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Liegner, E. (1974). The Silent Patient*. Psychoanal. Rev., 61:229-245.

(1974). Psychoanalytic Review, 61:229-245

The Silent Patient* Evelyn Liegner, M.S.W. Silence as a phenomenon in classical psychoanalytic practice has long been understood theoretically, but its management has been limited in the past to interpretive techniques which have rarely led to its resolution as a major resistance. This paper will deal with the understanding and management of silence and present alternate methods to the handling of silence therapeutically. Silence serves multiple purposes. In a positive sense, silence may indicate pleasure, joy, harmony, acceptance, approval, understanding, interest, anticipation, peace; in a negative sense annoyance, anger, fear, despair, depression, aggression, contempt, disinterest, withdrawal, or absence of emotion. Concepts of silence have crept into our language. We say, “Still waters run deep.” We give someone “the silent treatment.” We refer to “the strong and silent type.” In the Old Testament (Proverbs) we learn that “even a fool, when he holdeth his peace, is counted wise.” Carlyle, in Sartor Resartus, pointed out that “Silence is the element in which great things fashion themselves.” And it was Oscar Wilde who, in The Picture of Dorian Gray, observed, “He knew the precise psychological moment when to say nothing.” Silence unites and separates. As M. A. Zeligs wrote,27 it can reflect many psychic states and qualities of feeling. … 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 —————————————

Presented as a lecture entitled “Silence as Resistance” at the first annual lecture series of the faculty of the Center for Advanced Psychoanalytic Studies held at the New York Academy of Science, N.Y., April 1971. WARNING! This text is printed for the personal use of the subscriber to PEP Web and is copyright to the Journal in which it originally appeared. It is illegal to copy, distribute or circulate it in any form whatsoever. - 229 -

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. … Silence may be discreet or indiscreet. … Some of the most poignant emotional experiences in life are enjoyed or endured in reflective silence. … Grief, mourning, or … ecstasy. … are essentially silent. … A person truly overwhelmed with emotion usually reacts with silence rather man speech. During periods of depression, apathy, or boredom there is a general disinclination to speak. … On a physiological level, silence and immobility … serve as bodily protective (Homeostatic) mechanisms. … To be silent means to be safe from others and from oneself. Silence is also linked with heightened sensory acuity as a strategic, aggressive, or defensive maneuver observed in games, war, or love. Silence, Zeligs continues, provides a soothing atmosphere for the sick, aged, and bereaved. Silence in the hospital, nursery, church, library, or psychoanalyst's office provides a protective shell offering warmth or supplies on different functional, symbolic, and sublimated levels. The total impact of silence throughout life has, in fact, such a wealth of meaning and influence that only a modicum of its potential can be appreciated. For silence, like thought itself, premeates all levels of human functioning, from the infantile to the most mature form of mastery. Thus it provides a continuous medium for the communication and discharge of affect. The foregoing has been quoted extensively to emphasize the multiple facets of silence. In treatment, however, it is necessary to differentiate between silence as a resistance and silence as a communication. If we understand that resistance is anything that interferes with communication in the analytic hour and that silence at times may actually be a communication on the part of the patient, we will be less liable to engage in a power struggle with a supposedly recalcitrant patient. Despite this knowledge, the beginning analyst often feels that progress has ceased with the cessation of speech and feels compelled to induce his patient to resume speaking.

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Analysts often feel that sessions where the patients are verbal and emotional are manifestations of progress, while sessions with prolonged silences or gaps in communication are empty or wasted hours. In reviewing the literature one finds that despite the major problems silence presents to psychoanalysts, there are surprisingly few studies on this subject. In all twenty-four of Freud's collected volumes WARNING! This text is printed for the personal use of the subscriber to PEP Web and is copyright to the Journal in which it originally appeared. It is illegal to copy, distribute or circulate it in any form whatsoever. - 230 -

