined out in a table [pp. 189-190]. "The review question asked: How do people in professional caregiving roles describe their experience of silence, as an element of care, in interactions with patients or clients?" [p. 186].
After interpreting the "main arguments" of each article (succinctly listed in a table), our authors distinguish three "areas of focus" [p. 191] in this literature.:
Bassett and her colleagues say of their findings: "The interpreted line-of-argument concludes that silence supports therapeutic communication especially in spiritual and existential domains of care where words may fail. This may be particularly relevant at the end of life when speech is compromised and spiritual care is integral to care" [p. 193]. They acknowledge, "In this study, use of silence is discussed predominantly from the psychotherapeutic perspective," but they affirm relevance for the palliative care audience of the journal. Chaplains should see in this material much application to Clinical Pastoral Education and everyday work, as with such summary statements as: "In all settings, silence as an element of care is presented as complex and demanding. Silence, as presence, is a difficult skill to master; it takes experience and practice. It involves letting go of ego and a shift of focus from self to other that is integral to compassionate care." [p. 193]
- Focus one: the relationship of silence and speech [pp. 191-192]
- "...[U]nderstood and used skillfully, silence presents not as absence of speech, but as an active presence...." " In relation to speech, silences are described as pause, a way of listening and attending, and a way of communicating that is beyond words...." "...[S]ilent pauses allow the conversation to slow down[,] conveying respect and reverence" "...[S]ometimes a story is still in the process of creation; this may need time, space and a listener." An article by a hospital Chaplain in the US gives the "example of supporting a woman by the bedside of her dying mother, [noting] that it was when he 'stopped talking and let the moment be', that she was released to find a way forward" That author "claims that therapeutic silence accomplishes something that cannot be fully actualized in speech; this includes both respect and non-abandonment." Basset and her colleagues conclude this focus area with the idea that "the effects of silence in the clinical encounter are largely the responsibility of the clinician" [--see Back, et al. in Items of Related Interest, §III, below] and that "every silence presents a decision; wise decisions not to speak are described as intentional, deliberate or purposeful."
- Focus two: the use of silence [p. 192]
- "Ladany et al. [one of the four empirical research articles] find a range of client-focused reasons why therapists use silence in therapy; some convey a quality of themselves, such as understanding, empathy, respect, others are supportive in quality, including holding, facilitating reflection or giving the client permission to be themselves. A third category attends to the therapeutic space, honoring what has been said and providing the conditions that facilitate therapeutic work." "There is [general] acknowledgement that use of silence requires training and practice...," however "[i]n pastoral care, Moriichi and Capretto [the authors of the two Pastoral Care articles] note that training focuses more on what to say." Psychotherapy authors are quoted regarding how "silence demands authentic presence and a willingness to remain open to what emerges."
- Focus three: the practice of silence [pp. 192-193]
- Thirteen of the articles refer to silence as connected to some form of "practice," with the "distinction between use and practice...described...as 'the quality of mind the clinician contributes to the encounter'" [--see Back, et al. in Items of Related Interest, §III, below]. Examples would be "the explicit introduction of a meditative process during therapy, or the more implicit use of mindfulness techniques; it may be a recommendation to adopt a personal spiritual practice or simply to still oneself sufficiently to be fully present." One author "notes that shared silence leads to deeper connection between the individuals involved; others refer to a connection with something more that depending on personal spirituality may be the presence of God...." "Several papers describe being with another in silence as an act of non-abandonment, demonstrating willingness to remain in an uncomfortable place." One author highlights how "embracing silence demand[s] a mental shift from 'doing something for the patient' to focusing on 'being with the patient'; this demands personal courage."
The authors advocate for professional education about silence and for more research. Ultimately, their synthesis cannot go beyond the relatively meager body of literature about a phenomenon that "does not lend itself to any definitive interpretation, prescription or significance" [pp. 188, 191]. Their review acts principally as a call for greater attention to "an important element of communication and compassionate care" [p. 194] that can engender experiences that are "comfortable, affirming and safe" but "may also be received as awkward, embarrassing, frustrating or frightening" [p. 191]. And, for silence to be "particularly relevant in the spiritual and existential dimensions of care" [p. 194], there is a marked need for more of a pastoral perspective on the subject, to balance out the psychotherapeutic literature. The observation, for instance, that "[i]t is generally agreed that a strong therapeutic alliance is a pre-requisite for the use of silence" [p. 192] does not seem to take into account the pastoral dynamics that frequently support silence only a short time into chaplains' encounters. This reader would have liked to have seen the principal author's PhD dissertation, which centered on interviews with 15 palliative care chaplains [--see Items of Related Interest, §IV, below] incorporated in the review, but the article was actually submitted for publication prior to the dissertation's completion.
