Patient silence may cause the therapist serious anxiety. It is an enigmatic, over determined phenomena that has been variously defined and clinically addressed in psychoanalytic literature. This dissertation is a systematic literature review (with clinical illustrations) of psychoanalytic literature on patient silence. The findings have been classified into three broad categories: first, silence as resistance; second, silence as communication; and third, silence as creativity. Patient silence is illuminated as one of the greatest barriers to, and one of the deepest moments in an analysis.