silence is not given a heading of its own in the general index, although sleep, shame, smell, stammer, and speech appear in every volume—as does, of course, sex. In contrast, only one major symposium has been held on this subject, in 1961. The papers presented were published in the Journal of the American Psychoanalytic Association. 19 A review of the subject index and table of contents of the major psychoanalytic literature turned up approximately a dozen papers. Interestingly, one finds endless literary references to silence from poets, dramatists, musicians, philosophers, and religious leaders. Of particular interest is C. Roland Wagner's “Silence of The Stranger” 25 in which he probes the psychoanalytic meaning of the silence of Camus' hero, Meursault. In December 1967 an article entitled “The Effect of Silence on a Relationship,”11 concerning Ingmar Bergman's film Persona, appeared in Commentary magazine. And in 1971 Paul Goodman explored silence in his article “On Not Speaking” in The New York Review of Books. 13 With the aid of an excellent summary4 on the subject, I would like to present some early views of silence in the psychoanalytic literature. Freud was primarily interested in the intrapsychic meaning of silence. In his early papers9, 10 he referred to silence as a resistance to transference thoughts about the analyst. He also recognized it as opposition by the patient to remembering. He showed little interest, however, in studying or understanding its effect and meaning on the immediate analytic relationship. In general his focus remained theoretical and scientific. From about 1912 to 1930, silence was viewed primarily as a resistance to anal-erotic wishes. Ferenczi wrote a paper, “Silence Is Golden,”7 in which he equated the hoarding of words with the retention of feces. “Silence is”gold “only because taciturnity in and for itself means a saving.” Ferenczi differed from Freud in that he later became much more interested in the clinical phenomena of the immediate analytical relationship. Technical management during this period centered mainly on the use of educational measures and interpretation to encourage the patient constantly to resume talking. If the analyst failed in getting the patient to talk, he was expected to respond with a mirrored silence. This became the ritual rule of psychoanalysis despite the fact that as early as 1920 one analyst, I. Hermann,15 noted that silence seemed often WARNING! This text is printed for the personal use of the subscriber to PEP Web and is copyright to the Journal in which it originally appeared. It is illegal to copy, distribute or circulate it in any form whatsoever. - 231 -

to be intensified as a reaction to interpretation and encouragement. Although several small innovations were introduced between 1930 and 1945, the relationship between mechanisms of defense and the libidinal stages remained constant. In recent times there have been many theoretical advances in the understanding of silence. Calogeras4 sums up the overview of silence from 1945 on, as conceived by the 1961 Symposium on the Silent Patient:19 Silence … has taken on the manifold aspects of an ego psychological dimension of personality. Thus silence has been conceptualized as a highly overdetermined state which is not easily classified or systematized. Unfortunately, despite the greater understanding of silence and despite repeated references in the psychoanalytic literature to the negative reactions to interpretation, the handling of silence does not often demonstrate much advance in technique. Often the interpretation of silence to the patient fails in its intent and, moreover, random examples selected from reported cases indicate that (1) the analyst receives the patient's silence with hostility; (2) the analyst draws numerous conclusions concerning the effect of silence which, for want of further proof, may be attributable to other elements in the analytic situation. Analyst A. The patient acknowledged that my interpretation was correct and that she had other thoughts to substantiate it, but she would not talk about them. Analyst B. Despite my interpretations, the resistance of silence did not appear amenable to resolution. Analyst C. Since the silence was not resolved, the patient's ability to accept interpretations was obviously deficient. Analyst D. My material suggests that chronically silent patients react to a would-be therapeutic environment with a

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basic mistrust, making a successful analysis impossible. Analyst E. If I proposed questions or offered an interpretation, a more belligerent silence would take over. In actual fact, we do not know for certain what a particular silence means until the patient ultimately explains it to us in an un-defensive way. This explanation may occur at any time during the course of the analysis— sometimes not till the very end. It is true that increasing reports of negative reactions to interpretation have led to some decrease in the rigidity of the use of interpretation and insight as the primary or sole analytic rule. Glover,12 WARNING! This text is printed for the personal use of the subscriber to PEP Web and is copyright to the Journal in which it originally appeared. It is illegal to copy, distribute or circulate it in any form whatsoever. - 232 -

for instance, suggests the analyst adopt a more flexible attitude, pointing out that the fundamental rule may have to be sidestepped in the case of the chronically silent patient. Levy,17 in London, recognizes that unless the patient is made capable of following it, the fundamental rule cannot be rigidly adhered to in an analysis. Eissler, of course, has introduced his concept of parameters which he defines as “the deviation, both quantitive and qualitive, from the basic model of technique which requires interpretation as the exclusive tool.”5 He then goes on to describe the circumstances under which unorthodox methods can be permitted, the most important of which appear to be (1) when the classical technique does not work, and (2) when interpretation may be expected to resolve the effect of the parameter on the transference relationship. To summarize, there appears to be an obsessional need to fit every patient to the Procrustean bed of classical technique rather than to utilize techniques that would fit the patient's needs. Now we come to the basic distinction between orthodox psychoanalysis and modern psychoanalysis. The primary difference is that the modern psychoanalyst has at his disposal a variety of techniques suited to patients, including those who form positive transferences and those who form negative ones; those with the classical psychoneuroses as well as those with psychotic, psychosomatic, and behavior disorders, and with addiction syndromes. Because classical management of negativity and hostility through interpretation often led to therapeutic failure and to the conclusion that such patients were unsuitable as candidates for psychoanalysis, techniques based on maturational concepts using the negative and positive feelings of both patient and analyst have been developed. Here I wish to discuss their application to the silent patient. Silence serves multiple purposes and is not necessarily a resistance. Resistance is something that interferes with communication, but silence at times may be more of a communication and more helpful to the patient. Silence is considered a resistance only after the patient and the analyst have reached an agreement to enter treatment. After the patient has been given the instruction to talk, which he then disobeys, the silence becomes a resistance. It is, however, always a negative response to the order given to talk. One patient, in spite of his negativity, may be cooperating with the spirit of the order, while another may literally obey the order, but not the spirit. WARNING! This text is printed for the personal use of the subscriber to PEP Web and is copyright to the Journal in which it originally appeared. It is illegal to copy, distribute or circulate it in any form whatsoever. - 233 -