The article's greatest limitation may be that "no experience from an eastern cultural perspective is discussed" [p. 193], though one of the articles out of Pastoral Care "reports the cross-cultural learning experience of a Japanese author who trained and worked as a chaplain in America" [p. 188]. Still, by drawing together articles from diverse disciplines in Western healthcare, the authors champion an interdisciplinary approach. Chaplains should feel encouraged here to utilize such common ground for interdisciplinary discussion, practice, and research on silence.
Suggestions for Use of the Article for Student Discussion:
Our article this month should be quite engaging to all chaplains, but especially to students during their first units of CPE, as they grapple with silence in both patient visitation and in peer group time. Perhaps discussion could begin with the article's brief section on Silence and Anxiety and the observation: "Anxiety may lead to too many words and too little silence, but too much silence [has] also been identified as a source of anxiety..." [p. 191]. How do the students react to the assertion that silence "demands personal courage" [p. 193]? Does this affect the way they may think of the courage to be silent vis-à-vis the courage to speak up? And regarding the pastoral practice of listening, do they try to listen to silences as much as they do to words [--see p. 192]? The article is filled with thought-provoking points, so the group could simply be invited to raise those ideas that particularly stood out. If there are moments of silence in the discussion, then the group could suddenly be invited to think about what is immediately happening. Does the article make a case for concentrating on the subject of silence in clinical pastoral education? If there is an emphasis on palliative care in the group, then the article offers some special thoughts on that context of care. Students interested in research could obviously focus on the methodology sections regarding article selection and analysis [--see pp.186-188]. The article may also be used well with supervisory education students as a review, a resource, and even a challenge to conduct research.
Related Items of Interest:
I. The two articles for this review from the field of Pastoral Care:
Capretto, P. "Empathy and silence in pastoral care for traumatic grief and loss." Journal of Religion and Health 54, no. 1 (February 2015): 339-357. [(Abstract:) This paper evaluates silence as a therapeutic practice in pastoral care for traumatic grief and loss. Informed by the history of attachment and mourning theory, its research considers the basic effect that empathy has upon the therapeutic relationship around psychic difference. The study appraises the potential resources and detriments that empathic language may have for the grief process. Offering clinical examples in hospice chaplaincy, it refutes the idea that silence is formulaic tool to be used. It instead offers silence as the acceptance of the limits of empathic language and the affirmation of psychological difference and theological wholeness.]
Moriichi, S. "Re-discovery of silence in pastoral care." Journal of Pastoral Care and Counseling 63, nos. 1-2 (Spring-Summer 2009): 3-1-6 [[electronic journal article designation]. [(Abstract:) Pastoral care within the greater American cultural milieu strongly appraises the use of spoken words and tends to undervalue silence as a powerful and creative element for mutual connection with others and with God. In this essay the author proposes a "counter-cultural" adjustment in the perception of silence and its implications to the practice of, and theological understanding of, pastoral care. The author bases his theses on his own cross-cultural learning experiences, including his training in Clinical Pastoral Education (CPE), in the re-vitalization of ancient Christian wisdom, and in his current ministry to nursing home residents.]
II. The four works reporting empirical research chosen for the present review:
Barber, T. "Newly qualified counsellors' experience of silence within the therapeutic setting." Unpublished Master's Thesis, Roehampton University, UK, 2009. [(Abstract:) The aim of this study was to explore how participants experience silence within the therapeutic setting, as well as their past and training experiences of silence. Data was collected via the participants' discourse, during semi-structured interviews. Seven participants took part in the study. The data was analysed using Thematic Analysis (TA). Five themes were identified in the analysis: felt experience; the cognitive experience; silence as a control mechanism in childhood; silence taught as a therapeutic skill and silence seen as adding to the therapeutic process. The theme of cognitive experience contained the sub themes of power and control and internal dialogue. Therapists typically believed that silence was a useful phenomenon, which they became more comfortable with as they gained more experience. The findings further showed that their past experiences and training played a part in their use of silence.] [Available online through Academia.edu.]
Hill, C. E., Thompson, B. J. and Ladany, N.
"Therapist use of silence in therapy: a survey." Journal of Clinical Psychology 59, no. 4 (April 2003): 513-524. [(Abstract:) Eighty-one therapists responded to a mailed survey about their use of silence during a specific event in therapy and about their general attitudes about using silence in therapy. For the specific event, therapists used silence primarily to facilitate reflection, encourage responsibility, facilitate expression of feelings, not interrupt session flow, and convey empathy. During silence, therapists observed the client, thought about the therapy, and conveyed interest. In general, therapists indicated that they would use silence with clients who were actively problem solving, but they would not use silence with very disturbed clients. Therapists learned about using silence mostly through clinical experience.]
