Silence in Practice

Harvey, L., 2008. Silence in Practice. Reformulation, Summer, pp.11-13.

a workshop presented at the ACAT conference in January 2008

Over the years I have supervised a number of therapists and marked even more process reports. From this experience I feel it would be forgivable for me to imagine that in CAT, other than in my own experience, “Silence hardly ever happens”.
It seems strange that silence is rarely mentioned. I do not remember discussing it during the early days of my training, and a quick review of the books on the art of counselling barely give it more than half a page as a topic.

Freud, however, had a particular understanding of silence, as it signalled that his clients were no longer willing to free associate and he interpreted this as resistance. Today, although free association is not necessarily a part of a psychotherapeutic approach, silence still seems to signal danger to many inexperienced and some experienced therapists.

It seems to me that it would be an important dilemma to bring to supervision. Before rushing to make an interpretation or comment during a session, it might be advisable for the therapist to pause long enough to decide if the comment applies to the client or himself and be more open to considering all the possible implications of the silence before seeking to close it down.

Silence may be a comfortable space

Balint (1955) identified two meanings for silence in therapy. One he described as, “a frightening experience of a horrible emptiness full of suspicion, hostility, rejection and aggressiveness, a silence which blocks progress and is on the whole barren. The other is a tranquil, quiet experience of harmony, an atmosphere of confidence, acceptance, and peace: a period of tranquil growth, of integration”. He went on to say, “It is most important for the analyst to recognize which of these two types of silence he has to deal with…” Moreover, silence may have a meaning for the patient exactly opposite to what it has subjectively for his analyst. Obviously the danger is always present that the analyst’s interpretations might also be conditioned by his subjective reactions or by his theoretical expectations. Balint’s own analysis was with Sandor Ferenczi who spoke of the need for a prolonged analysis for the therapist for just this reason.

Certainly our own therapy can teach us about the power or pleasure of silence, and I have to admit that I have never been concerned with it in my experience. Recently I was completely surprised when my therapist interrupted whilst I was in full flow and suggested I might like to pause for a few minutes and reflect silently on what had just been said. It didn’t feel uncomfortable for me and I suspect she was actually trying to slow me down, as being talkative can be equally uncommunicative when subjects are being avoided. However, she did not interpret this for me, but left me to reflect/ learn as appropriate.

One process through which silence is diminished in CAT is the focus on diary keeping, time lines and psychotherapy files. It is worth remembering that these are often silent communications by the client and for that reason may appear less threatening. It may also be reasonable to allow clients to write down their feelings whenever they feel stuck. Where is the rule that says it has to be spoken?

A recent art exhibition I attended was called You Silently. I have to admit it took me a considerable length of time to recognize that the written word, whilst a form of communication, is also silent, just as most forms of Art.

It is also worth checking if the client has a reason for not wanting to speak – in a completely neutral way. I was once told by a client who suffered from OCD that she had a rule that day that she would not be able to speak of certain things. This not only proved very informative generally but eased the tension for both of us, as I felt she was being deliberately uncommunicative and she knew it but needed to be asked before she could communicate what to her was a ridiculous state of affairs.

Here is an example from Egan’s “The Skilled Helper”, a text on my reading list when I was following a course in counselling psychology and which I believe was also on the early advanced course in CAT.

Client says:

“What seems to be bothering me is a problem with sex. I don’t even know whether I’m a man or not, and I’m in college. I don’t go out with women. I don’t even think I want to. I may….. well, I may even be gay….. Uh, I don’t know.” (Peter then falls silent and keeps looking at the floor.)

Egan says that the following are poor responses:
It is a mistake to say nothing. Generally, if the client says something significant, respond to it, however briefly. Otherwise the client might think that what he or she has just said doesn’t merit a response. Don’t leave Peter sitting there in silence.

A question: A counsellor might ask something like: “How long has this been bothering you Peter?” This response ignores what Peter has said and his feelings and focuses rather on the helper’s agenda to get more information.

A cliché: A counsellor may say, “Many people struggle with sexual identity, Peter, especially at your time of life.” This is a cliché. It turns the helper into an instructor and may sound dismissive to the client. The helper is saying, in effect, “You don’t really have a problem at all, at least not a serious one”. The helper is once more involved in his own agenda.

An interpretation: A counsellor might say something like this: ”My bet is that this sexual issue is really just a symptom, Peter. I’ve got a hunch that you’re really not accepting yourself. That’s the real problem.” The counsellor fails to respond to the client’s feelings and also distorts the content of the client’s communication. The response implies that what is really important is hidden from the client. Once more the helper’s agenda takes centre stage.

Advice: Another counsellor might say: “Stay calm, Peter. Remember that you’re struggling with issues that everyone struggles with. I’ve got a booklet here that I’d like you to read.” Advice given at this stage is out of order; it could make things worse. The advice given has a cliché flavour to it. It also distances the helper from Peter’s concerns.

Parroting. Empathy is not mere parroting. The mechanical helper corrupts basic empathy by simply restating what the client has said. A tape recorder could do as well.