All of us have had patients who talked endlessly and said nothing new, while the silences of other patients have led to significant productive material. Many patients, for example, have reported the gratification and feeling of freedom at being permitted to remain silent. For some patients this permission was all that was needed to resolve the resistance. In modern psychoanalysis the resistance of silence may be interpreted or, depending upon the situation, the analyst may reflect the silence through mirroring, joining, or reacting with feeling—even to the extent of having an emotional explosion. In other words, in modern psychoanalysis anything that resolves this resistance, whether it be an interpretation or a reaction based upon the feelings induced in him by the patient, is to be used—preferably verbally. If, however, silence meets an important maturational need and occurs in cooperation with a harmless gratification (such as helping a patient on with a coat or offering him a Kleenex), why not gratify it? One must be certain, though, by careful study of the patient over a long period of time, that these nonverbal attempts to resolve the resistance are indicated and that they are not a self-indulgence on the part of the therapist. An analyst should use his judgment, intelligence, perception, and knowledge of the patient. Only if, in the analyst's opinion, the intervention will be helpful to the patient should it be used. Sometimes, despite this, we may be incorrect. We all make mistakes, but our patients give us many opportunities to correct them. All

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analysts have had the experience of saying what they felt to be wrong only to learn that these very remarks were helpful, and vice versa… A few words now about the analyst's silence. A paper by G. Aull and H. S. Strean3 on the analyst's silence sums up their recognition that the analyst's silence or a mutual silence with the patient can have the same frustrating or gratifying effects as verbal interpretation: If one conceptualizes a therapeutic experience as emotional and developmental in character, rather than as a series of didactic exercises … the analyst must govern his behavior so that the patient receives those necessary affective and maturational experiences which will aid him in overcoming fixation points and dealing with infantile conflicts. In other words, silence is a resistance on the part of the analyst if it interferes with new and relevant communication from the patient. The question is how to recognize it. At times the analyst himself may WARNING! This text is printed for the personal use of the subscriber to PEP Web and is copyright to the Journal in which it originally appeared. It is illegal to copy, distribute or circulate it in any form whatsoever. - 234 -

recognize it. At other times the patient may tell him, or the supervisor may tell him. If no one recognizes it and it persists, the analysis will go no place. The analyst is obliged to question all of his moods and all of his moves, rather than trust his spontaneous reactions. He should always expose himself to self-analysis, always ask himself the question: is what I am doing or about to do helpful? Unless he can say yes, he should not do what he is doing. The use and understanding of countertransference feelings is one of the most important tools available to the analyst in his treatment of all patients, particularly silent ones.

Three Case Presentations The following excerpts of three cases will illustrate the understanding and management of silence employing some of the techniques described in this paper. In each case only the problem of silence will be focused upon. One is six, one sixty-six, and one twenty-six.

Case 1 The six year old is a little boy who was brought in for treatment because of his abnormal and unusual silence. His mother reported to me that he was the third child, third son, unplanned (but not unwanted), of a Catholic family. She was able to say that she was somewhat disappointed that he had not been a girl, but her pleasure at the birth of a new child soon gave way to feelings of absolute despair because this child never ceased crying. He cried morning, noon, and night. Not matter what she did, she was unable to stop the crying. She was unable to comfort him. She told me, with tremendous feelings of guilt, that this was the first time she had ever revealed to anyone that when he was approximately three or four months of age she had picked up a pillow to suffocate him because she could no longer tolerate him. She was immediately horrified by what she had almost done and has lived constantly with this guilt. When the child was about seven months old, an incarcerated inguinal hernia, probably congenital in origin, was discovered. On the doctor's advice, the child was sent for surgery—with no visits from the parents permitted. He returned from surgery a quiet child. The mother reported that he seemed to be developing normally otherwise. She was aware that he seemed rather quiet, but she had two noisy boys and she was rather appreciative of the fact that he was quiet. She did not perceive this as an unusual problem until the child WARNING! This text is printed for the personal use of the subscriber to PEP Web and is copyright to the Journal in which it originally appeared. It is illegal to copy, distribute or circulate it in any form whatsoever. - 235 -

