“It was a silence filled with many things going on in it.”
– Dorothy Parker
Shut my mouth. That is one of the hardest things for me to do during a genetic counseling session, though paradoxically it is among the simplest. Despite decades of experience as a genetic counselor, I still have a tendency to dominate my interactions with patients. Maybe all of us are guilty of this to varying degrees. To some extent, it is a natural by-product of a clinical service with a significant educational component. Dialogue easily morphs into monologue.
But genetic counseling does not end at education. Instead the counseling component simultaneously flows from and shapes the educational aspects. I sometimes need a virtual dopeslap upside my head from Jon Weil’s or Seymour Kessler’s spiritual avatar to get things back on track.
How We Talk, a book about conversational analysis by the linguist N.J. Enfield, has helped heighten my awareness of my tendency to dominate counseling sessions. And it is a lot less psychologically painful than Jon’s or Seymour’s dopeslaps.
A typical conversation flows with a rhythm guided by timing cues. Speaker A says something and then Speaker B seamlessly follows with a response to what Speaker A just said, and so the conversational turn-taking flows through to the conclusion of the conversation. In normal everyday conversation the average length of the transition between when Speaker A stops speaking and Speaker B responds is ~200 milliseconds. Literallly in the blink of an eye Speaker B recognizes that it is the appropriate time to speak and has a response ready. The brevity of the silence interval is mute testimony to the stunning complexity of the human brain. Conversation is like a John Cage musical composition based on a pattern of silences. Silence is to conversation as zero is to numbers.
Of course, there are within- and between- individual variations in any conversation. There are also differences between languages, but the differences are slight. For example, in the Mayan language Tzeltal, the average transition time is 67 milliseconds, in Italian it is 310 milliseconds, in Lao it is 420 milliseconds, and in Danish it is 470 milliseconds. English is just above average at 236 milliseconds. No doubt a Dane would drive a Tzeltal speaker crazy with the extended transition time, but the difference between the languages is under half a second, within the range of an eye blink.
The dialogue from the screwball comedies of the 1930s and 1940s move along at dizzying speed because we perceive the transition times as almost non-existent. The great screenwriters intuitively understood this and Cary Grant, Katharine Hepburn, et al., effortlessly deliver witty repartee that leaves your brain gasping for breath.
When the transition time exceeds a half second, and especially as it approaches one second, Speaker A perceives the response as taking too long and tends to jump back into the conversation, “out of turn.” This One Second Rule is called a standard maximum silence. It is often more than a matter of Speaker B needing more time to formulate a response to a complex statement or question. The longer than expected delay can communicate that Speaker B thinks the response is “non-preferred,” that is, something that Speaker B feels may not be the reply that Speaker A wants to hear. And when Speaker A jumps in out of turn, Speaker A will re-phrase in a way that makes it easier for Speaker B to give a non-preferred response. Subtle non-verbal emotional interplay takes place in the space of a silent second. The silence of the iambs. The following fictional counseling scenario demonstrates this:
Scenario A
Counselor: So, do you think you want to undergo this genetic test?
(1 second pause)
Counselor: You don’t have to make up your mind right now.
(800 millisecond pause)
Client: Well, the test could be helpful. I am not sure about my insurance coverage, though.
Here, the 1 second pause suggests that the patient may not want the test, and the “long” pause pushes the counselor to jump in and say something that makes it easier for the patient to decline testing. The patient replies in a way that that the patient feels the counselor prefers to hear – the test is important – but bringing up insurance coverage gives the patient a “legitimate” reason to decline testing. Even though the counselor may feel that she or he was non-directive, the patient may have picked up on a message that perhaps the counselor thinks the patient should undergo testing, even if the counselor is not saying it in so many words.
Generally, Yes/No responses that occur within the first half second of a transition are perceived as more definitive whereas responses that are closer to one second or longer are usually interpreted as ambiguous. The following fictional exchanges between a counselor and a client illustrate this:
Scenario B
Counselor: So, do you think you want to undergo this genetic test?
(200 millisecond pause)
Client: Yes.
Scenario C
Counselor: So, do you think you want to undergo this genetic test?
(1 second pause)
Client: Um (3oo millisecond pause) it might be a good idea.
In Scenario B, the short transition time of the client’s response suggests a strong desire to have testing. However, in Scenario C, it takes the client 1.3 seconds to arrive at a form of Yes, the hesitancy in the response possibly reflecting a hesitancy to undergo testing. The interjection “Um” before saying “Yes” reinforces the perception of ambiguity. This 1+ second difference in transition time is a clue to skilled counselors to more deeply investigate the patients’ desires and reasoning, even though the counselors and the clients may not be consciously aware that clients are communicating clues to their ambiguity.
Of course, in the context of a counseling session, a delayed response could be due to the cognitive processing required to comprehend technical medical information or it could be due to psychological processing of an emotionally laden discussion. Which, to some extent, is the point here. A genetic counseling session is not usually an ordinary conversation (though a skilled counselor can make it appear that way), so the turn-taking of the speakers can be expected to have a different rhythm and follow different timing cues. But because we are so subconsciously attuned to the rhythm of normal conversation, the tendency for genetic counselors to sometimes dominate a session may stem in part from relying on the wrong timing cues and to speak out of turn before patients are ready to articulate their thoughts.
An interesting research project would be to record counseling sessions with the purpose of timing transitions between counselor and client. This could then be correlated with outcomes such as patient satisfaction and uptake of recommendations to see if they were influenced by conversational transitions. Transition times could also be used to guide the development of better counseling skills by helping the counselor to understand ways that transition times were used appropriately or inappropriately during the course of a counseling session.
To be sure, transition times are not the only non-verbal influence on the rhythm of a conversation. Posture, gestures, facial expressions, and eye gaze can influence the flow of conversations and serve to articulate the psyche. Reading the body of clients is as important a skill as being attuned to their verbal language. People are generally less aware of their body language and thus it can more “honestly” and directly reveal underlying psychological and emotional processes than verbal language.
It is extraordinarily difficult to be keyed into what Enfield calls “the inner workings of conversation,” especially in the moment of the conversation. It involves unlearning, or more precisely becoming aware of and being able to manipulate, a language protocol that has been subconsciously engrained into us since we burst out of our amniotic sacs. Becoming a good counselor is not simple nor is the path always straight. The graph of professional growth follows a jagged and at times recursive line. There is no breakthrough moment when you permanently become the genetic counseling equivalent of a Jedi Master, able to manipulate the Counseling Force to your will and you are infused with Yoda-like wisdom. Easy it is not.
Thanks yet again to Emily Singh for help with graphics.
The DNA Exchange 
Captured beautifully, the session is like a dance, sometimes we get the steps and we follow each other effortlessly and sometimes we just don’t!
We discussed the “rituals” of clinical care at Schwartz Rounds last week and this fits nicely with that. Do we wear white coats or not, which ice breakers have we come to depend on, which collection of words have we learned will best convey our messages, and now we get to think about the significance of a pause. I love it. Thanks!
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