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Where free speech and psychiatry meet

January 20, 2015
by H. Steven Moffic
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The benefits and risks of free speech have been in the news ever since the recent murders of Charlie Hebdo journalists by Muslim extremists. Although it is possible that this rallying cry was just an excuse for the murders, the extremists conveyed over and over that the satire of the Prophet Muhammad was inappropriate and blasphemous. Warnings were sent out for years, which included a successful fire-bombing of the weekly's office a few years back. In psychiatry, we know that the best predictor of future violence is such prior violence.

The defenders of free speech seem to feel that maintaing it takes precedence over any loss of lives and/or psychological hurt to those offended by such satire.

However, free speech is not free. It always has consequences. Saying this is not by any means blaming the victims or apologizing for the murderers.

In the USA, the Supreme Court has ruled on exceptions to the First Amendment, including incitement, child pornography, and threats, though it is often hard to delineate the boundaries of those exceptions.

In France, free speech, including strong and even offensive satire has been a primary value since revolutionary times. On the other extreme, authoritarian countries try to significantly limit free public speech.

The power of therapeutic speech

Of all people and professions, we in behavioral healthcare must appreciate the power of speech, whether in print, pictures, or pontificating. We know how important it is for our patients to be able to speak freely, to tell us their darkest secrets, secrets that they may not even consciously know yet, yet we have to be very careful to try to say the right things at the right time in response. If we don't, we risk making our patients feel worse and to increase their resistance to psychotherapy.

Freud, in his development of psychoanalysis, coined the term free associations, in order to encourage the patients free speech by saying whatever came to their mind, as banal or shameful or angry as it might seem. To enhance that, he put them on a couch with his back to them so non-verbal communication from Freud would be limited. The analyst should respond infrequently and carefully in making interpretations.

Remnants of such careful therapeutic speech is still present, or should be present, in any treatment, including 15-minute med checks. Paradoxically, the limited time may make the choice of words even more crucial.

Of course, there are limits to free speech in patients, just like in society. A patient ethically and legally needs to be told that if the patient conveys a clear desire to harm someone else or oneself, that the clinician must break confidentiality and try to make plans to stop those possibilities by obtaining more intensive treatment in a safer setting.

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H. Steven Moffic

H. Steven Moffic

H. Steven Moffic, M.D. retired from the clinical practice of psychiatry and his tenured...