started school. Incidentally, this child was perfectly capable of talking, but he would usually answer with one word responses. When he went to school the teacher called the mother in and told her that she thought there was something wrong with her son because, while he seemed to do his work, she had never seen a child so quiet. In the playground he did not participate; he just remained on the periphery. He would answer if called upon, otherwise one never heard a word from him. That first consultation was the one and only time I saw the mother. I was working in a psychiatric agency where the treatment plan was not controlled by me. She had been assigned to a group, and her group met before I came out to get the child, who was sitting alone in the waiting room. He was a most appealing little boy with large brown eyes—I introduced myself, and he followed me into my office and sat down. He was the closest I have ever seen to a living dead person. He demonstrated no anxiety, no discomfort, no tension. He sat absolutely still. He did not look around the room. He did not look at me; I sat just as quietly as he for the entire

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session. When it was time to leave I said, “We have to finish now.” He got up and he left. He came back the following week, and it seemed as though we were going to have a repetition of the first session. Suddenly I heard this very tiny little voice say, “What should I do here?” “What should I do here?” I asked. He shrugged his shoulders, I shrugged mine, and there was quiet for a while. After some time, I looked at him and asked, “Could you talk here?” He shook his head and so I made no further attempt to contact him. He kept coming back week after week. Occasionally a quiet smile would pass between us but there was no conversation. At the fifth session I opened the doors to the play cabinet. At first he did not look over to it but I sensed his interest. The next session he looked directly at it. I asked him whether he would like to go and explore. He walked over quietly. Then, for many sessions, he would select from the play cabinet a coloring book or a book to read and go over to a little table and chair where he would sit quietly reading and playing by himself. I would generally ask one or two neutral questions. The primary intervention or nonintervention at this time was that no attempt was made to intrude on this massive wall of silence. I understood that this was a terrified child who had experienced not WARNING! This text is printed for the personal use of the subscriber to PEP Web and is copyright to the Journal in which it originally appeared. It is illegal to copy, distribute or circulate it in any form whatsoever. - 236 -

only the pain of a congenital physical defect but his mother's wish to kill him as well. He felt his survival depended on the repression of all feelings and the suppression of verbal expressions of them. My first intervention, therefore, was nonintrusion. After many weeks, I noticed that he had taken out a checkboard and set it up, with two sides, on the table. He looked over at me, and I asked him whether I should come over and play, and when he said “yes,” I did. For many weeks we played checkers; then his activities expanded to include Candyland and card games. He never initiated conversation, but I would talk and he would respond to me. I regard this as my second intervention. I talked for him, and he responded. Eventually, he became more daring and brought other things out of the cabinet—such as guns, puppets, knives. His play began to be much more aggressive in character. The final intervention I made was that I verbalized emotion for him, demonstrating the entire gamut of human feeling. I focused on the repressed feelings of anger, violence, and fear, while he acted out dramas. He had become, by this time, a rather animated child, although he never initiated conversation. I was quite pleased and felt that soon we would be able to start analytic work. Unexpectedly, I received a telephone call from the mother. She exclaimed that she didn't know what kind of a miracle I had performed on her son, but he was just the most wonderful child—talking and listening in a perfectly normal way. Nobody could get over him; the teachers couldn't get over him; she couldn't; the neighbors couldn't; she wanted to thank me profusely for what I had done. That was the last I saw of him. I had seen the child for approximately a year. Nine years have passed since then, and I learned that there was no further contact with the family. This is an example of a partially resolved resistance, because the child was obviously not cured. What I did was to meet an important maturational need for him so that he could continue his natural development. In order for him to have been cured, he would have had to eventually develop a transference neurosis and fully emotionally experience with me his early traumatic life.

