Chapter 2: LITERATURE REVIEW

 

A literature review consists in locating, assessing and exploring the existing professional and research literature so as to sensitize the researcher to the phenomenon under investigation (Moustakas, 1994; Polit & Hungler, 1995). In order to conduct the literature research the researcher used the following sources: The British Journal and Guidance and Counselling; The British Journal of Psychotherapy; Changes; Counselling; Counselling and Psychotherapy Research; European Journal of Psychotherapy; Education; European Journal of Psychoanalysis; Free Associations Journal and Journal of the Society for Existential Analysis. Also both the British Library as well as the university library catalogue OPAC were used at great length.


As it stands at this point in the research the research question is:


“What is the therapist's experience of a client for whom the act of talking is problematic?”


It was found that a search using the words 'psychotherapist'; 'reluctance' and 'talk' individually and in combination was either too wide or didn't produce any meaningful results. However, “the study of human phenomena, starting with the way that they are first given in commonplace experience, is always the beginning point of a phenomenological study” (Giorgi, 1983: 83). On the basis that the commonplace experience of a client who does not talk may be regarded as a form of 'silence' the researcher proceeded to review the existing literature in relation to this phenomena in the context of therapy.

Given that psychotherapeutic progress is completely tied to the client's ability to use language (Freud in Gay, 1995; Zeligs, 1961, Balint, 1992), it is perhaps not surprising to find that relatively little materials seem to have been written in the domain of silence as a non-verbal form of communication in the therapeutic process.

For Zeligs (1961) however, silent moments in therapy can reflect various but arguably distinct and contrasting psychic states and qualities of feeling. He writes

                   “[silences] might evidence agreement, disagreement, pleasure, displeasure, fear, anger, or tranquillity. The silence could be a sign of contentment, mutual understanding, and compassion. Or it might indicate emptiness and a complete lack of affect. 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 be the sign of defeat or the mark of mastery” (Zeligs, 1961: 10).

Along with processes such as verbalization, thinking, remembering and postural expression silences are, he writes, an integral part of the therapeutic encounter.

Again with Balint (1992) one can recognise in his description of silences two different aspects of the phenomena. His own experience shows that they can effectively be experienced as

                  “an arid and frightening emptiness, inimical to life and growth, in which case the patient ought to be got out of it as soon as possible; or it may be a friendly exciting expanse, inviting the patient to undertake adventurous journeys into the uncharted lands of his fantasy life; silence may also mean an attempt at re-establishing the harmonious mix-up of primary love that existed between the individual and his environment before the emergence of objects” (Balint, 1992: 176).

Located somewhere in between those two very distinct states and quality of feelings it is perhaps not surprising to find that the most difficult task for the therapist in the situation where the client is silent is to know whether he has to intervene or not (Coltart, 1993). As Ihde (2007: 177) reminds us “face-to-face meeting without words results in awkward silence, because in the meeting there is issued a call to speak”.

In her research study Levitt (2002: 333-350) explores what she refers to as 'productive silences'. According to the author there would exist three 'Productive Pauses' which she claimed “are experienced as highly productive moments in therapy” (Levitt, 2002: 333-350). For Levitt the first of those pauses, 'emotional pauses', describe the lived experience of the client who comes into contact with an intense feeling or profound and powerful emotional state. Those particular moments of silence, she posits, are important experiential state in which the client needs time to make sense of his emotions.

As a second type of productive silence, 'expressive pauses' describe psychic states where the clients is involved in an active inner search so as to find the most adequate symbolic description of their current feeling state. At this stage a certain struggle may be a sign that the client is engaged in an intensive process where he is moving back and forth from the feeling to its symbolic representation.

Finally, 'reflective pauses' are those moments of understanding and insights, where the client questions or makes a connection between his experience, feelings and awareness. All three of those productive pauses, Levitt claims, may happen in succession and contribute significantly to the therapeutic process. In the same vein Winnicott (1982) recognised the need at times to leave the client 'alone' in his silence, which he saw as a necessary 'uninterpretive' act in order to help the client organise his private and internal mental development.

