Chapter 6 Cultural function and psychological transformation of silence in psychoanalysis and psychoanalytic psychotherapy

Elsa Ronningstam

The Swedish poet Gunnar Ekelöf (1959) wrote an important poem about silence:

In the above lines, the poet gives his readers a directive, to listen to the silence that is behind the words, in the rhetoric. These lines have special meaning for psychoanalysts who are often trained to think more about the words than about the spaces between them. And yet, silence has, over the past decades, interested scholars and scientists representing several areas of inquiry. By now their documentations bear evidence of the wide range of meanings and functions of silence. While silence in cultural contexts has been considered legitimate and understandable, its position as a psychological and psychoanalytic phenomenon has been much more controversial, raising questions about whether it is a resistance and obstacle to treatment, a symptom, or whether in and by itself silence can be considered a meaningful occurrence. In this chapter, I hope to bring together cultural and psychoanalytic thinking about silence. In my clinical experience I have often been impressed by my patients’ experiences of silence (both their own and others’) in their original families and communities, in their marriages and workplaces, and in their own internal lives. I have also often wondered how these experiences affect their participation in psychotherapy/psychoanalysis. I propose that silence can be understood as an active and meaningful psychological process that can be productively integrated into the course of a psychotherapy or psychoanalysis. More speciﬁcally, my hypothesis is that silence can function as a protection of an inner space and promote an inner transformation and connection between experiences, affect and verbal language that enables changes in interpersonal relationships.

Cross-cultural meanings of silence

In some cultures, silence is highly regarded and even idealized, like a virtue. In others, where talking is socially desirable, silence is considered an indisposition, equivalent to a handicap. In several countries it is a human right to remain silent. In others, inﬂuenced by threats and terror, silence can represent the narrow line between life and death, i.e. the means to survival. Some cultures are stereotyped as exceptionally silent—such as parts of the Finnish culture (Lehtonen and Sajavaara, 1985; Sajavaara and Lehtonen, 1997), while in others, like the Japanese culture, a complex, historically, and religiously determined use of silence and nonverbal communication may be nearly impossible to decipher for the less initiated (Morsbach, 1988).

In the recent ﬁlm Fast Runner, ﬁlmed in the Nunavut territory in Northern Canada, we follow the lives of the Inuit people and the legend of the man who runs naked over the ice to escape his deadly enemies. The people harbor their experiences and process feelings of longing, grief, fear, and humiliation, all without speaking. In the course of silence, beautifully intertwined in the ﬁlm with seasonal changes and daily chores, powerful personal realizations and transformations take place. The question is whether justice and coexistence will supersede deceitfulness and violence in the tribe. In another recent ﬁlm, Kandahar, which documents a woman’s efforts to reach her suicidal sister in Afghanistan, silence contains the fear and torment of a risk-taking and potentially deadly commitment. People’s silence, equally beautifully intertwine with the desert landscape and the striking colors of the women’s burkas (which effectively suppress their speech); courage and decisiveness coexist with terror, dread, and the anguish of uncertainty and waiting. Is she going to be able to hide her true identity and reach her sister before it is too late?

Some anthropological studies describe the containing function of silence. Among the people in the Northern Italian village Valbella (Saunders, 1985), an emotionally warm, intense, and expressive culture, both exuberant noise and grim silence are functionally equivalent. Silence is the strategy to manage emotionally difﬁcult and tense situations. People feel it is better to remain silent than to lose control and risk the tragedy of separation or estrangement. On an individual level, silence helps control strong feelings, settle disputes, and allow more passive expression of discontent. In less serious situations, people prefer the ‘noisy-avoidance’ style, i.e. to express intense emotions while focusing on non-conﬂictual issues. Another cultural aspect of silence is captured in the British expression ‘to send someone to Coventry’, i.e. to refuse to associate with a person (Encyclopedia Britannica, 1945, p. 617) or to treat someone as if he/she does not exist. In this context, silence represents a hostile act of ostracism and exclusion, sometimes also found in extreme religious sects.

In studies of politeness, well summarized by Siﬁanou (1997), silence is regarded as being particularly ambiguous. It can be used in interpersonal interactions as a means to protect personal territory, to demonstrate deference, or to preserve emotional neutrality (negative politeness). This type of silence is highly valued in England, where it is considered polite to avoid intrusion. In Greece, however, where people enjoy being involved with each other through conversation, this silence is perceived as distancing and considered impolite or even insulting. Interestingly, some Greek proverbs imply that silence can be even more threatening than arguments, i.e. ‘a dog that barks does not bite.’ Silence can also relate to being understood and indicate solidarity and common ground (positive politeness). The British respect for privacy and non-expression of strong or negative emotions is an example of such silence. In Finland, silence is considered harmonious and an expression of mutually positive attitudes. Being together without speaking is highly accepted. Furthermore, silence can also be a manifestation of polite indirectness² in which, by saying nothing, you still convey something (off-record politeness), i.e. to avoid asking for something because of shyness, embarrassment, or unwillingness to impose.