Case 2 My sixty-six-year-old patient had married late and been widowed early with no children. She came to me deaf in one ear and WARNING! This text is printed for the personal use of the subscriber to PEP Web and is copyright to the Journal in which it originally appeared. It is illegal to copy, distribute or circulate it in any form whatsoever. - 237 -

with a hearing aid in the other. Sitting directly opposite each other, we had no difficulty talking. She had had several operations on her ears. She was a depressed woman who felt quite hopeless and worthless. Although a retired schoolteacher, she was unable to get a volunteer position, she claimed, because of her “hearing difficulties.” There was nothing for her to do but wait to meet “the grim reaper”; however, she wasn't willing to go to meet him halfway. She was coming to me because her sister had advised her to do so, thinking it might help. What she wanted was to feel that she was of some value on this earth. She gave me some of her history, referring to herself as somewhat of a “Cinderella” in her family. She described herself as a timid, cooperative, obedient, conforming, nonrebellious person who had always been a listener, never a talker. She agreed to an exploratory period of treatment because I did not know whether I could be of any help to her. To my surprise, she agreed to use the couch and was able to hear my moderately raised voice. She had no difficulty in talking to

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me until she agreed to enter this exploratory period of treatment. But once she was on the couch and I gave her instructions to talk, she either remained silent or, from time to time, in various combinations, endlessly repeated these typical remarks: “I don't know what I'm doing here.” “There is nothing to say.” “I don't know what to talk about—my problems are too little.” “What can talking solve, anyway?” “I'm too stupid.” “I'm unable to discuss anything.” “I have no background in music, art, or literature.” “I have never talked in my whole life.” “I am only a listener.” “I am a blank; I have always been a blank.” “My mind is empty.” “I am unable to talk.” “I don't have the ability.” “I am shallow.” “I can't probe.” “I have never had any thoughts in depth.” “My thoughts are too unimportant.” “What am I going to do, tell you about my daily routine of having coffee and reading the newspaper?” “Maybe if I had more confidence I could talk.” “I can only repeat myself.” “I can't talk about nothing.” “Whatever thoughts I have don't say anything.” WARNING! This text is printed for the personal use of the subscriber to PEP Web and is copyright to the Journal in which it originally appeared. It is illegal to copy, distribute or circulate it in any form whatsoever. - 238 -

This, essentially, is what she was saying to me session after session, and what follows are the interventions I made to deal with her silence. When she said that she'd never been a talker, only a listener, and she needed someone to talk to her, I talked to her. We talked about books; we talked about movies. I was having very enjoyable conversations with her but getting no place as far as having her initiate spontaneous talk. She understood quite thoroughly what was expected of her here. Then she suggested that I ask her questions, which I did. She always answered the questions—as long as I kept asking them, she kept answering them. She still wasn't talking spontaneously. Then she suggested that I give her topics. I gave her topics, and she did very well there too. Then she suggested I teach her how to talk, since she didn't know how to talk. I told her everybody could talk. Obviously she had been talking to me. She said, no, I should teach her. I said, “You really want me to teach you? She said, “Yes.” “All right, you start with this morning. I want you to tell me everything you thought, everything you saw, everything you felt from the moment you awakened.” “I woke up at seven o'clock and I went downstairs and ate breakfast.” “How did you know it was seven o'clock?” I asked. “Well, my alarm clock went off.” “Where is your alarm clock?” “On my night table.” “Where is your night table?” “To the right of my bed.” “Where is your bed?”

I had her tell me every piece of furniture in that room, the decoration, where everything was situated, what kind of drapery material she had, what she saw when she looked out of her window, what kind of robe she had. By that time, of course, the session was almost over, but she was still talking away. “Now can I go down and get to my breakfast?” “Have you told me everything?” I asked. “Is there anything that you left out?” She said, “No, absolutely not. So I went downstairs to have my breakfast. …” “Didn't you pee?” With both exasperation and laughter, she responded “Oh, of course I did!”

We had actually not covered beyond five minutes after seven in the morning and our session was over. I had given her a demonstration WARNING! This text is printed for the personal use of the subscriber to PEP Web and is copyright to the Journal in which it originally appeared. It is illegal to copy, distribute or circulate it in any form whatsoever. - 239 -

