On the Millennium Trilogy

What to Say When the Patient Doesn't Talk

Lisbeth Salander and the Problem of Silence

By David Anderegg, Ph.D.

Psychotherapy, when it first began in Sigmund Freud’s day, was almost immediately labeled “the talking cure.” According to some historians of psychoanalysis, the talking cure was discovered almost by chance during the treatment of the famous patient “Anna O.,” who suffered from hysteria. She talked to Freud’s partner Josef Breuer incessantly and, in so doing, seemed to relieve herself of her neurotic symptoms, including coughing, squinting, occasional paralyses, visual problems, numbness in her arms, and an inability to speak in her native German (although she could speak perfectly well in English). She did not require the application of hypnosis that had, up until that moment, been the treatment of choice for the removal of hysterical symptoms. Anna O. talked and talked and talked; and then she got better. It was this fateful encounter that led Freud to suggest the method of free association: the patient was not hypnotized but was instead instructed to lie down upon the couch and say “whatever came to mind.” From that moment on, psychotherapy became the standard treatment for hysteria and, shortly thereafter, a host of other psychoneurotic illnesses for which there had previously been no effective treatment.

But there’s just one little problem: What do we do when the patient doesn’t talk? Not only can she not participate in the “talking cure,” but we don’t even know what’s wrong. We can’t cure without talking. Indeed, we can’t even diagnose the problem. Unlike other branches of medicine, psychiatry is at a distinct disadvantage when it comes  …

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