In Sweden the search for meaning in silence has a long tradition. Crafoord (1994) identiﬁed several types of silence: the searching silence where the vocabulary is not enough; the gray silence that reﬂects an inner absence of words; the passionate silence which contains strong, even dangerous feelings and impulses, often of an erotic nature; the pondering silence which contains a wordless and mutually shared certainty about its content; the creative silence that should not be disrupted, because something is about to take shape and form; the threatening silence that harbors resistance, protest, and detachment, as well as rage, envy, and revenge; and the black silence that conveys the ultimate rejection and self-destructiveness, the presence of death.

The cultural signiﬁcance of silence in psychoanalysis and psychotherapy

We usually think about silence in the context of speech, i.e. an absence of something that should be present. However, silence can also deﬁne the context in which talking takes place, as with the silent patient who suddenly begins to speak and whose silence had a speciﬁc signiﬁcance. People who begin a ‘talking cure’ usually have more or less complex experiences related to both talking and silence, which inﬂuence the way they form an analytic alliance and pursue the analytic process.

A woman who grew up in a family with a very secretive, secluded, and silent lifestyle conveyed that she was to be neither seen nor heard. Her father had, during his upbringing in an Asian country, experienced discrimination and terror. Despite his protected and successful life in the new world, he continued to enact his earlier experiences within the family. Starting analysis and breaking the silence was for this woman associated with strong feelings of guilt for revealing family secrets, but also with ambivalence and fear. As she began to change, she realized that she had been breaking several of the silent, invisible prohibitions that formed the foundation of the monumental family barrier. ‘I am not supposed to do this,’ she said, when noticing that she no longer was either invisible or silent. Another woman learned early that, being quiet and without feelings, she was considered a ‘good girl.’ Her silence was highly rewarded in her family, while her feelings were strongly criticized and punished to suppression. Psychotherapy was a speciﬁc narcissistic challenge. By talking, she was doing something less valuable and even dangerous, and she was no longer in control of her own status and self-protection. Another woman, an immigrant from Eastern Asia, repeatedly surprised me as she retreated into long silence after most of my interventions. Following each such long silence her comments were remarkably thoughtful and emotionally integrated. When I asked her what was happening, she smiled and said, ‘I am thinking about what you were saying,’ but she did not want to reveal the inner process that had led to these insights and transformations.

An additional complexity concerns the person’s selective silence, i.e. the avoidance of certain modes of interaction or experiences and feelings that for a long time can remain embedded in silence. It may be a challenging task to identify the meaning of such non-spoken material in the context of the patient’s regular talk and silence. This is speciﬁcally relevant for people from ‘high shame cultures’ who are used to hiding shameful experiences.

Silence as a psychoanalytic phenomenon

The ﬁrst panel on the ‘Silent Patient’ held at the American Psychoanalytic Association meeting in 1958 (Loewenstein, 1961; Waldhorn, 1959) addressed a groundbreaking question: Is silence a resistance or can silence have meaning that grants fruitful exploration? Although most reports thereafter agreed that silence is a form of communication or a way of relating to others, including the analyst, some authors still interpreted silence as a hindrance. For Hadda (1991), silence was a resistance, representing the patient’s fear that the analyst would not be sensitive to her need for mirroring, and for Kurz (1984), a resistance towards changes in the personality and opposing the curative goals of treatment.

The narcissistic function of silence as a protection of self-esteem has also been recognized. Weinberger (1964) suggested that silence is a form of defense against the fear of loss of self-esteem and status. Modell (1975, 1976, 1980) found that a speciﬁc non-communication of affects in certain narcissistic patients promotes a ‘cocoon-like state’ aiming at omnipotent control of the affects. This cocoon is like a grandiose illusion of self-sufﬁciency motivated by fear of closeness and intrusion from others, and it serves to regulate self-esteem and maintain inner control. Coltart (1991) identiﬁed feelings of shame as one cause of silence in a patient who remained speechlessly ashamed following several unprocessed losses and rejections. Morrison (1984, 1989) conﬁrmed that shame feelings can remain hidden, rationalized, or otherwise defended against. The signiﬁcance of shame-inducing events may also remain unknown (Tangney, 1991). Studies have identiﬁed shame as an overwhelming, painful emotion that triggers a desire to hide (Lewis, 1971; Tangney, 1996; Tagney et al. 1992) or withdraw from interpersonal relationships to protect from the anticipated painful additional exposure of shame (Schore, 1994). Furthermore, studies of loneliness and isolation have highlighted the narcissistic dilemma in relationships, i.e. the ‘inability to either be with the object or without it’ (Erlich, 1998) or the inability to tolerate emotional expressions where isolation represents a pre-semantic level of affect organization (Killingmo, 1990).