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of teaching her how to talk. It didn't do any good. She still claimed to be unable to talk. I had, of course, tried remaining silent. That didn't work at all. Finally, one day when she came in, I said to her, “You know, there is something I understand about you. Would you be interested in hearing it?” Of course, she was very interested. I told her I wanted her to know that she was just about the most cooperative patient I had ever had—consciously. Unconsciously, however, she was one of the most defiant patients I had ever had. I showed her all the evidence and explained it to her. She got up from the couch, turned around, smiled at me from ear to ear as though I had given her a most wonderful gift. She, timid, worthless, obedient, conforming person, was defiant! She was delighted to hear it, and she did talk the rest of the hour. I felt that my interpretation had been successful. Despite this, in the next session she again wasn't talking. I could feel my rage rising. She had succeeded in making me feel impotent and frustrated. When she came in the following time she said, “Look, I think we had better call it quits. I know you are trying very hard. I just can't do it. I think you had better discharge me. I mean, what's the point? I'm wasting your time, and I'm never going to be able to talk.” Suddenly, I began to yell at her with a genuine but planned rage reaction. I told her I had a gun in my drawer with six barrels, and I was going to put one bullet in and play Russian roulette with her. I was going to hold that gun against her head. She had better start talking because the minute she stopped I was going to pull that trigger and I wasn't kidding. I had been provoked beyond my limit and decided to express this to her therapeutically. When I expressed my rage toward her, she apparently perceived that she was an emotionally important person to me. This appeared to be the key, because she overcame the resistance and finally began to talk spontaneously. She became a cooperative patient and subsequently produced emotionally significant communications. The period I have described lasted about six or seven months. Evidently, by becoming so angry with her, I convinced her that she was really important to me and that I wanted to hear from her. I would describe this as a constructive use of negative countertransference. WARNING! This text is printed for the personal use of the subscriber to PEP Web and is copyright to the Journal in which it originally appeared. It is illegal to copy, distribute or circulate it in any form whatsoever. - 240 -

This woman knew that my explosive reaction was not intended to damage her, but to be helpful. I consider this a successful resolution because silence did not present itself as a major resistance again.

Case 3 This patient was probably one of my most difficult ones. She was an attractive, haughty, divorced, midWestern woman who was raised as a strict Methodist. She was an English teacher, literate, intelligent, wellmotivated, and interesting. I thought to myself, this is a patient I am really going to enjoy. But I was wrong. From the start she demonstrated a range of treatment-destructive resistances. I am going to focus only on the silence, but want to mention briefly some of the other major obstacles with which I had to deal. First of all, she was suicidal, and this resistance received priority attention. I had to deal with this problem first; otherwise I would have had no silence to treat. She would sleep during the hour. She would not talk. She would act in. She would act out. She wouldn't pay. She would run out of the office. She would fling money at me. She would be abusive to me. She did show some cooperation in keeping her appointments and in notifying me if there was going to be a cancellation. She did not pay me regularly—just enough to keep me from discharging her on that basis. This woman, once given instructions to talk, became mute. She simply would not talk to me. During the first year of treatment, I would estimate that she was silent 90 percent of the time; the second year of treatment, perhaps, 75 percent of the time; the third year 50 percent, and by the fourth year only 10 percent of the time. This woman wanted no positive relationship with me. She had the most intense negative narcissistic transference that I have ever encountered. She hated me with a passion, and I must admit that I often felt exactly the same way about her. The difficulty with dealing with her silences was that the meaning and nature of these varied from session to session. These silences induced many different feelings in me: discomfort, anxiety, sympathy, dislike, dread, fear, hopelessness, ineffectiveness, relief, hatred, vindictiveness, curiosity, compassion, and also understanding. I tried to learn what she wanted from me when she did talk. These were her characteristic remarks: WARNING! This text is printed for the personal use of the subscriber to PEP Web and is copyright to the Journal in which it originally appeared. It is illegal to copy, distribute or circulate it in any form whatsoever. - 241 -

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“I have nothing to say.” “It takes too much energy.” “It's much too exhausting.” “I don't want to talk.” “I'm never going to talk to you.” “You're not my kind of person.” “It's too boring.” “Nothing happens here.” “I hate women.” “This whole thing doesn't interest me.” “Nothing is changing; nothing is happening.” “Nothing is going to happen.” “Nothing can be done.” “I don't want any help.”

I used two interventions to deal with her silences. I either asked her object-oriented questions or I told her to tell me how she wanted me to function.* For instance, when she would be sleeping during the hour, I would let her sleep. She would come in the next hour, and I would ask her, “Did I do the right thing in letting you sleep?” Sometimes she would say yes; sometimes she would abuse me terribly for having her waste her time. She would say things like: “I can't talk to you because I am used to talking to people who talk.” I would answer her by asking whether she wanted me to talk with her. “No, I don't want to hear from you,” would be her reply. “I'm not interested in anything you have to say!” At other times she would say that I talked too much. I'd say, —————————————