The more 'negative' silences from the client, on the other hand, seem to have attracted more attention in the literature and appears to be presenting the therapist with an “ironic dilemma” (Bollas, 1987: 174), a “puzzling problem” (Balint, 1992: 26) or as Coltart (1993: 80) puts it

                    “a strange, unwelcome and disconcerting shock, one which taxes the analyst's skills to the utmost where much or all that one has faithfully taken in during one's training, and with cases under supervision, goes out of the window”.


Clients who have made it a feature of their therapeutic process to have many and long silences have been identified by the psychoanalytic literature under the name of 'silent patients', or sometimes referred to as 'difficult' or even 'deeply disturbed' patients (Balint, 1992: 14). In their extensive study on crises occurring in therapy Leiper and Kent (2001) use the term of 'impasse' in order to refer to the situation whereby the therapeutic relationship breaks down.


From a phenomenological-existential perspective we learn that the self is regarded as a 'sedimented self-construct' built from the product of both relational experience and foundational building beliefs, like for example fixed values (Worrell, 1997). The realisation for an individual that he can change his self may mean that it is not built on any concrete and solid grounds. Worrell (1997) claims that the resulting feelings of terror of 'non-being' (May, 1994; Bugental & Bugental,1984) may be struggled against and expressed in what he refers to as an 'ontological resistance' (p 10).

For Merleau-Ponty ([1945] 1962) the function of speech is, of all bodily functions, the most intimately associated with the existence in community. A loss of speech does not just mean a refusal to speak “it is an escape, a denial of Others, co-existence and the future”. What collapses is the whole field of possibilities. In those moments, the philosopher writes

                     “nothing further happens; everything looses its meaning, shapes and forms. Time becomes a recurrent flow of identical ‘now’ and the patient has withdrawn into his own body which has become 'the place where life hides away'” (p 187-188).

For Mearns and Cooper (2005) the event of a deep trauma leading to some loss of the ability to speak  in those clients are not just verbal; those client are “communicatively silent. Their whole expressive and communicative system has closed down – they have separated themselves from the interactive world. They have separated themselves from living” (p 99). In silence the body is left by and with itself, dissociated and extinct like a dead and empty shell. In those circumstances Balint (1992: 19) reports having experienced a feeling of deadness, being lost, futility, emptiness coupled with “an apparently lifeless acceptance of everything that has been offered”.

The notion of escape and withdrawal from the Others and the world into oneself is also taken up by Zeligs (1961) as for him the most intense emotional experiences in life are spent in reflective silence rather than speech. He writes

                    “Silences isolates and tends to create a closed circle. It serves to shut one’s inner thoughts and feelings and isolate so as to be safe from others and oneself. This may be a voluntary act, as in preparation for falling asleep, or it may be an unconscious protective process against any kind of threat, real or fantasied” (Zeligs, 1961: 25).

 

From a psychoanalytical perspective it was found that most authors regard a reluctance to talk as a form of 'resistance' the client deploys against the therapeutic process (Giorgi et al, 1983: 88; Coltart, 1993; Bollas, 1987; Greenson, 1961) and whose aim is to control the analyst (Coltart, 1993). In the context of what they refer to as an 'impasse' Leiper and Kent (2001: 140) suggest that a prolonged silence may be a sign of “defiance, passivity, a fear of fantasy/feeling or a fear of lack of interest”.

At this stage in the literature it seemed important to clarify the concept of resistance in the context of this research.

According to Zeligs (1961) soon as a contract is established between a patient and a therapist, the former is implicitly handed the position of 'patient-as-talker' while the latter is positioned as the 'one-who-listens'. This specific structure is central to the therapeutic alliance and until its termination is implicitly taken for granted by both participants. Any longer than expected duration outside of this arrangement, Zeligs suggests, may indicate a form of 'resistance' from the client .


