Table 3.

Definitions of speechlessness in the identified literature

Type of work	Study design / context of speechlessness and/or silence	In-text definition	Author / Year
Quantitative study	Study 1: A total of n = 210 students participated in a questionnaire survey and received prior information about speechlessness and its occurrence. Participants were asked to recall the last situation in which they felt speechless. Study 2: A total of n = 120 students were presented with a modified version of the questionnaire used in Study 1; however, identical information and instructions for completing the questionnaire were retained. In addition, students were asked to rate a list of 18 potential reasons for speechlessness on a three-point Likert scale.	Study 1: “Apparently, participants did not spontaneously think about the causes of their speechlessness at this level of detail. Analyses of the three most frequently mentioned loci suggest a number of plausible alternative sequences that result in speechlessness, as well as differences in the emotions associated with each sequence.” (p. 160) “Analyses of the three most frequently mentioned loci suggest a number of plausible alternative sequences that result in speechlessness, as well as differences in the emotions associated with each sequence. Although a multitude of events might prompt extreme emotional states and stress, the primary emotion driving the speechless event was fear, not surprise, and once speechlessness ensued, individuals reported being less confused than those designating other causes.” (p 0.161) Study 2: “Although recalled instances of speechlessness again favored those that were involuntary and participants attributed their speechlessness more to their inability to find words to express their intentions rather than their inability to express conceptually formulated messages in speech, individual comparisons of voluntary and involuntary speechlessness attributions with these loci of encoding difficulty failed to produce significant relationships. Because the means of the two encoding difficulty items and some of the involuntary speechlessness loci were quite high and because several of the voluntary speechlessness loci were rated quite low, the restricted ranges of the scales may have attenuated potential correlations between them. Thus, support for the first hypothesis remains circumstantial.” (p. 171) “The results not only demonstrate that different causal loci for speechlessness are associated with different affects, they also show that violated expectations and extreme emotional states in particular are likely to induce more negative affect than are the other causal loci, including those associated with strategic silence.” (p. 171) General Discussion: “The results of these initial investigations of speechlessness present a complex picture of the phenomenon.” (p. 172) “Such attributions as unexpected behavior, another’s overly intense behavior and extreme emotions suggest that expectation violations play an important, but not exclusive, role in potentiating speechlessness; thus, speechlessness may be implicated in interpersonal adaptation process (Burgoon et al., 1993; Guerrero et al., 2000). Specifically, speechlessness may at once be an indicator of violated expectations and, once precipitated, may require significant interpersonal adaptations for its management.” (p. 173) “If instances of strategic silence are excluded from the domain of speechless events, the present studies suggest that speechlessness or being at a loss for words is an involuntary state that renders interlocutors unable to produce speech for periods of time that exceed the usual durations of nonvocalized pauses in fluent speech.” (p. 173)	(Berger, 2004)
Qualitative study	The setting of the survey was an intensive care unit with ten beds for the intensive care of patients with various diseases, excluding trauma and/or infections with multi-resistant pathogens. The respondents were relatives of the hospitalized patients. Subjects of the survey formed the nuclear family (father or mother; child; relatives, married or in partnership). A total of 17 interviews were conducted and recorded. The entire interview was conducted considering one guiding question (What is it like for you to have a relative hospitalized here? Please explain).	“Many relatives, despite their initially expressed difficulty and fear, report that they cannot find a specific word to express the painful situation they are living. During the interviews, it was clear that they tried to find, by gesticulation and silence, a word that would express their feelings, but they were not able to. The feeling was stronger than what could be expressed in words, since words sometimes do not translate the experienced situations.” (p. 600)	(Fabiane & Corrêa, 2007)
Commentary / case description	First case/situation: A young, female patient in a psychiatric facility tried to commit suicide with gloves knotted around her neck. The author describes his perceptions and behavior in this situation. Second case/situation: The author describes dealing with a delusional patient who believes that a microchip is implanted in his molar. The patient insists on performing diagnostic measures (CAT-Scan / X-rays) to prove his version of reality (based on psychosis) and wants to have the molar removed. Third case/situation: The author generally describes the management of bigoted and sexually provocative patients.	First case/situation: ”A clinician in such situations has to say something — but what? Stricken with acute speechlessness, I knew that at the very least I didn’t want to swallow Lisa’s proffered bait and retaliate punitively.” (p. 507) Second case/situation: “He had made his request and waited for my answer. I had nothing to say for at least a few seconds, although it felt much longer. Then it dawned on me to just say what was inarguable: ‘Bill, here’s how I see things. I’m afraid I don’t think the chip is there but I know I can’t convince you of that, and I won’t even try. If I can be straight with you, I think your imagination is getting the better of you on this one.’” (p.508) Third case/situation: “Possibly the most common and malignant variety of clinician speechlessness is that caused by bigoted or sexually provocative patients. Here the doctor’s lack of words is complicated with shock and outrage, rather than with the anxiety of the previous examples.” (p.508)	(Kahn, 2019)
