À l’aide d’un exemple clinique, nous élaborons les différentes fonctions que peut avoir le silence dans les thérapies cognitives et comportementales de la dépression. Les silences d’une patiente déprimée, suivie en psychothérapie, sont documentés et analysés. Le silence peut, chez la même personne, tantôt produire un apaisement ou organiser la pensée, donc s’avérer productif, tantôt représenter une tentative d’échapper à du matériel douloureux, donc s’avérer peu productif. Ainsi, le thérapeute aura fondamentalement le choix, soit de respecter ces silences soit de les rompre et de parler. Pour l’aider dans ce choix, nous repérons différentes catégories de silences et les mettons en lien avec la littérature à ce sujet, afin d’introduire le silence comme outil thérapeutique à part entière dans le traitement cognitivo-comportemental de la dépression.

Cognitive behavioral treatment of depressed patients has been widely theorized. Our analysis attempts to add the specific dimension of silence as a therapeutic tool. Our assumption was that silence is a cognitive element in its own right with different functions in thought construction and in the interaction between patient and therapist. Our thinking was structured inductively, starting from a case study and then discussing clinical phenomena related to the empirical literature. The case study concerned Madame B., born in 1950 and suffering from recurrent depressive disorders. She was 55 years old when she started cognitive behavioral therapy (see annex for a functional analysis). Following a behavioral remobilization phase, situational analysis with cognitive restructuring was explored. It was at this point that the need to integrate silence as a procedural tool was imposed: her speech was poor, descriptive and interspersed with long pauses. The usefulness of these pauses was then discussed with the patient. From this clinical example, different functions of silence in shaping perceptions and mental images, and also in emotional management, were identified. These included healing, decentering, reestablishment of the continuity of cognition, collection of scattered elements, time required to retrieve memories, concentration, and intervals promoting metaphors and reformulations. Silence could also allow the patient to avoid painful cognitions and to distance themselves from their situation. The act of listening in silence to the therapist's speech was also discussed. Silence was then considered as a behavioral manifestation. Its therapeutic function allows the patient to identify bodily feelings, to slow down cognitive flow and to relax. Having looked at silence from the patient's point of view, the silence of the therapist was then explored. It is not always easy to remain silent. Reiterating what has been understood or discussed too quickly can be a way to avoid their own feelings. Verbal breaks should punctuate and follow the speech of the patient. Sometimes, during a silent moment, whilst sharing the emotions of the patient, therapists also discover themselves. The silence of the practitioner also promotes modeling. Learning from their example the patient can dare to be silent. Conversely, some of the therapist's silences may have a negative effect, creating the feeling of being let down or rejected. The therapist must be mindful of this. Following the clinical analysis, there was a discussion on scientific work on this subject suggesting that in psychotherapy, in addition to neutral silence, there exist two forms of silence: productive and non-productive. Levitt's study (Levitt, 2001 [7Levitt H.M. Sounds of silence in psychotherapy: the categorization of clients’ pauses Psychother Res 2001 ;  11 (3) : 295-309 [cross-ref]

Cliquez ici pour aller à la section Références]) distinguishes several productive silences: “emotional, expressive and reflective”. Emotional pauses related to intense feelings requiring a pause to access emotions, experience them and then recover. Expressive pauses allow the patient to articulate their ideas or to access the meaning of such emotion. Reflective pauses refer to internal questioning and interpretation. Amongst neutral silences “mnemonic pauses and “associational pauses” are also cited. Amongst non-productive silences Levitt distinguishes “disengaged pauses and interactional pauses”. Interactional pauses are of particular interest in helping us to refine the therapeutic relationship and their underlying issues. The last part of our discussion focused on all other clinical aspects, stressing the need to be very attentive to the quality of silence experienced in therapy sessions. It is important to define and classify these. The practitioner must also be attentive to the timing of pauses, their frequency, their length and the body language associated with them. These periods of observation and linking can be followed by sessions focusing on silence which will differ depending on whether the pauses are emotional or disengaged. The therapist may also incorporate pauses, if necessary, being careful to use this phenomenon as a therapeutic tool in its own right. In conclusion, the importance attached to silence in cognitive behavioral therapy is reiterated, as well as the need for further research and observation in order to move towards the validation of this tool.