From an existential perspective Loewenthal and Snell (2003: 17) suggests that the therapeutic encounter can be thought of in terms of Kierkegaard’s view of the patient's “Shut-upness unfreely revealed… for the shut-up is precisely the mute, and if it has to express itself, this must come about against its will when the freedom lying prone in unfreedom revolts upon coming into communication with freedom outside, and now betrays unfreedom in such a way that it is the individual who betrays himself against his will in dread”. Kierkegaard seems to imply that the client cannot but be anxious of revealing himself in words since the therapists very presence illuminates the client's inauthentic attitude.

In turn Fink (2007: 132) quotes Lacan as saying that “There is no other resistance to analysis than that of the analyst himself” which, in line with Leiper and Kent (2001) implies that if a client resists talking then the therapist is implicated in some ways. For Leiper and Kent (2001) it could be that this situation is provoked by the therapist not being able to bear her client's pain and therefore adopting a very rigid approach based on an 'individualistic view of causation' (p70).

In the same vein Stern (2003) suggests that in similar situations therapists might be blinded by certain aspects in the relationship and therefore limited in their faculties to create the necessary space for relating to their clients' experience. Balint opens this notion up by suggesting that if the client is running away from something he is also running towards 'an area of creation' (Balint, 1992: 26) - a relatively safer place in which he can work on the things that are distressing him.

Zeligs (1961: 23) claims thatspeaking is an ability which, if acted upon, forces the speaker to identify with his own thoughts whereas, while referring to Lacan, Bailly (2009) writes that language necessarily creates a relationship “between organism and its reality” Bailly (2009: 31-32): through a process of verbal symbolization the self becomes conscious of itself as an object and comes into being by the act of subjecting itself to something external to itself: an Other with its own rules to follow, or not, at one's own risk. Implied in this idea is the sense that feelings of anxiety may well be evoked since the speaker is inescapably dependent on the Other as language for what to say and how to say it (Fink, 1996).

In view of the above and in the context of therapy it is argued that the client may be seen to be recoiling from verbalizing  his ideas and subsequently fall into silence in order to avoid the dread attached to having to commit to one's own thoughts and therefore invite judgement. For some, Kierkegaard claims, having to face the fear of being neither understood nor approved is too menacing, and so notto venture and remain silent is to be safe. This attitude however, he warns, invariably leads to the worst kind of loss: “the loss of oneself” (Kierkegaard, 1849/1983: 34).

In turn Fink (1996: xii) refers to Lacan as suggesting that the subject can be conceptualized as a “stance adopted with respect to the Other's desire”. At first the infant defines himself in relation to the desires of the Other as parents, and then as an adult defines himself in relation to the desire of the Other as the society at large. Indeed in the context of her work Coltart (1993) remarked that at times some of her patients felt a very strong wish to please her and so fell silent as part of a deep fear to get it wrong.

In the same vein Rigas (2008) recalls working with a client who did talk, but the words she used didn't seem able to convey the real distress of her feelings. In a desperate attempt to communicate Rigas thinks that the client resorted to a primal form of communication called ‘projective identification’ (Rigas, 2008: 37 - 41) in which he subsequently became “infected with the sickness of the setting”. Bollas (1999: 83) refers to a similar phenomenon in terms of “an occasional madness of the psychoanalyst” as he recalls having changed for the worse, regressed and gradually lost his identity as a therapist as well as his empathy towards the patient to eventually be assailed by feelings of guilt.

For Rigas his interventions had become formal and false, his comments superficial as he recounts feeling a growing dislikes for the patient; sessions felt like a 'void' where he was unable to have thoughts or reveries but instead “an experience of contact with something as dangerous as death itself” (Rigas, 2008: 42); the patient’s internal space felt like a place he could not reach as his words would not have any effects.

In turn Rycroft (1958: 3) speaks of clients who “equates being understood with being devoured or penetrated” and therefore make it practically impossible for the therapist to understand them. Those clients, he writes, may doubt the sincerity of the therapist on the basis that their relationship only exists in order to allow him to earn a living and so proceed to undermine him by insisting he lacks the essential qualities to be a good therapist. Along the same lines Coltart (1993: 81) writes that a client “can drive himself into silence because of his own alienating feelings of fears and greed, or his sadistic wishes to bite, devour and hurt”. For Ferenczi (1953: 38-40; 258-259) a silence can be an expression whereby the patient “equates strength with retention of all feelings” orat other time the patient may be filling up the analytical space with unimportant matters as a “loquacious form of silence”.