Qualitative study	Recruitment of patients through pain association leaders. Four patients from the same pain association were invited to participate in the study; these patients constitute the study population. Data collection by focus group interview. The interview was conducted and recorded in a semi-structured format. Interviews were transcribed and analyzed using qualitative content analysis.	“Protracted pain may be difficult to describe in words, and it can be hard to find words to describe all the dimensions that the pain entails. Not even swear words are enough to describe the pain. Pain can take the words out of a human being’s mouth and render him or her speechless.” (p. 777)	(Koskinen et al., 2016)
Qualitative study	Data collection in a geriatric rehabilitation clinic. Patients constituted incontinent geriatric patients (> 59 years). For data collection, guided interviews were developed on a prior observation of the patients’ care. Three groups consisting of affected patients, nursing staff, and medical staff were interviewed.	“Nevertheless, there are areas of treatment where speechlessness seems to prevail between professionals and patients, at least experts state […]: Incontinence is one such condition that seems to leave interlocutors sitting speechless across from each other.” [original citation: „Dennoch, es gibt Behandlungsbereiche, da scheint Sprachlosigkeit zwischen den Professionellen und Patienten zu herrschen, so konstatieren zumindest Experten […]: Inkontinenz ist eine solche Erkrankung, die Gesprächspartner sprachlos einander gegenüber sitzen zu lassen scheint.“ (p. 268)] “Instead of allowing speechlessness to prevail, a communication bridge - verbal as well as non-verbal - needs to be built with patients.” [original citation: „Statt Sprachlosigkeit walten zu lassen, muss eine Kommunikationsbrücke – verbal sowie non-verbal – zu Patientinnen und Patienten gebaut werden.“ (p. 272)]	(Kummer et al., 2008)
Qualitative study	Interview with parents of children with cancer (< 12 years; not hospitalized at the time of interview). Thirty-two one- or two-parent families participated in the survey. In summary, n = 49 parents were interviewed. Mother and fathers were interviewed separately. Interviews were audio-recorded and transcribed. Superordinate themes were derived based on the transcripts.	“When Maire told me her story I became overwhelmed with unarticulated feelings of exhaustive emotional pain. Her non-verbally communicated emotional pain took me by surprise because of such an overwhelming sense of anxiety, despair and helplessness […]. It unconsciously triggered my memory of a personal crisis in another social context. This enabled me to recognize the depth of her emotional pain and to contain it. Nevertheless, it overwhelmed me in such a way that I became speechless, unable or comment or ask related questions. Other possible reactions could have been to split it off immediately, or for example, deny its painfulness by reassurance […].” (p. 118)	(Lillrank, 2002)
Commentary	The author describes in detail the situation of an emergency operation with resuscitation measures, in which the affected person dies while a close person (relative) is present. The author then goes into detail about the feelings of the relative as well as the feelings of the emergency physician and operationalizes speechlessness to describe the situation.	“Another speechless experience is highly relevant to medicine because here the borderline of language coincides with a borderline of medicine: the confrontation with death.” [original citation: „Eine andere sprachlos machende Erfahrung ist hochgradig relevant für die Medizin, weil hier die Grenzlinie von Sprache mit einer Grenzlinie der Medizin in Eins fällt: die Konfrontation mit dem Tod.“ (p. 283)] “While emergency medicine is invasive and stringent, psychosocial support starts first with the bereaved person’s experience that another human being perceives and takes him seriously and shares his speechlessness, his speechless grief and helplessness - beyond words.” [original citation: „Während in der Notfallmedizin invasiv und stringent gearbeitet wird, setzt die psychosoziale Unterstützung zunächst mit der Erfahrung des Hinterbliebenen ein, dass ein anderer Mensch ihn wahr- und ernst nimmt und seine Sprachlosigkeit, seine sprachlose Trauer und Hilflosigkeit – jenseits aller Worte – teilt.“ (p. 283)] “The need for emergency medicine highlights that even the domestication of death is only partially successful. When a person dies despite the physician’s commitment, the physician is confronted with functional helplessness: The occurrence of death or the inability to stave off death cannot be blamed on him or her” [original citation: „Der Bedarf an Notfallmedizin zeigt auf, dass auch die Domestizierung des Todes nur teilweise gelingt. Wenn ein Mensch gegen das Engagement des Arztes stirbt, ist der Arzt mit funktionaler Hilflosigkeit konfrontiert: Das Eintreten des Todes oder das Unvermögen, Tod abzuwehren, ist ihm nicht anzulasten“ (p. 284)]	(Müller-Cyran, 2007)