Ladany, N., Hill, C. E., Thompson, B. J. and O'Brien, K. M. "Therapist perspectives on using silence in therapy: a qualitative study." Counselling and Psychotherapy Research 4, no. 1 (July 2004): 80-89. [(Abstract:) Twelve experienced therapists were interviewed about their perceptions of why they used silence in therapy. Qualitative analyses revealed that these therapists typically perceived themselves as using silence to convey empathy, facilitate reflection, challenge the client to take responsibility, facilitate expression of feelings, or take time for themselves to think of what to say. Therapists generally indicated that a sound therapeutic alliance was a prerequisite for using silence, and they typically educated their clients about how they used silence in therapy. Therapists typically believed they did not use silence with clients who were psychotic, highly anxious, or angry. They typically thought they now used silence more flexibly, comfortably, and confidently than when they began doing therapy. Therapists typically believed they learned how to use silence from their own experience as a client and from supervision.]
Tornoe, K. A., Danbolt, L. J., Kvigne, K. and Sorlie, V. "The power of consoling presence -- hospice nurses' lived experience with spiritual and existential care for the dying." BMC Nursing 13 (2014): 25 [electronic journal article designation]. [BACKGROUND: Being with dying people is an integral part of nursing, yet many nurses feel unprepared to accompany people through the process of dying, reporting a lack of skills in psychosocial and spiritual care, resulting in high levels of moral distress, grief and burnout. The aim of this study is to describe the meaning of hospice nurses' lived experience with alleviating dying patients' spiritual and existential suffering. METHODS: This is a qualitative study. Hospice nurses were interviewed individually and asked to narrate about their experiences with giving spiritual and existential care to terminally ill hospice patients. Data analysis was conducted using phenomenological hermeneutical method. RESULTS: The key spiritual and existential care themes identified, were sensing existential and spiritual distress, tuning inn and opening up, sensing the atmosphere in the room, being moved and touched, and consoling through silence, conversation and religious consolation. CONCLUSIONS: Consoling existential and spiritual distress is a deeply personal and relational practice. Nurses have a potential to alleviate existential and spiritual suffering through consoling presence. By connecting deeply with patients and their families, nurses have the possibility to affirm the patients' strength and facilitate their courage to live a meaningful life and die a dignified death.]
III. In a personal communication with the Network, principal author Lynn Bassett has said that the following article "had a huge impact on my own practice, as a chaplain," and she would like to have it recognized particularly for our readers.
Back, A. L., Bauer-Wu, S. M., Rushton, C. H. and Halifax, J. "Compassionate silence in the patient-clinician encounter: a contemplative approach." Journal of Palliative Medicine 12, no. 12 (December 2009): 1113-1117. [(Abstract:) In trying to improve clinician communication skills, we have often heard clinicians at every level admonished to "use silence," as if refraining from talking will improve dialogue. Yet we have also noticed that this "just do it," behavior-focused "use" of silence creates a new, different problem: the clinician looks uncomfortable using silence, and worse, generates a palpable atmosphere of unease that feels burdensome to both the patient and clinician. We think that clinicians are largely responsible for the effect of silence in a clinical encounter, and in this article we discuss what makes silence enriching --enabling a kind of communication between clinician and patient that fosters healing. We describe a typology of silences, and describe a type of compassionate silence, derived from contemplative practice, along with the mental qualities that make this type of silence possible.]
IV. Lynn Bassett's PhD dissertation regarding silence:
Bassett, L. "Spiritual caregiving silence:
an exploration of the phenomenon and its value in end-of-life care." Unpublished Doctoral Dissertation, Lancaster University, UK, December 2016. [(Abstract:) Towards the end of life, silence seems to take increasing prominence in caregiving relationships. A complex phenomenon, silence has been less explored than verbal interventions, yet to be an effective element of care, silence requires skill and practice from professional caregivers. This research, undertaken in the United Kingdom between 2013 and 2016, sought a deeper understanding of a type of silence that contributes to palliative spiritual care. A two phase phenomenological methodology was adopted, using heuristic inquiry and hermeneutic phenomenology. Data were gathered through self-inquiry and unstructured interviews with 15 palliative care chaplains. A descriptive and hermeneutic analysis facilitated explication of the lived experience to produce an interpretation of the nature, meaning and value of spiritual caregiving silence in end-of-life care. Spiritual caregiving silence emerges as a way of being with another person, complementary to speech and non-verbal communication, in which the caregiver takes both an active and participative role. It evokes a sense of companionship and connection and creates accompanied space, allowing the other person to be with themselves in a way they may not be able to be alone; this demands a depth of engagement from the caregiver. Silence provides a means of, and medium for, communication beyond the capacity of words and has the potential to enable change, leading to expression and acknowledgment of truth. It offers patients, and their families, opportunities to find acceptance, restoration and peace. The thesis concludes that spiritual caregiving silence is a person-centred phenomenon that supports the wellbeing of patients at the end of life, and their family members, by drawing on cross-disciplinary knowledge and experience. The interpretive process, illuminated by examples of specialist lived experience, has produced a deeper understanding of the phenomenon that may find resonance with the experience of other caregivers, to stimulate further discussion and inform clinical practice.] [Available online.]
