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<jats:p> While Cage’s 4’33 opens an audience’s ears to how much we silence sounds, we also miss much of what silences convey. It seems Cage’s piece could be entirely about listening. Silence is where we listen from. In what ways can we consider silence in music therapy work? The article revisits PhD research examining the detailed occurrence and management of silences during free improvised musical duets and silences in everyday conversation. This research made use of both musical microanalysis and conversation analysis, identifying similarities and also important differences between verbal and musical exchanges. These findings are still relevant today and provide a solid base from which to consider music therapy improvisatory silences. Applied music and psychoanalytic theory are included, as a way to view and review music psychotherapy work in the area of silence, with two clinical vignettes illustrating the application of these theoretical threads. It is shown that fundamental to an appreciation of silence in therapeutic work is the acknowledgement of a deep, layered listening presence. </jats:p>