Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Saturday, March 29, 2014


The idea for this post came from a reader who prefers to remain anonymous, but I did want to give due credit, so, you know who you are, and thanks.

Silence is very important to me, both professionally, and personally. I'm pretty sure I picked the right profession for myself, because I don't much like talking (I do like listening), and I'm comfortable sitting silently with patients.

As an aside, one of the attendings from my residency did his residency, way back, at Menninger, when the Menninger brothers were there. So he was surrounded by a lot of analysts for 4 years, and he told me, "For people who spend their days listening, when you get them in a room together, they sure do like to talk."

I have found this to be true, but maybe not to the extent I formerly believed. In one of my first analytic classes, we read a paper about choosing patients who are appropriate for analysis. When I walked into the classroom, before class started, the guy teaching the class asked me what I thought of the paper. So I summarized. "You can't be too sick, you can't be too well, and you never know 'til you try." At the time, I thought that was pretty much everything there was to say about the paper, even though we went on to discuss it for 1 1/2 hours.

Now I'm not so sure. Maybe it has something to do with the value analysis places on language-it is, after all, a "talking cure" (Note that the phrase was coined by Bertha Pappenheim, AKA Anna O, while she was being treated by Joseph Breuer for hysteria. Hers is the first case recorded in Studies On Hysteria, by Breuer and Freud). Or maybe it has to do with the fact that the more time you spend listening to a person, the more you discover how much more there is to know about that person. And the same is true for most, if not all subjects. The more you know about a subject, the more complex you realize it is. So if I thought there wasn't much to say about that paper, it was probably a reflection of my ignorance.

What about silence? It's not the therapeutically exclusive provenance of psychoanalysis. It happens often in face-to-face therapy, and it may even be more difficult to tolerate in that setting than in analysis, where both the analyst and analysand are protected by the lack of eye contact.

Silence can take on many meanings in a therapeutic setting. For the patient, it can be withholding and aggressive, as in, "You can't make me talk!" It can be a form of hiding, as in, "I'm ashamed of my thoughts and feelings, so I'm not going to humiliate myself by sharing them." It can be an attempt to level the playing field, "You don't tell me anything about yourself, so I won't tell you anything, and that way I won't feel helpless and inferior."

It can also be an expression of trust, "I'm comfortable enough with you that I don't feel obligated to entertain you or be socially appropriate by babbling or trying to make conversation." And it can represent an attempt to share an experience or idea that is difficult to verbalize.

Patients have feelings and thoughts about the therapist's silence. It may be seen as punitive, humiliating, rejecting, abandoning, empty, containing, comforting, and many other things.

Therapists also have views about their patients' silences. Are they being hostile, or controlling? Are they confused? Are they attempting to sort through some experience that has not existed for them in the verbal sphere? Are they frightened? Am I doing something wrong? Am I doing something helpful? Do they need me to say something? Am I distracted and therefore have nothing to say?

These questions obviously reflect therapists' feelings about their own silences.

One important question is, why is silence often experienced as uncomfortable? The straightforward answer is, because that's not what people do in normal social interactions. But why is that? What's wrong with not talking? It's true, we're social beings, but speech is not the only form of communication.
At parties, people who don't talk much are considered uninteresting. In many educational settings, children who prefer to take in a discussion and not comment frequently are often thought to not be paying attention. And in medical school, when I was in new, complicated settings like the OR, or the ICU, and was asked by residents or attendings if I had any questions, I usually didn't because there was so much new information to absorb, I hadn't yet reached the point of being able to formulate a question. This was sometimes viewed as evidence of lack of interest on my part.

So we can agree, I think, that both silence and speech are complicated. One thing I wonder is, what happens when clinicians not only don't have time to talk with their patients, but don't have time to sit in silence with them, either?

