The silence of patients in therapy provides many challenges to the therapist. It is vague, undefinable and is difficult to challenge. It can signify resistance and negative transferences but can also be a space for the patient to communicate something that cannot be expressed in words. As a result of its ambiguous nature it can challenge the therapist’s confidence in their own abilities and create anxiety or tension in the therapeutic relationship. This paper aims to explore some of the developments in the understanding of patients’ silences in therapy, as well as some of the ways an therapist can work with silent patients. It is hoped that the paper will help therapists to understand more about what a patient’s silence can mean and also provide guidance on how best to work with silence in therapy.