(Cross-posted at Making Sense of Psychiatry)
Back in 1979, when I was a 3rd year medical student on surgery rotation at the Audie Murphy VA Hospital in San Antonio, I had the experience of working with an elderly man who had suffered a severe stroke of the left middle cerebral artery, causing him to have global aphasia. This unfortunate soul had advanced atherosclerosis manifesting as peripheral vessel disease, with resultant gangrene in his legs. He had already had above-knee amputation of both legs, and was subjected to repeated surgical debridement of his stumps due to advancing gangrene. He was presumed to be demented from his stroke, although it was difficult to determine how much so because of his grossly impaired verbal expression and comprehension. He was functionally nonverbal, unable to express his thoughts and feelings, or to understand others’ words. However he would make it clear to us how miserable he was when he was taken from his hospital bed and transported to the operating room for his near-weekly debridements. Not only was he agitated, but he would curse up a storm: “Shit!! Goddammit!! Oh shit!! Oh shit!! Goddammit!! F**k!!” This was the only kind of speech that I ever heard from him during my three weeks on the rotation.
This pattern of cursing results from sparing of the non-dominant hemisphere–where the strictly emotional components of speech reside–after loss of function in the dominant (usually left) hemisphere of the brain, where more communicative speech and comprehension arise. Expletives are basically unreasonable speech, typically uttered on impulse in emotionally charged circumstances, with emotionally communicative value. The non-dominant parietal lobe appears to be responsible as well for generating and processing the emotional cues and content of normal speech, such as intonation and inflection. Musicality is likewise a function of the non-dominant hemisphere–an association that might justify the irresistible appeal of curse words to rap artists. (Okay, I know that’s not the whole story.) But it’s worthwhile to note that these non-rational, emotion-driven elements of human communication seem to be important enough to merit their own half of the brain.
In my psychiatry residency I was taught to observe emotional issues from a rational, dispassionate perspective, and to discuss them accordingly with patients and peers. But once I started practicing psychiatry on my own, it became clear to me that patients often had enormous difficulty acknowledging their negative emotions. Going by the book of clinical propriety, I did my best to identify anger in my patients, since anger is at the core of many psychological conflicts and symptoms. But many of my patients refused to acknowledge “anger” when directly questioned about it, even when it seemed obvious that it was a problem. After years of practice I eventually stumbled upon the realization that patients were much more likely to give me an affirmative answer if simply asked: “Doesn’t that piss you off???!!” I had discovered a principle of communication that would henceforth inform my growth as a clinician.
For many people the word “anger” is associated with feelings of guilt and shame, especially when it’s directed toward someone they’re supposed to love. Such patients will go to great lengths to deny it to others and to themselves. As a mental health professional, I have a more neutral view of anger, accepting the fact that it’s a natural element of almost every intimate association. This resistance to acknowledging anger is compounded by the fact that patients often come in for examination under some sort of duress, may experience the necessary candor of a psychiatric interview as being intrusive, and/or are afraid of being judged or “analyzed”. However, this resistance can often be overcome if the clinician will simply use the same words that the patient uses to express their feelings. In the case of anger, those words are curse words.
Think about what you say to yourself or to others when you’re angry at someone. Do you say or think, “I’m really angry”? If you’re a Martian, maybe–but most of us have more colorful means of expressing ourselves. For one thing, that manner of phrasing puts the onus on yourself–and if you’re REALLY angry, you don’t think that it’s something you are, but rather that something is being done to you. Which is why we have this delightful little allegation that someone has “really pissed me off”. And despite the phrase’s apparent vulgarity, I’ve yet to find one patient that won’t eventually own up to the fact that someone has on some occasion pissed them off.
Over the years I’ve relaxed into my role as a clinician, becoming freer in my style of communication. In my residency I was trained in self psychology, an analytic model that centers on issues of pathological narcissism and the therapeutic value of empathy. During those years I completed some groundwork in the art of getting into someone else’s shoes–or more specifically their heart and head. Since then cursing has become increasingly prevalent in popular culture and public conversation, for better or worse. If truth be known, it’s a rich and substantial part of my own personal vocabulary. And as I’ve come to be more myself in my clinical practice, it’s become part of my clinical vocabulary as well–not as a personal indulgence, but as a therapeutic tool.
