Good for the good god! Utils for the util throne!

Do You Believe Me, Doc?

[Content warning: psychiatrists having ethically complicated conversations with patients]

I recently attended the Michigan Psychiatric Society conference. It was all downhill after I heard the name of the first poster presentation. The study – investigating the tendency of anti-Parkinsons medication Requip® to cause nightmares as a side effect – was titled “Requip For A Dream”. I didn’t stay long enough to see whether that won the poster contest, but if it didn’t there is no God.

But I also attended a couple of forums and Q&A sessions, and in one of them a doctor asked the question:

“What do I say when one of my psychotic patients – who is telling me how he is Jesus, or is being pursued by the FBI, or something like that – glares at me and asks ‘You don’t believe me, do you?’”

The lecturer, who was a very prestigious psychiatrist of some sort, said that his standard response was “I believe that what you are seeing and experiencing is real to you.”

This is the sort of nice, pat answer I would expect from a clever and prestigious psychiatrist. It ticks all the boxes. It is kind and compassionate. It doesn’t technically lie. It doesn’t validate the patient’s delusions. And it acknowledges the patient’s emotions without being dismissive or confrontational.

On the other hand, if I was that patient it would enrage me.

Let me distinguish this from a very very similar concept where I think this answer is exactly correct. Suppose someone is having hallucinations, like believing there are spiders crawling all over him. He asks “You don’t believe me, do you?” I think the exactly correct answer is to say “I one hundred percent believe that you are experiencing spiders crawling all over you, that their appearance and features are extremely convincing, and that you’re not making this up. But there are not real spiders on you.”

And if you responded to the guy who thought he was Jesus with “I one hundred percent believe you are feeling a strong, almost irresistible urge to believe you are Jesus. But I don’t think you are actually him,” that would remove most of the creepiness for me (I also don’t think it would be very popular with patients).

But somehow this guy’s phrasing pressed my buttons. It wasn’t just that he wasn’t answering the question. It was that he was denying that the question was the sort of thing that needed to be answered, denying that there was a real fact-of-the-matter about Jesus at all, or denying that it was worth worrying about.

But if you’re worried you’re psychotic, that’s probably the most important question to you. The reason this came up at a big conference is that it’s a really common question. Psychotic people ask it a lot. If you’re psychotic, then the fact that you believe these strange things no one else believes has become one of the central things in your life. And to you it’s less important that the person be Validating And Accepting than that you settle this problem that is tearing your life apart.

And this answer isn’t even subtle about what it’s doing. It’s like “Obviously I don’t believe you, but I’m going to avoid saying so in so many words, and I bet you won’t even notice or care. You’ll just be grateful I’m acknowledging you at all”. It’s condescending, is what it is.

I’m not psychotic (I think). And I’m probably more concerned with there being a Real-World-With-Truth-Values than the average person. So maybe the prestigious expert is, as is often the case with prestigious experts, right. But I really don’t want to follow his advice. It would leave too bad a taste in my mouth.

I haven’t decided what I am going to say in its place. But in a perfect world, where I get exactly the right patient, the response I would really like to give is: “If you were me, would you believe it?”

I think, in this fantasy, if I picked the right patient they would laugh and say “Nope!”. Because psychotic people are smarter than they are usually given credit for, and also usually have good senses of humor, and at least we would both establish where we stood in a non-confrontational way.

And it’s always interesting how often deluded people know in the back of their head that their delusions are wrong, or at least questionable. Like I can just ask people “I’m here to do a psychiatric evaluation of you. Do you have any strange beliefs I should know about?” and they’ll say “Well, I believe I’m being pursued by the FBI.” I ask “Are you being pursued by the FBI?” They say “Yeah.” I asked once, because I was very curious and making things up as I went along, “Then why did you bring it up so quickly when I said I was a psychiatrist looking for symptoms of mental disease?”

My patient didn’t have a good answer for that. I didn’t get the impression it was some very logical “Well, I realize statistically most people who think they’re pursued by the FBI are psychotic, so I’ll just mention it, even though I personally am not.” It seemed more like another example of people, whether psychotic or not, being kind of garage-dragon-y.

This brings me to the other question I get from people a lot, which is “Do you think I’m crazy?” I think the Officially Correct Answer here is to say “Of course not”, which isn’t very convincing precisely because it’s obviously the Officially Correct Answer psychiatrists give to everyone. Even worse (but surprisingly common) is “Crazy isn’t a technical term”. Thanks. I’m sure that must be very reassuring.

Again, a fantasy answer I would like to give if I have exactly the right patient is “If you’re asking that question, don’t worry.” Which I think is sort of true. If you’re in a psychiatric hospital, and your conclusion is that maybe this means you might be crazy, you have some pretty good reality-based thinking going on. If you’re in a psychiatric hospital, and your conclusion is that maybe this means the FBI has found out you’re Jesus and is trying to stop you, that’s the guy who’s in trouble.

And again I worry that I might be getting too clever. Probably some of these patients aren’t very smart, or aren’t very cynical, and a simple “No, of course not” would be reassuring in a way a weird self-referential answer wouldn’t. So far I have just given some version of the simple answer. But when there’s someone I know well, and who’s especially jaded, and I doubt the simple answer would go over well, I really want to try something less cliched and more honest.