Ascribing a communicative function to silence has stimulated studies of its subjective signiﬁcance and integration into the analytic process. This is in line with interdisciplinary perspectives that deﬁne silence as a ‘metaphor for communication’ (Jaworsky, 1997). Closely related but not identical to silence is nonverbal communication. Winnicott (1958, 1963) noticed that signiﬁcant relating and communicating can be silent, and he differentiated between simple non-communication, i.e. being alone in the presence of another, and active non-communication, which is more defensive and accompanied by anxiety. He also identiﬁed an authentic non-communicated core in the developing self that may remain isolated in silence. The unconscious, symbolic, or affective meaning of nonverbal interactions has recently been underscored (Jacobs, 1994; Pally, 2001), and, as Rizzuto (1995) pointed out, part of the complex task of the analyst’s listening involves paying attention to what the patient cannot say, maybe even to himself. Both research in neuroscience and studies of early infant behavior have signiﬁed the role of nonverbal indicators for self-regulation and attachment. A complex process of activating and signaling nonverbal cues occurs in the transference–countertransference matrix between patient and psychoanalyst/therapist, which promote empathy and understanding, as well as interfering reactions, such as dysphoria, anxiety, or detachment (Pally, 2001).

Interpersonal and intersubjective psychoanalytic approaches have paradoxically inspired further studies of the meaning of silence. For some authors, silence represented an early identity formation or developmental arrest, and through the silence the patient disclosed to the analyst an early disturbed or lost relationship. Kahn’s (1963) patient conveyed how it felt to live with a severely depressed mother, and Weinberger’s (1964) patient re-enacted a partial loss in relationship to his mother due to changes in her presence and attitude.

Silence as part of an active developmental process or therapeutic transition is analogous to speech, with its own relational qualities in a nonverbal line of development. Silence can be like a respite, providing a chance to rebuild walls that have been ruptured catastrophically. Hence, silence can resemble a retreat or a space for resolving dilemmas that words cannot comprehend (Kurz, 1984), or it can provide a protection and legitimization of the core authentic self (Gabbard, 1989). Leira believed that the sensory interaction, her own attentiveness, and the nonverbal interaction between her and her patients promoted a ‘working through of elements in early attachment’ (1995, p. 60) that led to the development of emotional depth and greater autonomy in the patients.

As noticed, the distinction between silence as a defense or resistance versus silence as a protection has some major theoretical and technical implications. While interpretation of the function of silence to underlying aggressive or sexual aims is beneﬁcial in cases of defensive silence, the function of protective silence to maintain self-cohesiveness and shield nonverbal aspects of the authentic self requires a different technical approach involving nonverbal interaction, sensitive attentiveness, and gradual exploration. Jacobs noted that ‘silence in the analyst not uncommonly contains elements of countertransference’ (1998, p. 68), and that the patient’s silence can have its counterpart in the psychotherapist’s/analyst’s silence. Understanding of the transference–countertransference matrix between the patient and the therapist, and identifying the patient’s internal object relationships as they are expressed in projections and projective identiﬁcations (Gabbard, 1989) can reveal additional meaning of the silence that may not be readily discernible.

In this chapter I apply a transference–countertransference model to further explore different ways silence may contribute to transformation and change during psychoanalysis or psychotherapy. The question is: What can occur in the silence that might promote and account for changes in the personality? I am proposing that, in the case of Susan, which I discuss, silence serves two functions: ﬁrst, to protect the patient’s core self and provide a space to resolve early problems in attachment, affect, and self-regulation, and second, to contain a transference–countertransference matrix that includes projections of Susan’s internalized mother- and father-related objects on to me. Later this inter-relational matrix promoted affect regulation and enabled transformation in the patient’s capacity to internally access and to verbally convey her own experiences and affects in relationship to me. I attempt to describe how this speciﬁc process of affect desomatization, affect differentiation, and affect verbalization developed. I also propose that my own culturally based tolerance for silence and ability to remain attentive and actively exploring while silent contributed to this transformation.

Susan—A case of silence in the sixth year of treatment

For Susan, silence had both a cultural origin and served several psychological functions. Before the phase of silence that began in the sixth year of treatment and lasted for about one and a half years, Susan communicated by describing life events and interactions with others. She was a watcher, an eyewitness of events and she made elaborate, precise, and witty descriptions of others and their whereabouts, while she preferred not to be seen or involved. Her words were in a subtle way separated from her inner affects, and she used global labels (I hate this/love that) to express preferences or inner states.

Susan, a single woman in her late thirties, diagnosed with narcissistic personality disorder, major depression, and chronic suicidality, began intensive psychoanalytic psychotherapy with me, four times a week, shortly after she had made a near-lethal suicide attempt by overdose. Two events preceded this attempt—her mother had died of cancer and Susan had opted to leave her job as a director of a chemical laboratory. Her departure was prompted by a demotion. She found the proposal extremely humiliating, but she chose to hide her strong reactions in silence while she walked out of the laboratory, never to return. After unsuccessfully applying for several jobs, she felt lost, and secretly began to make detailed plans to end her life. She remained silent about these plans, even to her previous psychotherapist whom she saw twice a week at the time. Susan described how she withdrew and fell into a pleasant state of isolation. She felt superior, calm, in control, protected from all defeats, and free from feelings of agony, anger, and hopelessness.

