When is Silence Golden?

Silence can be very difficult to tolerate for both the analyst and the patient.  In fact, because so many patients want an active and engaged therapist, I often fear that protracted silences may even drive the patient away and out of therapy.  While ongoing silences can be rich in psychic material, I have found that silences are often misunderstood.  And unless the patient has an understanding of how therapy works, silences are not particularly useful.  It’s essential to initiate patients to the therapeutic process by first establishing a safe and empathetic environment that gradually allows them to tolerate longer silences.

Difficulties with silence are not the patient’s alone.  I struggle with longer silences as my reflex is to intervene with a question or statement to alleviate my patients’ (and my own) anxiety.  Because of my discomfort, my impulse is to replace the silence with action.  An important part of the therapeutic process is figuring out whose feelings are whose and when to break the silence.  It’s essential, of course, that I don’t break the silence out of my own anxiety, but only when the patient’s anxiety is becoming unbearable for him or her, not for me. Intervention at an inappropriate moment can interfere with the patient experiencing feelings that need to be experienced.  At other times, a question or statement that breaks the silence helps the patient feel more secure in the room.

In classical analysis, silence is an essential tool.  The classic theory is that the patient should lead the treatment; if the patient is silent, the therapist waits for him or her to engage.  While this approach is clearly valid, many patients find it helpful if, at times, the analyst leads.  But with the analyst leading, there is of course the danger that the treatment will follow the therapist’s agenda and not that of the patient.

It also makes a difference if the patient is lying down on the couch or is sitting in the chair, facing me. Invariably, those who lie on the couch find it easier to endure silence.

A couple of examples illustrate this dilemma:

I had a patient, a man I had seen for many years, who came in one session, lay down on the couch, and remain silent throughout the whole session.  I struggled silently with whether to intervene, at what point, and whose anxiety was whose.  I decided to let silence reign and not let the anxiety — which was no doubt at least partly mine — compel me to action.  At the end of the session, my patient sat up.  He then thanked me for allowing him the space to sit with him without verbalizing.  He said that he really needed that time to just be.  I was happy that I didn’t succumb to my own discomfort and ask a question or give an interpretation.

A patient I’ve been seeing for a number of years comes into each session with nothing to talk about.  He depends on me to ask questions and even after years of treatment, is very resistant to bringing in material for us to explore.  He is someone who cannot access his feelings and for whom unconscious resistance has thwarted his treatment.  After a long period, I decided to allow him his resistance and accept his need for me to elicit details of his week.  Since he cannot access his feelings, exploring occasional silences has been fruitless.  He needs me to check in with him to ground him and prevent him from fleeing as a result of his unconscious resistance.  As I tailor each treatment to the needs of the patient and the dynamics of the dyad, I accept my more active role with this patient because the circumstances clearly warrant it.

Protracted silences present a dilemma for the analyst.  I often explore these silences and the non-verbal feelings they induce.  Such exploration allows me to discover vital information about the patient.  On the other hand, when silence is intolerable for the patient, I learned to respect this and offer action that helps the patient feel safe and secure.





A Political Dilemma

What happens when a patient expresses a feeling or opinion that induces strong counter-transferential feelings in an analyst with passionate political opinions and views? The classical viewpoint, of course, is to keep such thoughts to one’s self. But what happens when the patient exhibits attitudes that are clearly prejudicial and at times even abhorrent to the analyst?

Following the old adage that the personal is indeed political, I am proud of my activism — albeit with age it’s more verbal than active — but at the same time I am committed to creating a safe and empathic environment for my patients.

As an analyst, my role is not to educate about politics or to explore prejudice even if what I hear is hostile bigotry. Yet, when I am confronted with thinking that I find offensive or culturally dangerous (albeit only verbal), my emotional response is the same as it would be outside the office. Do I remain silent? Will my own need for exploration represent my agenda rather than that of my patient? And how do I prevent such thinking from influencing my view of that patient?

Fortunately I am not confronted with this dilemma often. When it has happened, I have remained silent and let myself be with my counter-transferential feelings. But this does leave me wondering as to what might be a helpful and ethical intervention.

A patient of mine had consistently expressed his dislike of lesbians. When he was particularly angry, he referred to them as “cunts.” Since I’m very sensitive to sexism, the use of that word left me bristling. Because I continually remind patients that I want to hear all their feelings, I never responded. But I did struggle silently with whether to explore his animosity (my own agenda) or continually listen as he expressed his anger. Although we often worked on his anger issues, when he used that word I ultimately held and respected his feelings with silence. I often wondered if there would come a point when I might lead my patient to explore his prejudicial views. That time never came.

Many years ago I had a patient who was conservative politically and had no patience, sympathy, or understanding of minorities’ position in society. At one point he referred to Hitler as a great man. I asked him what he meant by that and he referred to Hitler’s power. I did not go any further with the comment, thinking that to do so may feel to him like an attack. Nothing else was said by this patient during the time I saw him that would allude again to the Hitler comment. That comment still haunts me all these years later. I often wonder if and how I might have responded differently to hearing something so abhorrent.

While these are extreme examples, there have been many subtler examples that contribute to this same dilemma. I wonder how much of my commitment to bettering society might extend to my one-on-one relationships with patients. Although I always err on the side of caution, I continually wrestle with how my silence as a therapist ultimately conflicts with my passionate political commitment to affect change.