62
In the psychotherapy literature, Lane et al. ( 2002 ) assert that silence must be
done skillfully in order to convey “safety, understanding, and containment (p. 1091).
When done unskillfully, they note it can imply ‘distance, disinterest, and disengage-
ment’ and thus damage trust” (p. 1091). Two studies of therapist views of silence
found their reasons to use silence included to facilitate reflection, encourage respon-
sibility, facilitate expression of feelings, and convey empathy (Hill et al. 2003 ;
Ladany et al. 2004 ) and also to give therapists some time to think of what they want
to say (Ladany et al. 2004 ). Sharpley et al. ( 2005 ) studied the relationship between
silence and rapport in initial therapy sessions and found significantly higher amounts
of silence during portions of the sessions rated as “very high rapport.” Moreover,
silences initiated by therapists and terminated by clients were more likely to con-
tribute to rapport than were silences which were both initiated and terminated by the
therapist.
Levitt ( 2002 ) asked clients to discuss pauses in video-recorded therapy sessions
and found three sorts of productive pauses: emotional pauses, in which clients
moved more deeply into their specific feelings; expressive pauses, in which clients
were searching for words to express their ideas and/or name their feelings; and
reflective pauses, in which clients were questioning, gaining further awareness of an
issue, and/or connecting ideas and gaining insight/realization.
3.5.2 Patient Characteristics that Pose Attending Challenges
Limited Communication Ability
Providing genetic counseling to patients with limited communication ability is chal-
lenging. Sometimes limited communication is due to psychophysiological reasons.
For instance, Kring and Stuart ( 2008 ) describe individuals with major depressive
mood disorder as having dampened facial, vocal, and gestural expressive behaviors.
They tend to exhibit less eye contact and have a flat, dull, and slow tempo when
speaking. This is not to be confused with cultural differences [cf. Kim et al. ( 2003 )
about Asian-American culturally endorsed behavior] or with thinking the behavior
reflects motivation or intent as opposed to an underlying physiological state
(Patterson 2003 ).
Smith et al. ( 2014 ) described a genetic counseling case in which the patient’s
disease progression posed communication challenges. The patient had sporadic
ALS and maternal history of HD. The authors noted that, “Assessment of our
patient’s nonverbal communication was also limited given his disease progression,
which significantly limited his physical movements...Therefore, alternative
approaches had to be used in order to establish a working relationship with the
patient and understand his needs and desires. Our approach was to limit the infor-
mation conveyed to what was most necessary to communicate and to utilize yes/no
questioning to facilitate our patient’s involvement. Additional counseling time was
also provided to accommodate the patient’s limitations” (p. 730).
3 Listening tofiPatients: Attending Skills