Childhood and adult history

Susan was the middle of seven siblings. She learned from her mother that she was a ‘replacement’ for an older sibling who had died shortly after birth. The mother repeatedly told Susan that she was strange looking, different from the rest of the family, and never able to do things right. The mother also accused Susan of having caused her burdensome stress and constrictions both before and after birth, especially as the mother secretly feared that she would lose this child too. Susan learned to take pride in not showing emotions, and, when disciplined, she relished watching her mother’s anger escalate into uncontrolled fury as she faced Susan’s undefeatable silent non-responsiveness. The father was more distant but respectful towards Susan, and through others she learned that she actually was the father’s pride and favorite daughter. Although this was never openly admitted or discussed within the family, Susan was much aware of her mother’s envy towards her. Susan described herself as a lonely and unprotected child, often singled out for various negative reasons, and never feeling that she belonged. She always had a strong need for ‘a way out’ inasmuch as she often was the scapegoat, accused of being bad or wrong, or the target of cruelty and humiliation by others. Her major ‘way out’ was silence and withdrawal into solitude.

Susan told me about the many functions of silence in her family. One was to hide shameful family scandals. Another was to withhold praise and positive attention, e.g. that Susan was her father’s favorite, which she learned from his colleagues. A third function of silence was to manage strong feelings such as pain and humiliation, e.g. that Susan for several months was the target of daily cruelty from a housekeeper. The family also kept boundaries through silence, and Susan learned not to talk to her father when he read the newspaper. In addition, decisions about major changes and plans were kept in silence, such as plans for family vacations or a move to a different house. Susan learned early in life to navigate herself in this complex matrix of family silence and secrets, and to protect her own space and integrity by spending time alone boating, hiking, or biking outdoors, or indoors in her room. Nevertheless, from her early teens she engaged in baseball coaching and became highly regarded among children and families in the community.

I understood that Susan had developed a cocoon-like position in her family, a narcissistic space that protected her own self and helped to prevent intrusion from others. Susan had obviously learned to neither reveal nor even feel her own feelings, and to organize her observations of herself and others as descriptions of events rather than conveying her own experiences. What remained unclear to me at this point was whether Susan felt that she was not allowed to talk or sensed that she should avoid or withhold talking due to loyalty, shame, guilt, or fear of loss of inner control; or whether she was indeed not able to talk, i.e. did not have the connections between the words and her inner experiences and feelings.

After working in the computer business for a few years, Susan shifted her career to research and worked for ten years in a chemical corporation. She began as a research assistant, but gradually advanced to become a director with independent responsibility for one section of the chemical operations. Although she preferred work to socializing, she had several close long-term friends whom she had met either through her family or at work. She described that they met regularly, shared a sense of humor, and traveled together. She never married, but dated a man for several years who died in a car accident. When her mother was diagnosed with cancer, Susan became her primary carer. Although their relationship changed as the mother became appreciative, and help-seeking, Susan was relieved when the mother passed away. Six months later, she abruptly walked away from her job as she faced an unexpected demotion. One and a half years later, she made a serious suicide attempt while in psychotherapy twice a week.

The ﬁrst ﬁve years of treatment

Following her suicide attempt, Susan participated in a long-term intensive treatment effort including a group and milieu-focused partial program, family therapy, cognitive behavioral therapy, and intensive psychoanalytic psychotherapy with me for four sessions a week. It also included psychopharmacological treatment with antidepressants and mood-stabilizing drugs. Several gains occurred as she separated and moved away from her family, established her own living quarters, and developed independent relationships with those family members she appreciated.

Susan formed a compliant alliance with me, and, as she gradually connected with and accepted me, she faithfully attended her sessions. My attempts to explore transference reactions, or feelings and fantasies about the therapy and me, were usually unsuccessful, as Susan either rejected my suggestions or in other ways made it clear that my interventions did not make sense to her. Equally fruitless were my efforts to interpret or relate Susan’s behavior to inner feeling states. However, although no visible transference had developed, following Rizzuto’s (1988, 1995) expanded deﬁnition of transference, and Modell’s (1975, 1976, 1980) observations of the ‘cocoon transference,’ I still considered a type of transference present, i.e. one that in the context of Susan’s history indicated her need to protect herself from intrusion from me, to hide her feelings, to avoid interactions and dependency, and to maintain inner control. I sensed that she had developed a cocoon-like transference in which I was like a function in her life, a new object to whom she related out of a sense of duty. She experienced her treatment in general and the psychotherapy in particular as unpleasant, ‘like a religious chore I am supposed to do,’ she said, and ‘hopefully something good will come out of it in the end.’ I understood this to be either a defensive stand or an aspect of her negative attachment, but I also noticed her expression of hope.