These are some interesting quotes about silence, that I found on PEP-Web:

From the APSaA Winter Meeting, 1948:

CHAIRMAN: President William C. Menninger, M.D.
2:00 P.M. Robert Fliess, M.D. (New York): Silence and Verbalization: On the Theory of the Analytic Rule.
Discussants: Therese Benedek, M.D. (Chicago); Robert C. Bak, M.D. (New York)
Author's Abstract: Verbalization releases regressive affect, collateral to repressed ideation, thus interfering with the maintenance of repression. The speech-apparatus is substituted for different erotogenic zones, whereby speaking becomes excretory instinctual discharge, words excretory product, and silence equivalent to sphincter closure. Technical and theoretical consequences deriving from these “pleasure-physiological” considerations are discussed.

Greenson, R.R. (1961). On the Silence and Sounds of the Analytic Hour. J. Amer. Psychoanal. Assn., 9:79-84

The most frequent silence met with in psychoanalytic practice is the silence of resistance. This silence means that the patient is either consciously or unconsciously unwilling to verbalize. Since the patients in our psychoanalytic practice are attempting to communicate to us in accordance with the basic rule, i.e., attempting to put all their thoughts into words, if they become silent, it means that they are opposing the procedure of psychoanalysis. It is then our task to overcome this obstacle by attempting to find the motives for this resistance. Here, we are often aided in our task by the fact that the patient communicates despite his resistance...
Silence, however, may not only indicate a resistance to a certain content but may itself be the content which the patient is trying to convey. For example, patients may fall silent during an analytic hour when they are unconsciously repeating some historical event in which silence was an important element. Primal scenes and primal auditions often make their first appearance in the analytic hour as a restless, agitated, wide-eyed silence. The patient is repeating in the presence of the analyst the silent excitement and anxiety of the primal experiences.
Silence may indicate an identification with a silent object. This happens frequently in the analysis of candidates, who in this way identify with their silent analyst. This should be kept in mind when the silent patient seems to be not only comfortably silent, but confidently and poisedly silent. Furthermore, silence can represent an identification with an inanimate object, a sleeping object, or a dead object. This reaction, however, I have only seen in extremely disturbed and repressed patients.

Zeligs, M.A. (1961). The Psychology of Silence—Its Role in Transference, Countertransference and the Psychoanalytic Process. J. Amer. Psychoanal. Assn., 9:7-43

Let us first conjecture as to what a state of silence between any two (or more) human beings might signify. Obviously it could reflect many different psychic states and qualities of feeling.2 It might evidence agreement, disagreement, pleasure, displeasure, fear, anger, or tranquility. The silence could be a sign of contentment, mutual understanding, and compassion. Or it might indicate emptiness and complete lack of affect. Human silence can radiate warmth or cast a chill. At one moment it may be laudatory and accepting; in the next it can be cutting and contemptuous. Silence may express poise, smugness, snobbishness, taciturnity, or humility. Silence may mean yes or no. It may be giving or receiving, object-directed or narcissistic. Silence may be the sign of defeat or the mark of mastery. When life-and-death situations are

2 Because of its ubiquity, silence has been thought about in many frames of reference. Poets, dramatists, and philosophers have loosely used the concept "silence" metaphorically and allegorically to symbolize death, eternity, truth, wisdom, strength, etc. Literary references to silence are frequent in the classics from all periods of history...
3 It is interesting that the aphorism, "Silence is golden, " represents what is left of the complete saying, "Speech is silvern, but silence is golden, " the part about speech having since dropped out of popular usage, historically attesting to the transitoriness of speech as compared to the permanence of silence. This derives from an ancient proverb written in Aramaic which first appeared in the Talmud Megillah and Midrash Rabba Esther (Chapter 6) in relation to prayer, as follows: "If a word is worth one selah, silence is worth two. (Silence invokes Thy praise.)"... The later Hebrew equivalent then became, "If a word be worth one shekel, silence is worth two, " pointing to the material advantage of keeping one's own counsel...

being sweated through there is little occasion for words.3 Silence may be discreet or indiscreet. A tactful silence serves to prevent the expression of inappropriate thoughts and feelings. The art of being tactful combines the skilled use of silence in verbalized as well as nonverbalized action. Thus there is a hidden component of silence in every verbalization. When complete silence is inappropriate or impossible, a gesture, grimace, or mimetic expression serves as a compromise between verbal and nonverbal communication.

I'd love to hear about people's experiences with silence, so please comment.