Since more people are cussing on their own time, I’ve found a surprising amount of tolerance and even appreciation of my casual swearing in the course of exploring patients’ feelings. Sure, I suppress it while I’m getting to know a little old lady with strong religious principles. But unless you’ve tried it, you’ll never know how cathartic it is for that same woman when–after you’ve gained her trust, and listened to the litany of emotional abuse and denial of needs that she’s endured in her marriage–you tell her, ”Pardon me, but your husband sounds like a real dick!” It moves her, sometimes to laughter–and do you know why? Because for years she’s been thinking those same words day in and day out, never giving voice to her taboo thoughts, because of those very principles–and for the first time she feels like she’s not alone with those feelings, nor a sinner for having them.
In general the use of profanity in treatment has a liberating effect, making most patients feel more at ease with me and more open to their own feelings. I’ve found, for example, that if a patient is heading down the well-trodden road to ruin and feels defensive about it, he’s likely to take offense at my observation that he’s making the same mistake he’s made before. But it’s amazing how that opinion gets greater consideration when it’s phrased: “Are you sure you aren’t f**king up?” It seems strange, if you regard cursing as being more harsh and less diplomatic–but when you think about it, isn’t this how friends frequently communicate with each other? Rather than escalating tension, cursing in this context softens the elitist image of the provider and the formality of a professional setting, introducing the comfort of familiarity into the clinical conversation. Nowadays I curse rather casually in the course of my practice, whether discussing anger or any other sort of emotional material, since it seems to promote an atmosphere of free expression for all concerned. Besides, it’s a more honest representation of myself–and putting myself at ease usually puts my patients at ease as well.
The first objection that will likely be raised is that the use of profanity is “unprofessional.” The concept of professionalism embraces several different aims, not all of which I find compelling. The ones I really care about are those driven by the ethical consideration of putting the patient’s needs ahead of my own, as detailed in this article by Herbert Swick MD, and in this .pdf file from the Australasian Society for Infectious Diseases. It’s noteworthy that both of these documents emphasize the altruistic imperatives of professionalism, and observe that these ideals have been given short shrift in recent years due to escalating commercial pressures. I believe many of the superficial criteria commonly used to gauge professionalism–such as dress, language, and demeanor–are aimed at propping up the mystique and perceived authority of providers and the profession, rather than enhancing the care of the patient. I see them as marketing maneuvers, not ethical concerns–and frankly I don’t give a rat’s ass about preserving my alleged dignity or promoting the image of psychiatry. On rare occasions patients have complained–but in the clinical pursuit of shared trust and disclosure, I regard such complaints to be an acceptable risk. My guiding purpose in practice is to help my patients get better, doing the best I can using the available means.
A typical psychiatric visit nowadays consists of a discussion of “symptoms” instead of feelings, incorporating the newfangled biologically-oriented buzzwords like “racing thoughts”, “bipolar”, and “chemical imbalance” that have given rise to a whole new generation of psychobabble. This mode of communication allows psychiatric providers to strut their medical expertise, project authority, and maintain an elite veneer of “professionalism”. It also enables them to remain emotionally aloof and above the fray, avoiding the entanglements of a genuine emotional rapport. Its bloodless superficiality promotes the reductionist model of biological psychiatry–sucking the juice out of life and its emotions, then boiling it all down to a collection of alleged chemical reactions. The patients that play along with this model quit listening to their own feelings, seeing them as biological manifestations rather than messages from the heart.
My use of cursing in the clinical setting is an indoctrination into another worldview altogether, where feelings have purpose and value. By getting down into the dirt I make patients more comfortable with me and with themselves, and engage that non-dominant half of the brain (where musicality, speech inflection, and profanity all arise) to get a more complete understanding of their experience. Understanding the patient’s experience, of course, will strike a more biologically-oriented psychiatrist as entirely irrelevant–but that’s not at all how I roll.
There’s yet another reason for this post, besides sharing this clinical revelation and its utility. I draw upon my clinical experiences to write much of the material for this website, and my aim is to make it an honest reflection of my personality and my practice. Cursing is a significant part of both, so it only follows that this website should reflect that as well. One of the more desirable aspects of getting older is that you quit giving a shit about what people think of you, and feel more comfortable in your own skin. My use of profanity is a part of me that some readers will appreciate, and others won’t. So effective immediately, please take note of the following advisory: This website’s going to have naughty words in it, maybe even some naughty thoughts–and if you don’t like that, there are plenty of other, more “professional” resources available online. The rest of you are welcome to stick around–and I’ll do my best to keep it real, OK?