Susan had a long history of warding off any type of wishes or longings vis-à-vis other people, which now seemed applied to me. I sensed that she felt endangered by getting close to or beginning to depend upon or long for another person, believing that she would get severely hurt and disappointed, or lose control and fall apart. She was secretive and selectively silent, but she often surprised me when she unexpectedly revealed new secrets. I often wondered what created those moments when Susan accessed new memories, alternative perspectives, or signiﬁcant additional details; was it a sign of altering or deepening transference that enabled her to evoke memories or other experiences vis-à-vis me, or was it a transformation that took place in Susan due to our interaction?

During this part of the treatment, Susan recovered and reconstructed memories and personal history in an effort to establish a sense of herself. She discussed in depth her conﬂictual relationships to her mother and brother, including feelings of anger and envy, and she gained some distance and understanding. She gradually began to recognize changes in her mood and affect states and identify some of the causing events. However, her affects remained separated from her words and it was unclear what contributed to Susan’s ability on one level to actively participate in such an intensive and interactive residential partial program and get stronger, and seemingly gain understanding and ability to manage herself, and yet on another level remain untouched. Her capacity to differentiate and regulate feelings, especially anger, remained poor. She turned anger inward into excruciating humiliation and self-scorn and suicidal ideations. Although Susan was capable of doing skilled and advanced work tasks, her attempts to get back into the professional ﬁeld usually ended in sudden functional collapses. Moreover, she also suffered from a series of unexpected losses of close friends and relatives who died during a period of two years.

The phase of silence

In the sixth year of treatment, Susan suddenly became very quiet. This occurred in the context of her terminating the partial program and moving into her own apartment. Although the treatment plan included both work and group therapy, she chose to spend a lot of her time home alone, and she became protective of her time and space. It was more important for her to be and have her time than to do something with her time (Erlich, 1998). She isolated herself and did not let anybody in. She had only sparse contact with very few people, and said that she usually preferred and enjoyed her time alone, as she felt in control. For long periods she literally secluded herself in a narcissistic cocoon that encompassed her home. However, she also noted that, if she spent too much time by herself, she began to feel detached and suicidal, wishing to join her dead relatives and friends. Her relationship with me changed; during the sessions she was present but more emotionally ﬂat and constricted, and much less interactive compared to the previous years. She appeared to ‘be in herself,’ and I noticed that the connection to me was tenuous and in contrast to her sense of belonging to her dead relatives, foremost her mother.

The silence was noticeable in Susan’s use of fewer words and shorter sentences. Her language lost its former rich and diverse intellectual and symbolic quality and became sparser and more concrete. Her words were detached from her feelings. She replaced descriptions of experiences with accounts of headaches, binge eating, and suicidal ideations. Sometimes she only hinted at more global physical or psychological states, like ‘I am having a very bad day,’ or ‘I feel better today.’ During her sessions she had long periods of no speech, usually without eye contact. In some sessions of 45 minutes, she could say as few as three to four sentences; in others, she became involved in periods of brief interaction with long intermittent silences; while in still others there was a very slowly emerging dialogue that could occupy a major part of the session. I usually looked at Susan most of the time throughout the sessions; she sometimes looked at me when she talked, but usually she looked down, straight in front of her, or to the side, and often she had her eyes closed. This ‘silent period’ lasted about one and a half years, during which a gradual shift took place as Susan initiated more interaction and was more able to communicate her feelings and experiences.

The transference–countertransference matrix

Initially, I had strong concerns about Susan’s silence, and I felt confused and painfully frustrated. As she maintained this isolated position in which she put herself out of reach of my interventions, I felt ‘disarmed’ and incompetent. I also felt confused by the paradox of her faithful and predictable attendance of the sessions, combined with her emotional distancing and verbal non-communicativeness. My efforts to interpret her silence or suggest reasons for her not talking, i.e. ‘Maybe it is more difﬁcult to talk because the treatment is just you and me now,’ or ‘Maybe you miss the intensive interactions with the others in the group program,’ felt intrusive. She adamantly rejected my suggestions, as they did not seem to make sense to her, but, yet, I also noticed that she did not reject me. Still, I felt as if I was hanging on a very thin relational string.

As the treatment continued, I realized that Susan’s silence was more profound and existential and, to my surprise, I noticed that I continued to feel present, curious, and creative. That contrasted to my experiences of silence with some of my other patients with whom I could feel empty, constricted, numb, or dreadfully bored. With Susan, however, I intuitively sensed it was crucial to respect and understand her silence. Baker’s (1993) suggestion that the presence of the analyst/therapist provides a constancy that could allow a new type of object relation seemed relevant, as did the idea of silence as a respite or sanctuary for rebuilding ruptured ego and self-regulatory functions.

