A Psychiatric Perspective on Therapeutic Speech

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PSYCHATRIC VIEWS ON THE DAILY NEWS

I don’t know about you, but I’m pretty bewildered about the current societal uproar about what free speech, hate speech, and the first amendment mean. One related hot button example is how the leaders of 3 well-known private eastern universities were questioned about antisemitic speech violations of their own code of conduct at a congressional hearing less than a week ago.

As I was writing the first draft of this column on Saturday, the University of Pennsylvania president, a lawyer by profession, resigned after having equivocated on whether students who called for the genocide of Jews should face disciplinary action. She referred to the qualification of context, causing some individuals to think that this was a legalistic response to a moral question. More surprisingly, perhaps, the chair of the university’s board also resigned without much of an explanation.

Evaluating such speech spurred me to try to better understand the meanings and distinctions. In the January 16, 2019, article “The First Amendment: Categories of Speech,” the Congressional Research Service covered the variations of free speech. Unprotected speech is presumptively unconstitutional and, in recent times, included: obscenity, defamation, fraud, incitement, fighting words, true threats, speech integral to criminal conduct, and child pornography.

More or less, it seems like unprotected speech is more likely to cause psychological harm. Sometimes it is also called speech violence. Words can cause undue stress. Where to draw the line, however, is a challenge. A case is made for “trigger warnings” on campus because they cause distress, but actually the impact of triggers is quite individualistic and depends on personal trauma history, which might not be at all publicly visible. Verbal microaggressions may be harmful to some individuals—especially to those individuals from groups that have been historically oppressed—but not to others.

Evil speech (“lashon hara”) refers to language prohibited in Jewish law. It technically refers to true speech that is dangerous to the subject of the speech, as is malicious gossip, but not necessarily all gossip.

In general, it seems to me, “harmful speech” is that which causes undue and unnecessary distress or danger in the recipients because psychological or physical safety is violated. Most familiar is hate speech, although even here a distinction needs to be made between appropriate hate, such as that of Hitler by those terribly harmed by the Nazis in World War II, and undo hate. Harmful speech has received increasing attention online, with the challenge of how that can and should be managed.

The degree of harmful speech can vary, which in this situation includes genocide, killing, and torture. On the spectrum can be muffled verbal threats all the way up to actual action. That reminds me of the varying state laws about involuntary inpatient commitment of the patients with mental illness or those deemed dangerous. Threats may not be enough, and some sort of actual conduct, like harming someone, is required. However, in loss of life, it is too late because the harm is extreme and permanent.

In personal relationships, harmful speech is critical to intimate relationships, such asin marriage and families. Research indicates that contempt is particularly destructive.As the recent New York Times December 1, 2023, article “8 Things You Should Never Say to Your Partner, According to Therapists” conveys, it also helps to avoid generalizations in an argument (eg,“you always), deflections (eg, “yes, but”), comparisons (“you should be more like”), and dismissals (“calm down”). Reparative speech is crucial to soften unresolved conflicts, such as using positive humor. Family and couples therapists encounter these exchanges.

Despite all of these interesting complexities of speech and remaining confusion about them, we in psychiatry are probably more clearly concerned with speech that is therapeutic. However, I couldn’t find any discussion about therapeutic speech per se. There is speech therapy, but that refers to correcting medical problems in physical speaking.

I might even go so far to suggest that therapeutic speech can be considered to be the cornerstone of psychiatric care, as exemplified by:

• Explaining the need for treatment without causing shame or humiliation in the would-be patient;
• Explaining adverse effects of medication in a way that provides adequate and informed choice for the patient, but doesn’t unnecessarily scare them away from trying it;
• Providing interpretations in psychodynamic psychotherapy in the right way at the right time for patient acceptance; and
• Adjusting the general protocols of cognitive behavioral therapy to each individual patient.

Therapeutic speech in psychiatry and other specialties can be said to be the art of medicine. It also fulfills our Hippocratic ethical priority and aspirational goal to do no harm, a goal that is also relevant to society and the art of being human.

Dr Moffic (he/himhis) is an award-winning psychiatrist who specialized in the cultural and ethical aspects of psychiatry, and is now in retirement and refirement as a private pro bono community psychiatrist. A prolific writer and speaker, he has done a weekday column titled “Psychiatric Views on the Daily News” and a weekly video, “Psychiatry & Society,” since the COVID-19 pandemic emerged. He was chosen to receive the 2024 Abraham Halpern Humanitarian Award from the American Association for Social Psychiatry. Previously, he received the Administrative Award in 2016 from the American Psychiatric Association, the one-time designation of being a Hero of Public Psychiatry from the Speaker of the Assembly of the APA in 2002, and the Exemplary Psychiatrist Award from the National Alliance for the Mentally Ill in 1991. He is an advocate and activist for mental health issues related to climate instability, physician burnout, and xenophobia. He is now editing the final book in a 4-volume series on religions and psychiatry for Springer: Islamophobia, anti-Semitism, Christianity, and now The Eastern Religions, and Spirituality. He serves on the Editorial Board of Psychiatric Times.