The object-oriented question is the preferred response when working with patients in a narcissistic transference state. Although such a patient is unaware of the analyst as a separate person and is generally preoccupied with his own inner feeling states, the need for communication does exist and eventually the patient seeks some contact from the analyst. For such patients ego questions which relate to their already fragmented and disoriented feeling states are very disturbing and often experienced as attacking, damaging, and evidence of their defectiveness. Thus questions asking the patient what he feels and what he thinks should be avoided. In contrast the object-oriented question is unrelated to the ego but is directed to the analyst and the external world. Questions regarding the weather, current events, other persons' attitudes, or what he thinks the analyst may be feeling or thinking fall into this category. This supplies the patient with the needed verbal feeding on a self-demand schedule without the danger of unwanted further regression. The manner in which the patient contacts the analyst is the guide to understanding what he needs. The judicious study of the contact function helps the analyst to determine what object-oriented questions he can ask with genuine interest. Severely regressed patients may seek no communication, and it then becomes the analyst's responsibility to educate the patient to make contact by the example of asking several such questions each session. This enables the patient to continue giving progressive communication which serves as the key to the maturation of the personality. This is the goal of modern psychoanalysis. WARNING! This text is printed for the personal use of the subscriber to PEP Web and is copyright to the Journal in which it originally appeared. It is illegal to copy, distribute or circulate it in any form whatsoever. - 242 -

“I'll be glad to shut up. You start talking and I won't say a word.” This would make her very angry. Repeatedly she'd say that she could not talk to me. As for what she wanted from me, she said: “I want a man's power and I'll have nothing less. I could be a good man. I should have been a man. I can't be a good woman, because I don't like women. With the power of a man, life would be very simple. I would operate efficiently and economically. I would find a woman I wanted. I am geared to being a man; I think like a man. I was born the wrong sex.” Naturally, she repeatedly told me I couldn't do anything for her. She didn't want to come to me; she didn't want to talk to me. She would run out of the office. When I asked why then she kept coming, she would say she had nothing else to do, nothing better. She wanted to go to a male therapist. She had to get to a man. There was a lot of verbal interchange concerning this wish. What kind of a man? Should he be married? Should he be single? Should he be divorced? Black? White? What difference would going to a man make? What difference would it make if she went to an analyst with a penis? After all, if he were an unethical analyst, she would only get another screwing, of which according to her reports she had had so many. She looked at me and said, “You're an obscene, disgusting woman.” She gave up talking about going to a male analyst. Her next idea was that she needed a group, as she was never going to be able to talk to me. We got a lot of talking out of that too, because we explored, very thoroughly, what kind of a group. I had also begun to feel that a group would be very good for her. I had even

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notified a group analyst and prepared him for her arrival. I must say he did not seem too pleased when I described her. I was not to be so fortunate. She did not leave and she would not leave even when encouraged to do so. Each time that I would ask her a question I would get a barrage of verbal abuse. This woman had massive hatred toward her mother and wanted no part of a positive relationship with me, but she remained attached to me. Where else could she pour out so much venomous hatred and still be accepted? The basic problem in this case was one of extreme negative suggestability. She was unwilling to cooperate or to agree to any recommendation I made, whether it was to talk, find another analyst, leave treatment, or kill herself. Since she was unwilling to agree to the rules of treatment and consistently used her silence as a weapon against WARNING! This text is printed for the personal use of the subscriber to PEP Web and is copyright to the Journal in which it originally appeared. It is illegal to copy, distribute or circulate it in any form whatsoever. - 243 -

me, I reversed the usual procedure and presented myself as someone who was willing to agree to any plan or recommendation from her. In joining her recommendations, by the verbal exploration of her own treatment plan (group, male analyst, my behavior during sessions, etc.), her negativity left her no choice but to defiantly become more positive. Ultimately, this led to the abandoning of silence as a weapon. However, her arsenal was not depleted, as many other difficult resistances emerged in the course of her lengthy treatment. The methods used with these three patients appear as though they are empirically derived. While it is true that it is important to use whatever methods help the patient to make progress (and in that sense all successful therapy should be open to pragmatism), there are also theoretical grounds for handling these patients in the particular ways described. A full discussion of the scientific and theoretical basis for the methods used is beyond the scope of this paper. I refer interested readers to Spotnitz's Modern Psychoanalysis of the Schizophrenic Patient. 24 To sum up, the basic need is to understand silence, not merely to get the patient to talk. “Essentially, the analytic process takes place in the realm of speech, and we understand silence in a patient as being a part or a form of speech. The patient may be, may remain, or may become silent at any point of his analysis, for any length of time, and in any of innumerable ways.”18

References 1 Altman, L. L. The Waiting Syndrome. Psychoanal. Q., Vol. 26, 1957. [→] 2 Arlow, J. A. Silence and the Theory of Technique (Symposium on the Silent Patient). J. Amer. Psychoanal. Assn., Vol. 9, 1961. [→] 3 Aull, G., and H. S. Strean. The Analyst's Silence. The Psychoanalytic Forum, Vol. 2, No. 1, 1967, pp. 86-87. 4 Calogeras, R. C. Silence as a Technical Parameter in Psycho-Analysis. Int. J. Psycho-Anal., Vol. 48, 1966, pp. 536-542. [→]