I experienced a complex range of projections and projective identiﬁcations; my sense of helplessness, powerlessness, and frustration seemed to reﬂect in part Susan’s own experiences in relationship to her critical aggressive mother and to her distant but idealized father now projected on to me. On the other hand, my sense of perseverance, presence, and participation during this phase was probably associated to Susan’s projection and my identiﬁcation with her idealized father and her being his favorite and idealized daughter and with her idealizing aging mother for whom she had been the special carer. On a deeper level, I felt let in and included in Susan’s withdrawn, silent, and lonely space that she had adopted as a protection in early childhood. On the other hand, I also felt that our relationship was reduced to a minimum. Her dutiful attendance could easily turn into a powerful aggressive rejection that would erase me from her internal world. Nevertheless, I sensed that I also was partly trusted and needed for something that at the time I was not able to fully identify. More than before, I felt like a ‘lifeline’ or ‘lifesaver’ especially since for days or even weeks in a row I was the only person Susan had contact with.

In addition, in the countertransference I noticed an aspect of the silence that was strongly inﬂuenced by my experiences in my own cultural background. I grew up in a Protestant farming village in Northern Sweden, close to the Arctic Circle, on the same latitude as Northern Alaska, Middle Greenland, and Northern Siberia. The Gulf Stream contributed to a relatively warm climate with marked contrasts between the seasons. At the winter solstice, the sun barely reached over the horizon, and at midsummer it barely reached under the horizon, providing 24-hour daylight. Although I was fortunate to grow up in a community where people did speak and communicate, still, silence was a predominant phenomenon. Some silences were restful and thoughtful, and words were not necessary. Other silences were empty because words were missing, especially for conveying feelings. Still other silences could be described by a truism, i.e. ‘speech is silver but silence is gold.’ But silence could also represent distancing and/or elimination of threatening, painful, or hateful matters and experiences. People embedded their losses, failures, or scandals in silence. They treated their enemies with silence, and managed overwhelming conﬂicts and threats in silence. They waited in silence, grieved in silence, and rejoiced or prided themselves in silence. In anthropological terms, I have a high, culturally determined tolerance for silence and, in psychoanalytic terms, silence is to a high degree ego- syntonic to me. I was used to waiting in silence and I had learned to observe details and look for context, meaning, and communication in the silence. My experience of silence related to people’s survival and perseverance. I grew up in the aftermath of the tuberculosis and the Spanish inﬂuenza epidemics that heavily affected Northern Sweden during the early twentieth century. Thousands of people lost their lives, and most families were in some way affected, including both my mother’s and my father’s. As much as silence served survival and protection against the unbearable, uncontrollable, and threatening, it was also related to distancing and erasing, but, foremost, it was closely related to hard work, faithful collaboration, and persistence, and to tenuous hope and conﬁdence in the future. As an immigrant, I brought into the psychoanalytic psychotherapy with Susan my understanding of the complexity of silence that I so closely had seen and experienced among the people I grew up with. The silence was also brought to me in my relationship to my father, who then was in his nineties and gradually had lost his ability to speak. During my visits to the far North, this new silence between us provided a space for me to be in his presence and reﬂect upon my own cultural inheritance. In our silence, I also wrote a narrative of my father’s life for a historical anthology of the village.

I felt embarrassed as I reported on this new phase of silence to my supervisor. Silence was not supposed to occur at this time in Susan’s treatment. My supervisor was an experienced psychoanalyst, and extensive knowledge and deep devotion to my work was enormously valuable, as was his interest in the silence and attention to the sparse interaction in the therapy. Following his advice, I focused on exploring the shifts that Susan reported in her mood, motivation, somatic state, or eating behavior, or in other aspects of her life. Doing so aimed at helping Susan to identify and express her reactions, and to begin to verbalize feelings and inner experiences in relationship to me. My supervisor also strongly advised me to ‘not let her get away,’ but instead to systematically and actively encourage and involve Susan in explorations of her reactions and feelings. This strategy inﬂuenced the transference–countertransference matrix. Rather than being critical and intrusive and trying to explore her feelings in relationship to me, my active exploratory position helped me to balance my countertransference and be aware of the major risks for enactments. I felt it was important to respectfully stay with the material she brought to the sessions, the manifest content of her experiences. I accepted that she needed to keep me on the outside and I intuitively felt it was important to respect her self and space. I sensed the risk of being too intolerant and intrusive, like her mother, or too disengaged and idealizing, like her father. As I was waiting and attending to her silence, I was balancing between, on the one hand, engaging Susan in our relationship and pulling her into life, and risking the eruption of her underlying unintegrated rage that could have led to her erasing me and our relationship. On the other hand, I believe that a less interactive approach might have promoted her detachment into a psychotic process and suicide.

Vignette 1

This vignette is a slowly emerging dialogue during a 45-minute-long session a couple of months into the silent phase. (For the purpose of clarity, I present process notes with my comments.)

As usual, I opened the session by asking how Susan was doing and what she wanted to talk about. This was followed by her initial silence (6–8 minutes).