Sympathy and Agreement. Being empathic is not the same as being sympathetic and at its worst, sympathy is a form of collusion with the client. Egan, G. (1994) The Skilled Helper. Ch 5. Brooks Cole Publishing

In the workshop, I asked, ‘What are some good responses?’ Needless to say many considered that they may have answered as above. This highlights the danger of being too formulaic either in advice to therapists or to clients.

Once the response is given, advisable or not, the ongoing task is to actually listen to or observe the next response from the client. Too often in case reports the interventions are inadequately analysed.

Here is an example from Analytic Theory, taken from Baker, R. (2000) Finding the neutral position: Patient and Analyst Perspectives. J. Amer. Psychoanal. Assn. 48:129-153

In a clinical seminar, Dr. J., an analytic candidate, presented a control patient who had been in analysis for only five weeks. Dr. J. said he disliked his patient, who, he emphasized had been awkward from the outset, openly distrusting him and constantly complaining that he said little or nothing in response to communications. In particular the patient described his father as a boorish man who always demanded the compliance of his family, even when he was in the wrong. The analyst sought sympathy from me and his colleagues and tried to elicit support that the case was inappropriate for a candidate.

In the session Dr J reported, he had arrived five minutes late. The patient was silent throughout the session, saying nothing until the analyst called time. “That’s the sort of problem he faces me with all the time,” Dr. J said. In our discussion a number of questions were raised. A seminar member asked if he had apologized for being late or had offered an explanation. “No of course not,” the analyst replied, “ it’s not as if I was very late, and anyway if I did offer an explanation it would be like I was deferring to him, and besides that would be a self-disclosure and not strictly neutral.” Another colleague suggested that he might have interpreted the patient’s silence as a communication that he wanted the analyst to know what it feels like to be kept waiting. To this Dr. J. replied that that would be his association and not that of the patient, again a breach of neutrality. “Anyway”, he continued, “predictably, at the start of the next session the patient complained that I was late the previous day.” Dr. J. then interpreted his patient’s criticism as an attack. In consequence, the patient distanced himself from the analyst, resulting in further interpretations of the patient’s hostility towards him.

The impasse, including the analyst’s part in it, was clear to all members of the seminar. Dr. J’s perspective was that he was right in believing that he had an impossible patient. He was unable to see that his dislike of the patient, his lack of empathy, and his inability to admit that he was at fault by being late had led to the patient experiencing him as an actualized transference object. The patient’s perspective was that his analyst was behaving in reality like his father, a man who demanded compliance and could not admit mistakes. In such situations, impasse may lead to termination, the unfortunate outcome in this case.

Here is an example from Brief Psychotherapy, taken from an article by Curtis and Silberschatz.

A 60-yr-old widow entered our brief therapy program with the presenting complaint that she was unable to have fun. She reported that recently she had decided to take a vacation and had gone so far as to drive to the resort and check in, but then had decided she should not stay and returned home. She was a very successful executive, but worked many more hours than she was paid for, frequently going to her job on weekends or even in the middle of the night. When she had time off, she often felt lost. At such times, she would usually call upon one of her grown children to see if she might baby-sit or perform some other chore for them.

The therapist learned that the patient had come from a very impoverished background and that her mother had been extremely passive and compliant to her rather brutish husband. The patient reported that her mother had looked 60 when still in her 30’s and had died in her 40’s, apparently worn out by the effects of poverty, an abusive husband, and the need to care for more than ten children, both her own and those of relatives.

In the early hours of the therapy, the patient responded to the therapist’s questions, but with little elaboration. There were frequent silences as she seemed to wait for the therapist to ask her something. There were no spontaneous associations, and the patient took no initiative in presenting or discussing issues. When the therapist enquired about her thoughts during the silences, she would reply, for example, that she had been thinking about his shoes, and then say no more.

Rather than seeing this pattern as resistance, the therapist interpreted the patient’s silence as a reflection of her discomfort over taking control and doing something good for herself. He noted that during therapy the patient was acting helpless just like her mother because she felt uncomfortable about getting more out of life than had her mother. Following this interpretation, the patient began associating more and exploring issues. She also confirmed the interpretation by recalling how her mother, after having a foot amputated, would hop around on one leg, waiting on her healthy but indolent husband.

Curtis J.T. and Silberschatz, G. (1986) Clinical Implications of Research on Brief Dynamic Psychotherapy 1, Formulating the patient’s Problems and Goals. Psychoanal. Psychol. 3-3-25.

The Work Shop Task was to break into groups and produce diagrammatic reformulations that outline responses in the various therapists discussed when faced with silence. The reciprocal roles may appear obvious but it is worth thinking outside the usual box and seeking innovative exits. These diagrams can then be made available online and hopefully by the end of the workshops we will have produced a tool that can free more inexperienced therapists from the presumed tyranny of the silent patient and encourage them to reflect more broadly and more openly on the occurrence of silence.

I would like to say that we produced the answer to everything but of course we didn’t. An important observation however was that we should take care to communicate from the position of the client and not that of the therapist. In this way we can avoid being all-knowing, rescuing, silencing, rejecting, or ignoring. We may be more tolerating and focus more on being containing, and even just permitting.

Linda Harvey

Full Reference

Harvey, L., 2008. Silence in Practice. Reformulation, Summer, pp.11-13.

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