NOTE: An oral abstract of the dissertation was presented at the 9th World Research Congress of the European Association for Palliative Care (EAPC) in Dublin, Ireland June 9-11, 2016 and was published as an abstract in Palliative Medicine:
Bassett, L., Brearley, S. G. and Bingley, A. F. "Silence: a dimension of spiritual care beyond words." Palliative Medicine 30, no. 6 (June 2016): NP60-NP61. [Background: In end of life care, silence seems to play an increasing role in communication between healthcare professionals and patients and their families. Yet times of silence may be under-used and under-valued as a dimension of spiritual care. This may be exacerbated when healthcare professionals are not comfortable with silence themselves. Greater understanding of the phenomenon may help to inform palliative care practice. Aim: To explore the nature, meaning and value of silence in spiritual care giving at the end of life. Methods: A two phase phenomenological study utilising heuristic inquiry and hermeneutic phenomenology was undertaken in the UK. Data were gathered through reflective journalling and conversation-style interviews. A reflexive and hermeneutic approach to analysis was adopted to explicate the lived experience in order to pro- duce an interpretation of the essence of silence as a dimension of spiritual care at the end of life. Results: 15 palliative care chaplains participated in the study. Silence was identified as a powerful medium for communication at times when words fail and when there is no longer any need for words. Silence is also an enabler of speech, creating an "accompanied processing space" where deep truths can be articulated and shared. In the presence of a caregiver who is willing to transcend their own vulnerability and stay with another in a non-verbal space, silence can offer an environment where acceptance, healing and peace may be found. Conclusion: Care giving silence complements the spoken word as a person-centred dimension of spiritual care. It has particular relevance when verbal interventions seem inadequate, unnecessary, or intrusive. In a culture which privileges speech and activity, this understanding supports a claim for the recognition of the value of silence, which may find wider resonance with chaplains and other palliative caregivers. The study is self-funded.]
V. Among other sources that explicitly address silence in chaplains' interactions:
Fitchett, G. and Nolan, S. Spiritual Care in Practice: Case Studies in Healthcare Chaplaincy. London/Philadelphia: Jessica Kingsley Publishers, 2015. [See especially the section on Communication Skills (pp. 266-267), but also see the various mentions of silence in the case accounts: e.g., "In part, my silence was intended to honor Angela's suffering and to give it the space and respect it deserved, but I was also considering how to proceed" (p. 76); and "The hope was that this facilitated silence would indicate to her that her agony, and how she expressed it, would not be dismissed or minimized, but rather valued" (p. 220).]
Stikeleather, D. V. "Strategic presence: the effect of the Tibetan Buddhist chaplain's presence on the family's process during end of life medical feeding decisions." Unpublished Master of Divinity Thesis, Naropa University Boulder, Colorado, April 15, 2010. [Silence is mentioned at many points, but see especially those in the section headed by the term (pp. 17-19): e.g., "Silence speaks volumes about attention to another person. It creates a presence that allows the other to flourish in the resultant space. ...[S]ilence fills the space with presence, the presence of companionship. Elizabeth Kübler-Ross speaks of a 'time when it is too late for words... it is the time for the therapy of silence with the patient.' ...Judith Lief points out another use of silence: 'When we sit quietly with another person, we gradually become more aware of that person's presence. We begin to accept and appreciate him. Those two qualities, awareness and acceptance, are the ground of kindness. ... Margaret Mohrmann describes a patient visit where there were no words, but only tears...."] [Available online.]
VI. Silence has figured into several of our Article-of-the-Month selections. For instance, our May 2016 article, "Implementation of a Post-Code Pause: extending post-event debriefing to include silence," involves the a strategic 10-15 second silence with hospital staff "to honor the life of the patient if he or she died or to celebrate the life-saving work of the team if the patient survived" [pp. 59-60]. In our December 2015 selection, "Chaplains on the medical team: a qualitative analysis of an interprofessional curriculum for internal medicine residents and chaplain interns," one finding was: "Multiple residents described learning how effectively they could help patients by simply being present and using silence" [p. 564]. And, Colleen Delaney's Spirituality Scale, featured in our June 2005 selection ("The Spirituality Scale: development and psychometric testing of a holistic instrument to assess the human spiritual dimension"), contains the item, "I use silence to get in touch with myself" [p. 158].
VII. At the time of writing the review, all three authors were faculty members for the Being With Dying Program at the Upaya Institute and Zen Center (Santa Fe, NM), offering professional training programs for clinicians in compassionate care of the seriously ill and dying.