[I am looking at Susan, noticing that she looks pale and burdened.]

Patient: Today I feel horrible … yesterday was a better day.

[Following my supervisor’s strategy, I focused on exploring the context of the shift from ‘better’ to ‘horrible.’]

Analyst: When did you notice this change?

P: I don’t know … Maybe yesterday evening …

A: What were you doing when you noticed the difference?

P: I don’t know … nothing special … [Long silence.]

[I wondered if Susan actually did not know, or if she did know but was unable to tell me, if she indeed did not want to tell me, or if she wanted to tell me but on her own terms. I also wondered whether during the silence she was just keeping me away and protecting her inner self from me, or whether and in what way she was inﬂuenced by my interest in her shifting state.]

A: Was something happening or going on around the time of the shift?

P: Not really … [Silence.] Yes, actually … my brother called. It was about my car.

[I wondered what enabled this memory and contributed to Susan’s willingness to convey the event to me.]

A: Was it something about your brother’s phone call that you reacted to?

P: No … [Long silence.] I had a huge bowl of ice cream.

[I had previously noticed that Susan’s eating in response to sudden craving or hunger usually represented a non-speciﬁc way of regulating affect, i.e. a regression in affect in the context of some unexpected or disturbing event or experience.]

A: Hmmm. [Silence.]

P: Then I got a headache. [Silence.]

[Obviously S’s reactions to her brother’s phone call were overtly expressed in urges of uncontrolled eating which usually also led to a migraine headache, but what did she actually experience during and after her brother’s phone call?]

A: Maybe you had feelings and reactions to your brother’s phone call?

P: He thinks that I am completely incompetent!

[Susan identiﬁed and described her observation and interpretation of her brother’s communication and intentions.]

A: Incompetent? [Silence.]

P: He wants to look at my car and decide about the repair.

[Susan continues to describe her understanding of the brother’s intentions.]

A: You obviously have some feelings and reactions to that.

[I am focusing on trying to link Susan’s somatic reactions to her understanding of her brother’s intentions.]

P: [She sighs. Silence.] I hate that!! I just feel awful.

[Susan expresses a global undifferentiated state of dissatisfaction, displeasure and frustration without being able to convey her own emotional experiences and feelings.]

A: So you got angry with your brother.

[I continue my attempts to translate her comments into feelings.]

P: He intrudes in my life. I wish I did not have to deal with him.

[Susan responds with a description of her brother’s behavior and a passive and vaguely expressed wish to be able to set boundaries in relationship to her brother. Obviously, it was premature of me to focus on her emotional reaction.]

A: In other words, you felt intruded upon by your brother.

P: Something like that …

[Finally, we reached an agreement about Susan’s experience. I decided not to ask whether she also felt intruded upon by me in the same way as by her brother, because I had previously noticed that she turned down such parallels as if they represented too much intrusion and control on my part upon her inner experiences and/or as if she needed to avoid or prevent feelings of rage towards me and the risk of disrupting the relationship. I also sensed that it was too early to connect her episode of eating and her accompanying headache as a reaction to having been intruded upon by her brother. Instead, I decided to focus on exploring her efforts to take ownership of and communicate her experience to her brother.]

A: Did you tell him?

P: Oh noooo! I would never do that!!

In the countertransference I felt as intrusive as her brother now and her mother in the past, and I sensed that my presence was in many ways a painful and aggravating experience. Nevertheless, she maintained an alliance with me throughout the session, as did I, and we reached an agreement. Several years later she conﬁrmed that my questions evoked her strong aggressive reactions. I felt I had a hard task as I balanced between being an active explorer, a lifesaver, and a protector and participant in her silence, balancing between her potential distrust and rage, and working towards establishing a new type of relationship that also could involve more of Susan’s affects and emotional experiences, including her rage.

Vignette 2

This vignette of a session a few months later presents a step further in Susan’s ability to experience inner longing, and her accompanying reactions and feelings about being rejected.

Susan mentioned for the ﬁrst time ever that she missed her father who had left for his annual winter vacation. She was bothered by his absence in her internal world, and she said, ‘I feel as if I have lost my father’s spirit in me.’ She mentioned how she experienced herself as different from her father. Before, she used to feel more similar and equal to him, especially professionally. While on vacation, the father forgot to call Susan on her birthday. First, she described feeling hurt, as if she did not matter to him. Then she struggled with inner feelings of anger. ‘I don’t want to get angry at someone,’ she said, ‘especially not at my father. I will start to dislike him and it may lead to that I don’t talk to him, and that will be most painful for me.’ I asked if she associated feelings and expressions of anger with total loss and silence, and she said, ‘I used to erase people from my mind if I got angry at them.’ I asked myself whether she believed that if she got angry with me, she would erase me too or that she would erase me instead of expressing her anger towards me, but I sensed that it was too early to discuss this with her.

