The Meaning of Patient Silence
A Guide for Therapists
Joe, age 15, enters your office and slumps in a chair, legs spread apart, arms crossed, head down, hidden under the hood of his sweatshirt. “Hello”, you say. He grunts.
You are in a couple’s session. The louder Mike gets, the quieter Evie becomes. He piles statements and accusations like cordwood. She goes silent.
Kiisha has been doing well during the first 3 months of therapy. Today she is looking more down than usual. Answers to your questions are in monosyllables. She can’t seem to stay in the conversation.
Every therapist has experiences like these now and then. What does it mean when a patient refuses to talk or just doesn’t seem interested in sharing? It’s important to the person’s therapy that the therapist handle such lapses in conversation with tact and skill.
Patient Silence Does Not Mean:
Resistance: Let’s get the idea that silence is “resistance” out of the way. One of the most valuable things I learned from theorist Lynn Hoffman is that the whole notion of resistance blames the patient for when treatment gets stuck – as if we are so brilliant and comforting that we are “irresistible.” Nonsense. Hoffman and her colleagues instead talked about the persistence of patterns of patient behavior that are part and parcel of what brings them to therapy in the first place. By that standard, not talking isn’t “resistance.” Instead it is the persistence of a behavior clients use when they don’t feel safe or don’t have the skills to verbally share what is going on for them in session.
Failure to engage in treatment: I also reject the idea that clients who fall silent are refusing to “engage.” Not to engage is to engage in a particular way. As soon as there is someone else in the room with any individual, a conversation is going on, though it may be nonverbal. Our efforts should not be directed at the narrow idea of engagement as verbal dialogue. We should instead be working to understand the meaning of the client’s nonverbal engagement.
So if being silent it isn’t resistance nor a lack of engagement, what is it? Let’s take a look at some of the most common reasons that patients who come to us for help don’t offer enough verbal information for us to be helpful.
Patient Silence Might Mean:
Fear: The client may be afraid of your judgment; afraid of your rejection; afraid that you won’t honor confidentiality. A court-involved client may fear legal repercussions if he or she says something. A teen who has been hurt by adults doesn’t understand why you might be any different. A partner may be afraid that anything said in session will be used by the other partner in their next fight.
Emotional overload: Therapy can trigger deep feelings of pain, grief and anger. It can also activate great relief, satisfaction and even joy. The welling up of feelings can be difficult for a patient to manage and even more difficult to put into words.
Lack of verbal skills: Not everyone has practice in expressing themselves verbally. Not everyone grows up in families where there is lively conversation or where English is the primary language or where it is safe to have opinions. Such clients need time to construct what they want to say.
Personality type: Some clients are introverts. Being the focus on someone’s attention and being expected to interact is not their favorite thing. In fact, they have a life-long pattern of avoiding novel interactions with people they don’t know very well.
Thinking: All silences aren’t born of caution. Some are becasue of a patient’s need to reflect on what has been said or felt in session. Some people need time to think, to gather their thoughts and then to put them into coherent sentences.
Symptom of illness: The silence may be a symptom of a depression, post traumatic stress disorder, bipolar depressed state, etc. The client isn’t giving the therapist a hard time. He or she is in significant pain.
Power struggle: This is merely another symptom. The patient has a two position switch in interactions, believing that he or she is either in charge or is too vulnerable. The solution is to stay in charge by “sayin’ nothin’.”
Getting even: It’s true: Hurt people hurt people. You may have said something in the last session that angered the client or hurt his/her feelings. In response, he or she has decided to make you uncomfortable or to show you how ineffective you are by staring at you in angry silence.
Defiance: Silence can also be a message to someone other than you, the therapist. This situation most often occurs when someone other than the client has insisted on therapy to solve a problem. Whether by a court, an anxious parent, of spouses who are threatening divorce if their partner doesn’t go to therapy, the individual is at best reluctant, at worst furious and defiant. The silent message to you and the referring person is, “You can make me be here but you can’t make me talk.”
What To Do:
Whatever the reason(s) clients have for staying silent, it is up to us to meet them where they are.
Sometimes matching client silence with an accepting silence of our own can be helpful. Sometimes we can venture in carefully by asking for permission to guess what might be going on. Sometimes it is helpful to educate the person about confidentiality and the process of therapy. And sometimes it is useful to offer the client the option of writing down or drawing his/her thoughts. Your skills, experience and intuition can be put to work to do what the client can’t do, i.e., move the conversation you are having to a more verbal level.
Silence can indeed be “golden.” With therapist support, compassion and insight, the meaning of a patient’s silence can be mined for useful information and can result in one of those important ah-ha moments.
Hartwell-Walker, M. (2017). The Meaning of Patient Silence. Psych Central. Retrieved on March 18, 2018, from https://pro.psychcentral.com/the-meaning-of-patient-silence/