The client who remains deeply silent may provide the therapist with an impression that some emotional damage have occurred very early in his life, at a 'pre-verbal' level which Balint refers to as 'the basic fault' (Balint, 1992). At this level, Balint claims, the contrast in intensity between the experience of satisfaction and frustration can be enormous and sees the client suddenly cease to cooperate and adopt an attitude which could be reflected in a refusal to move and change as well as a complete refusal to bear any difficult tensions or anxiety in therapy. The author adds that any kind of interpretations offered to those clients may be experienced as either something “highly pleasing, gratifying, exciting or soothing”, or instead as “an attack, a demand, a base insinuation, an uncalled-for rudeness or an insult, unfair treatment or injustice” (Balint, 1992: 18-19).


In a similar fashion Coltart (1993) experienced her clients as being trapped by feelings of shame, persecution, or sorrow and so finds that theoretical ideas around the affects of meanness, spite and grudgingness can be of significant help.

In those particular circumstances it is recognised that therapists may generally find it difficult to remain sympathetic, objective and passive but instead becomes emotionally involved (Balint, 1992; Rigas, 2008). Therapists may allow themselves to be affected by the client and change their therapeutic approach accordingly or get drawn in and deliberately choose to carry on with the approach they have always been using while reassuring themselves that their technique has survived the test of time and that their interpretations can deal with any types of situations.

Leiper and Kent (2001: 140) suggest that in those instances the therapist may show feelings of defiance passivity, fear of fantasy/feeling or fear of lack of interest. Potential feelings of failure in the therapist may ensue and become difficult to untangle from the client's, eventually risking to resulti in disastrous consequences for the therapeutic relationship. In this instance the authors argues that the therapist's feelings of knowing while not being able to escape the situation may result in powerful feelings of shame and incompetence which undermine his self-esteem. At worse, those authors write, “the therapy can seem like a charade” (Leiper and Kent, 2001: 89) as the therapist finds himself in complete denial of the situation as he carries on believing that his work is still helping the client.

It is vital that the therapist wake up from this state of mind” writes Leiper and Kent (2001: 70). According to them the therapist should take his responsibility of the situation and identify what has become stuck in the therapeutic process. At the end however, Rigas (2008: 43) claims that “what is of the utmost importance is the analyst’s survival!”.

Mishandling a silence can perpetuate violence and ultimately leaves the client feeling violated, controlled, rejected and persecuted(Zeligs, 1961; Coltart, 1993; Mearns and Cooper, 2005).

In the eventuality that a client becomes reluctant to talk the therapist needs to be patient, intuitive, capable of tolerating not knowing while being creative (Coltart, 1993, Leiper and Kent, 2001). For Mearns (Means and Cooper, 2005: 105) “there is a very narrow boundary between encountering and invading”, while Giorgi (Giorgi et al, 1983: 88-89) cites Maes as claiming that it is 'attentiveness' which is at the heart of the therapist’s listening and observing activity. For him

              “The therapist must listen and observe his own reactions as well, inasmuch as his disciplined self-awareness either promotes or detracts from the emotional climate necessary for the analysis as such”.

 

For Mearns (Mearns and Cooper, 2005) who works from a person-centred position, the work of psychotherapy for traumatised silent patients cannot be approached from a 'normal' position defined by reality as one usually apprehends it. In those situations, he claims, only phenomenology and a form of ethics appropriate to the actual situation may provide a functional basis from which to work from. Perhaps this idea is reflected in Ihde's words “If there is an ethics of listening, then respect for silence must play a part in that ethics" (Ihde, 2007: 180.

