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.