The Silent Patient

April 16, 2010

Phillip arrived at the appointment for his first psychiatric outpatient session, filled out the paperwork, told me he was depressed, shed a tear, and became completely silent. No amount of coaxing from me could get him to talk. He looked down or into space, avoiding my eyes, and just sat there for the entire 50-minute session.

Phillip arrived at the appointment for his first psychiatric outpatient session, filled out the paperwork, told me he was depressed, shed a tear, and became completely silent. No amount of coaxing from me could get him to talk. He looked down or into space, avoiding my eyes, and just sat there for the entire 50-minute session.

He accepted an appointment card for the next week and showed up. Again, he had nothing to say. He nodded in agreement when I complained that we were not getting anywhere, since he was so quiet, but still no words came out of his mouth. We did that for at least 8 sessions.

His “hour” was about as uncomfortable as could be. I tried being quiet myself, switched to asking questions, or explained how therapy was supposed to work, but still Phillip just sat there without talking. At the end of each session, he paid the bill by check and left with next week’s appointment card in hand.

Fortunately, this occurred during the middle of my psychiatric residency training, but my conversation with my supervisor was almost as painful as seeing Phillip. Whenever I brought up Phillip, the supervisor listened intently but offered no advice. After I recited the latest happenings (nothing new, just continued silence), the supervisor asked me how I felt. After several sessions with me going on about my frustration with the patient, I ventured into telling the supervisor that he was not making things any easier for me with his lack of response. Eventually, fully aware of the parallel, I decided to be quiet as well. If the supervisor wanted to tell me something that would be fine, but if he didn’t, I would remain silent.

So now I had 2 hours of silence per week-one with Phillip and another with my supervisor. After another couple of weeks of utter silence, the supervisor showed up with a copy of The New York Times, which to my shock and dismay he began reading during our session.

That act of reading the newspaper instead of attending to my needs was absolutely infuriating and I blew up. I told him that he could damn well put down the newspaper. I had a very difficult patient on my hands and needed his help. Instead of help, I got nothing, and now he had the audacity to read during my time!

We used up what remained of that supervisory session with me telling him what I thought of his help. After the supervision session was over and I had time to think about my predicament, I decided on a plan. Perhaps the supervisor was actually telling me something.

I decided to bring The New York Times to my next session with Phillip. When he arrived, we exchanged our usual “Hellos” and then he did his thing-silence. After about 5 minutes, when it was clear that we were in our usual standoff, I picked up the newspaper and began to read. In fact, I was beginning to get involved in an article when Phillip exploded. His words were shockingly similar to my own of a few days before.

He was incredibly angry with me for not helping him. Why didn’t I help him-didn’t I see how much trouble he was in? How could I just stand by and do nothing? Phillip went on to tell me about his trouble. Nothing in his life was going well. That was why he wasn’t able to talk before.

Before each session, he would promise himself that he would talk, but after he arrived, he could not bear speaking about the things going on in his life-his son’s suicide, his daughter’s running away from home, his wife’s terminal illness, the demotion at work. Everything was horrible. His life was a shambles, and he was completely overwhelmed. Of course, he could not talk about it. Whenever he thought about his trouble he became even more depressed. “I am thinking of suicide and you are calmly reading The New York Times,” he said. “What kind of psychiatrist are you?”

From that point forward, Phillip did a lot of talking and gradually pulled out of his profound depression. As a precaution and eventually as a talisman, I brought The New York Times to each session. Even today, more than 30 years later, it sits on the corner of my desk, awaiting the arrival of the next patient who refuses to talk. Almost to my dismay, I have never again had the opportunity to read the newspaper during a session.