From Mearns' account one learns that when working with a mute patient it is important not to expect them to speak back or reciprocate in any way (Mearns and Cooper, 2005). Instead, the author emphasizes the importance of being authentic in one's own approach. For him in those situations “I have to present myself exactly as I see myself, warts and all, with all my doubts, fears and, particularly, including how I feel here and now” (Mearns and Cooper, 2005: 101). Finally, he warns, if a person is protecting himself then the therapist should be making it his first priority not to invade him.

In an effort to connect with traumatically silent clients Mearns refers to what he calls an attitude of 'situational and contact reflections' which sees his communication being kept very broad and mundane (Mearns and Cooper, 2005: 103). Therapists make contact not just on a deep and emotional level, but also and most naturally through a range of different kinds of more 'down-to-earth' subjects which connect with the client. Mearns also stresses the importance of the softness in the voice and the genuine caring for the client in an effort “to earn the right to engage” with him (p 112).

For Coltart the transference, and more specifically the counter-transference or internal feelings evoked in the therapist during sessions, “become the instruments par excellence of the work” (Coltart, 1993: 86). In the same vein Balint speaks of the therapist needing to be absolutely indestructible and 'in tune' with his client whilst allowing him to experience what the psychoanalyst refers to as a “harmonious inter-penetrating mix-up” (Balint, 1992: 53) whereby the most accepting, understanding and nurturing therapeutic environment should be fostered for the client: the therapist must be 'there' and accepting the client to the highest degree possible while not offering much resistance.


Almost all literature points to how sensitive the therapist should be towards the client during periods of silence. Mearns (Mearns and Cooper, 2005: 106) talks about the client 'being a barometer of his own presence to his own presence' which enables him to gauge the quality of his own presence with him. The client, the author recalls, was able to sense the level of his focus or his drifting. In turn Kreitemeyer (Kreitemeyer & Prouty, 2003: 155) use the terms 'contact rhythm' in order to describe the unspoken experience of resonance between them and their clients. Finally, for Coltart (1993: 89) the observation by the participants in therapy is a two-way process: “the patient is studying the analyst's silence with just as much keenness as the analyst is studying his”,  while Zeligs (1961: 17) writes “if the analyst's silence in one way or another denotes impatience, boredom, indifference or hostility, this will surely be sensed by the patient and thought of as a disapproval, rejection or condemnation”.

For Leiper and Kent (2001: 90) the best therapeutic approach for resolving silent impasses is one characterized by “imaginative but disciplined flexibility”, whereas Mearns talks of using his imagination as a powerful way to “freshen up his empathy” (Mearns and Cooper, 2005: 106). He would imagine what might be going on for the patient during sessions in order to stay 'connected' with him between sessions. Also in his account Mearns mentions the importance of supervision where he explores the boundary between full involvement and over involvement. For him learning about who we are in terms of our boundaries is a fundamental part of freeing ourselves so as to offer clients the possibility of a relationally deep encounter (Mearns and Cooper, 2005: 107). Finally Mearns argues that engaging at relational depth is also to let the moments 'be' and not attempting to dissect them endlessly so as to render them superficial (Mearns and Cooper, 2005: 109).

While Merleau-Ponty ([1945] 1962: 190) argues that it is only confidence and friendship within an authentic relationship that can allow for a change in existence, for Clarkson (2005) the key factor during those moments is a continuing, stable and dependable therapeutic relationship. In turn Coltart (1993) speaks of 'faith' of the therapist in his training, the psychotherapeutic process and in himself while 'avoiding memory and desire'.

At the end however, Coltart (1993: 86) finds that working with silent clients is intensely gratifying as both participants truly listen while the bodily senses become “unbelievably sharpened”. She writes

             “Above all, we have the gratifying, if at times alarming, sense that we are truly heard in what we say. One thing we can be sure of with a silent patient is that both participants listen”.

Silences are privileged opportunities to reflect deeply on what the therapist does, develop patient endurance and ultimately witness some deep and lasting changes in the patients (Coltart, 1993; Leiper and Kent, 2001). 

The researcher is now going to examine and explore the currently existing approach in research.

   

 

Contents

Abstract

Introduction

Literature review

Methodology

Research method

Findings

Discussion

References

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