Nancy McWilliams, in Psychoanalytic Diagnosis (1994), writes of the crucial service therapists provide to both individuals and society by allowing patients, especially the more disturbed ones, to spill offensive material.
I think about this often in my role as clinical consultant to a crisis line. Callers frequently spew racist, sexist, and homophobic thoughts. The staff engages in endless debate about allowing safe ventilation versus not tolerating vile language. Some will move quickly to set limits if the caller rants, while others will absorb an outburst, then try to understand what has triggered the upset. Well-intentioned counselors may also consider it their duty to challenge prejudice. There is talk of banning some callers altogether.
After acknowledging how difficult the work is, I speak about projective identification, the meaning within the rants, countertransference, risk assessment, appropriate limit setting, curbing the impulse to retaliate, and our role as counselors. My attempts to address frustration are often inadequate.
Even more concerning is the possibility of violence. After horrific incidents such as the Isla Vista murders, it seems obvious that more must be done to prevent troubled individuals from dangerous unraveling. But what? Raging crisis line callers are usually not in Tarasoff or 5150 territory; they're letting off steam. However, one never really knows. In an age of heightened anxiety, it is all too easy to opt for restrictive intervention under the theory of better safe than sorry.
But safe for whom?
I once worked with an isolated man with a severe trauma history. Edward liked to share with me in graphic detail violent revenge fantasies and racist rants. I never quite knew if tolerating his tirades offered safe ventilation or was harmful collusion.
Edward provided some guidance by saying, "This is the only place I have to talk about these things. I am a perfect gentleman everywhere else."
Edward usually entered the room fuming and with a fixed psychotic stare, then gradually relaxed his stiff posture.
"See you next week, if you can stand it," he'd say on his way out the door.
Occasionally, I couldn't stand it, and would ask him to stop because I felt abused.
"If you find this abusive, you have no idea of what abuse really is," Edward would retort.
A fair point.
When I left the agency, Edward gave me a card that said, "You have been appreciated more than you know."
I have appreciated that lesson ever since.