I was talking with a friend recently who knows about music .Somewhere in the conversation a comment was made about the spaces between the notes being as important as the notes themselves. Not being a musician but being a counsellor, I began my own improvisation on this theme, playing with the idea of the gaps, spaces, silences and such like that appear in clinical work. I am comfortable with silence in a session. I once had a patient who came to seem me who sat through three fifty minute sessions and said not a word. At the end of each session I said that I would be here next week if he wanted to come and see me. He came for three sessions but not a fourth. I subsequently discovered from a colleague on the ward that the patient had taken a vow of silence-for various personal reasons. (I often wonder what he made of these sessions.)

If I am tired I find it harder to be quiet and am more inclined to interrupt more and talk more. I think I need to keep myself awake sometimes and remind my self that I am in the room with my patient. It also takes me a little more effort to allow a silence to grow. If I am tired I worry that I am going to lose my patient and that they will feel I am not doing my work properly. The psychoanalyst Wilfred Bion said “Some silences are nothing, they are 0, zero. But sometimes that silence becomes a pregnant one; it turns into 101- the preceding and succeeding sounds turn it into a valuable communication,as with rests and pauses in music and gaps in sculpture.” 

This was the case with my silent patent. Whilst almost no words were spoken-except for a few attempts by me to try and interpret the silence- the sessions were not onerous. I felt no pressure to persuade him to talk and he seemed able to keep silent. 

In contrast to this an exercise I sometimes give to my nursing students is an exercise in silence. I ask them to assess a ” patient” for a period of time- say 10 minutes. The “nurse” is unaware that their patient has been briefed to say nothing for the entire interview. The responses from the assessing student are fascinating to watch. One or two students can simply sit with their patient in quietness. Others get angry. I have heard students threaten their patient with forced injections, the crash team,being sectioned or secluded.A desperation sets in that they must get some information out of their patient. The reflection afterwards often shows how much student nurses feel obliged to get “facts” out of their patient- when the real “facts” are there before them in the silence, if they can allow themselves to listen. To quote Bion again “If he ( the analyst) cannot respect the silence, there is no chance of making any further progress. The analyst can be silent and listen- and stop talking so that he can have a chance to bear what is going on.”

I suspect, of course, that is another reason why it sometimes feels easier to talk too much. We don’t want to hear what might be being said. I often wonder if this is one reason why so many mental health nurses seem to be so busy so much of the time. If they sit down with a psychotic patient they may be faced with their own madness; their own not-knowingness and impotence. With a competent clinician this shared experience can be enriching and therapeutic. Both parties enter a new realm. The nurse learns to feel something of the patient’s distress and disturbance. The patient is able to feel held and not alone in their world.But this requires courage from both parties. And a willingness to learn together.

It is in the silences that i often hear best what my patient is saying. when I have heard what is being said then I can comment on it and try to give it shape. But too many words get in the way.