5 Eissler, K. R. The Effect of the Structure of the Ego on Psychoanalytic Technique. J. Amer. Psychoanal. Assn., Vol. 1, 1953, p. 110. [→] 6 Eissler, K. R. Remarks on Some Variations in Psycho-Analytical Technique. Int. J. Psycho-Anal., Vol. 39, 1958. [→] 7 Ferenczi, S. Silence Is Golden. Further Contributions to the Theory and Technique of Psycho-Analysis. London: Hogarth Press, 1950, p. 250. 8 Fliess, R. Silence and Verbalization: A Supplement to the Theory of the Analytic Rule. Int. J. Psycho-Anal., Vol. 30, 1949. [→] 9 Freud, S. The Dynamics of the Transference (1912). Collected Papers, Vol. 2. London: Hogarth Press, 1950. 10 Freud, S. Further Recommendations in the Technique of Psycho-Analysis (1914). Collected Papers, Vol. 2. London: Hogarth Press, 1950. WARNING! This text is printed for the personal use of the subscriber to PEP Web and is copyright to the Journal in which it originally appeared. It is illegal to copy, distribute or circulate it in any form whatsoever. - 244 -

11 Garis, R. The Effect of Silence on a Relationship. Commentary, December, 1967. 12 Glover, E. The Technique of Psycho-Analysis. London: Baillière, Tindall and Cox, 1955. 13 Goodman, P. On Not Speaking. The New York Review of Books, Vol. 17, No. 9, 1971. 14 Greenson, R. On the Silence and Sounds of the Analytic Hour (Symposium on the Silent Patient). J. Amer. Psychoanal. Assn., Vol. 9, 1961. [→] 15 Hermann, I. Die Psychoanalyse als Methode. Vienna: International Psychoanalytic Verlag, 1920. 16 Khan, M. Silence as Communication. Bull. Mennin. Clinic., Vol. 27, 1963.

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17 Levy, K. Silence in the Analytic Session. Int. J. Psycho-Anal. Vol. 39, 1958. [→] 18 Loewenstein, R. M. The Silent Patient: Introduction (Symposium on the Silent Patient). J. Amer. Psychoanal. Assn., Vol. 9, 1961, p. 3. [→] 19 Loewenstein, R. M. Symposium on the Silent Patient. J. Amer. Psychoanal. Assn., Vol. 9, 1961. [→] 20 Loomie, L. S. Some Ego Considerations in the Silent Patient (Symposium on the Silent Patient). J. Amer. Psychoanal. Assn., Vol. 9, 1961. [→] 21 Nagelberg, L., H. Spotnitz, and Y. Feldman. The Attempt at Healthy Insulation in the Withdrawn Child. Am. J. Orthopsychiat., Vol. 23, No. 2, April 1953. 22 Nelson, M. C., B. Nelson, M. Sherman, and H. Strean. Roles and Paradigms in Psychotherapy. New York: Grune and Stratton, 1968. 23 Rosenthal, L. A. Study of Resistances in a Member of a Therapy Group. International Journal of Group Psychotherapy, Vol. 13, July 1963. 24 Spotnitz, H. Modern Psychoanalysis of the Schizophrenic Patient. New York: Grune and Stratton, 1969. 25 Wagner, C. R. The Silence of The Stranger. Modern Fiction Studies, Vol. 16, No. 1, 1970. 26 Weisman, A. D. Silence and Psychotherapy. Psychiatry, Vol. 18, 1955. 27 Zeligs, M. A. The Psychology of Silence: Its Role in Transference, Countertransference and the Psychoanalytic Process (Symposium on the Silent Patient). J. Amer. Psychoanal. Assn., Vol. 9, 1961, pp. 8-11. [→] WARNING! This text is printed for the personal use of the subscriber to PEP Web and is copyright to the Journal in which it originally appeared. It is illegal to copy, distribute or circulate it in any form whatsoever. - 245 -

Article Citation [Who Cited This?] Liegner, E. (1974). The Silent Patient*. Psychoanal. Rev., 61:229-245 Copyright © 2009, Psychoanalytic Electronic Publishing.

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WARNING! This text is printed for the personal use of the subscriber to PEP Web and is copyright to the Journal in which it originally appeared. It is illegal to copy, distribute or circulate it in any form whatsoever.

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