This vignette further reveals an aspect of my countertransference that Susan’s silence could represent me being erased from her internal world. I was impressed by her fragile and dangerous balance; exposing and protecting her newly emerging experience as an existing human being with own feelings and longings, and anticipating her powerful rejection of her father and me out of fear of being rejected, or condemned because of her longings. Several years later, in the termination phase, she conﬁrmed this by saying that I had ‘passed the test,’ and if I had behaved differently, she easily could have become frustrated and resentful towards me and consequently erased me too. In other words, Susan contained in the silent relationship her anger and rage towards me to be able to maintain the relationship with me. She was not able to handle her intense, unintegrated anger, and the silence probably enabled the anger to be. Susan did not ignore her anger, but nor did she directly express or experience it.

Epilogue

Susan gradually began to interact differently with me and initiate her talking to me more frequently. This was still a very fragile capacity that easily overwhelmed her and she was still prone to retreat to silence in complex or challenging situations. Nevertheless, in the end of what I deﬁned as the ‘silent phase,’ Susan was able to identify an inner experience and accompanying feelings and convey this in her verbal interaction and relationship to me. She had begun to feel, tolerate, and process her affects and to process inner psychological conﬂicts, and she was on her way to becoming the owner of her own feelings. This was like an embryo of internal change that she gradually continued to develop during the following years of treatment. A special milestone occurred four years later when Susan discovered me as a separate person, who was able to see and hear her. She suddenly said, ‘This is embarrassing, but I just realized that I have been talking to another person—you!—for all these years. This is horrible! I have to stop psychotherapy immediately.’ She felt guilty for having revealed secrets, and ashamed for having exposed herself to me and she foresaw her ending our relationship. A few weeks later, she forcefully and emphatically told me, ‘I hate you when you ask questions!!’ I realized that Susan’s new ability to express her feelings of rage and hatred towards me while continuing to stay in the relationship with me was a major sign of progress. Obviously, by verbalizing feelings of shame and discussing the shame-triggering events, Susan was able to identify and process other feelings, foremost rage and envy (Morrison, 1984, 1989). This ability also enabled her to more independently explore her feelings and experiences with me, and she began to ask, ‘What am I reacting to?’ and ‘Why am I feeling this?’ In the termination phase several years later, Susan spontaneously acknowledged the value of the silent phase and expressed her gratitude to me for respecting her silence and for my capacity to be silent with her.

Conclusions

Susan’s silence has to be understood in its context: following termination of a more than four-year intensive multimodal treatment during which she had uncovered conﬂicts and verbalized experiences that never before had been put into words. While remaining in continuing intensive psychoanalytic psychotherapy, within this silence context, she gradually began to develop a new and more genuine relationship with me.

I see this development as representing a multilevel complex process. First, the silence served to protect and provide space for Susan’s inner transformation and development. This was made possible because Susan in the silence gradually could make connections between her inner experiences, her verbal language, and her affects (Rizzuto, 1988). The silence served like a sanctuary or a retreat that provided a space for searching for and accessing her private, non-communicative core of herself (Gabbard, 1989).

Second, the silence also involved a transference–countertransference matrix that represented a delicate and tenuous balance between maintaining and erasing the relationship between Susan and myself. As much as I represented a hope of a possible new object relationship for Susan, I also represented an intrusive threat that easily could trigger her anger and fear by assuming the projective identiﬁcation of her critical mother. Or I could have assumed the role of someone unreachable and longed for, like her representation of her father. On the other hand, as much as Susan represented hope for me, she also represented a challenge: at any time I could have rejected and erased her by being too intolerant or intrusive; in addition, in the silence, I could have distanced myself vis-à-vis Susan and devoted my attention to interests of my own.

Third, the silence phase was highly inﬂuenced by my own cultural background and what I brought into the relationship: my tolerance and acceptance of being silent in the presence of another, and my gradual acknowledgment of the internal complexity and pressure that Susan may have experienced in the silence. While this objective cultural experience made me less sensitive to and more accepting of the threatening or aggressive aspects of the silence, it also helped me in several ways: to identify the patient’s need for protection of her internal space; to control my own enactment; and to maintain an empathically appreciative therapeutic stance. The image that Susan presented, of erasing her father from her internal life, conveyed to me the nature of her rage and anger. In retrospect I believe that my familiarity with a more silent culture enabled me to appreciate and identify with Susan’s protective efforts of her internal space, and it helped me to control my impulses to be too intrusive or too rejecting.

It is difﬁcult to determine the mode of therapeutic action in the case of Susan with any certainty. However, some aspects suggest that the silence phase served an important purpose: the context and the timing of the phase, after more than four years of intensive multimodal treatment; the length of the phase; and the gradually emerging changes that become more explicit in the therapeutic alliance several years later, and especially notable and verbally conﬁrmed during the termination phase. The absence of obvious connections between silence–intervention–change indicates that the nature of change may be more complex, especially in a patient like Susan with narcissistic defenses, unintegrated rage, a fragile internal self, and tenuous object relationships.

Notes

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