But even that’s not the answer I fantasize about giving later on, when I have my own practice and patients whom I’ve known for years and I can pick out the ones who are a lot like I was when I was younger and seeing a psychiatrist. For them the answer will be “Yes, of course. So am I. So is everyone. The interesting question isn’t whether you’re crazy, it’s whether you function anyway. Let’s try to work on that.”

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73 Responses to Do You Believe Me, Doc?

  1. > deluded people know in the back of their head that their delusions are wrong

    My impression is that this is true too of a lot of religious people, and New Age people, and alternative therapy people, and other people who believe untrue things. They know their “beliefs” are false, but they are emotionally attached to them, so they obfuscate for themselves.

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    • adbge says:

      I share this intuition. For instance, let’s say you’re speaking with someone who believes in the healing power of prayer and you say, “Oh, that’s interesting. So if I took two groups of patients, and assigned one group a ‘prayer squad,’ you would expect them to live longer. Let’s see what we can find on Google Scholar.”

      And when faced with this sort of consequence, they usually start backpedaling — even before we’ve done any searching. So, do they really believe it? I don’t know. I worry about being uncharitable and/or patronizing, but it seems like most people walk around with a not-too-sophisticated notion of belief. (Or maybe a too sophisticated notion?) Or maybe we can interpret a mind more as like a society, so one module holds explicit beliefs, while one holds anticipations, and the two aren’t in sync.

      Off-topic, but I read “Buddhist modernism and the rhetoric of meditative experience” on your recommendation and it was excellent, so thanks!

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      • Anonymous says:

        I am rather less charitable then you; I suspect many people profess belief in things as a status indicator and in-group signalling method, and they either know the belief is false somewhere internally but choose to say otherwise, or haven’t bothered to even check whether they really truly believe in that stated aspect of their beliefs or not. On being challenged, they immediately start backpedalling to signal that of course they were actually of the opposite belief all along in an effort to signal that they belong to your in-group and deserve status in your eyes. I suspect you’d get rather different reactions (probably doubling down in favor) if you were, say, speaking to someone about the healing power of prayer in front of a group from their same congregation rather than privately for these status-related reasons.

        I rather suspect most beliefs held by most people are more about displaying status and group affiliation than any actual attempt to form a coherent, consistent pattern that is an accurate map of the outside world. Most people don’t try to work out reality from first principles.

        If you want to get recursive, of course, this post is obviously intended to demonstrate my superior rationality beliefs and understanding of internal human thought processes to your own, and thus raise my status and the like in this community which values….

        etc.

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      • ChristianKl says:

        I think most people who believe in prayer believe that God is an agent on it’s own who might grant some prayers but not others and who doesn’t necessarily play along for the sake of an experiment.

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        • Mark says:

          And even if you found a way to retroactively look at prayer efficacy, god would have known that you were going to to eventually do that so wouldn’t have intervened in the first place.

          I’m thinking an enterprising young social-scientist demon might be able to nullify all future prayers by including all prayers in some sort of gigantic experiment and the devil will finally win. God obviously didn’t think his non-interfering when scientists are watching policy through.

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        • Ken Arromdee says:

          I suspect that a lot of the people who give that answer don’t understand that experiments constantly detect things that work in some cases but not others. Instead they have a naive model of an experiment as something that produces a single result that either proves or disproves something.

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      • Glad you liked Sharf’s “Buddhist modernism and the rhetoric of meditative experience”!

        His critique applies, with adjustments, to the current secular mindfulness meditation movement as well, I think. There’s a lot of misunderstanding of what meditation does and how, which is rooted in the Perennialist theory of mystical experience (http://en.wikipedia.org/wiki/Perennial_philosophy). Recently, there’s enthusiasm for the idea that neuroscience validates Perennialism, which is kind of disastrous IMO.

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      • mayleaf says:

        I actually think it’s possible to truly believe in the power of prayer, while still immediately backpedaling when someone suggests a Google scholar search. People who believe in the power of prayer are very used to “scientist-types” criticizing their beliefs. Therefore, they have an advance prediction that any “scientific” method of inquiry will probably conclude that that their beliefs are wrong.

        But this doesn’t lead them to believe that prayer doesn’t work — it just leads them to believe that science is not to be trusted (at least when it comes to prayer), and that anyone who suggests “science” as a way of testing prayer is obviously biased towards trying to invalidate the power of prayer. So they end up thinking that scientists are the biased ones who only trust data that supports their presupposed beliefs, hence their criticism that scientists are “closed-minded” and “dogmatic” — and their claims of “science can’t explain everything”, and “non-overlapping magisteria”, and such.

        These people’s actions are consistent with a true belief in the power of prayer — they’ll earnestly and devotedly pray for a sick friend’s health, and honestly predict that it’ll help their friend recover faster. They have, in their mind, plenty of “evidence” that prayer works, it’s just that of all their evidence is anecdotal. But they see anecdotal evidence as sufficient, and, more importantly, they see “using science” as an experiment that’s rigged against them — and so is less likely to draw accurate conclusions about whether prayer works or not.

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    • a person says:

      I share this same intuition.

      But on the other hand a lot of theists say shit like “atheists all secretly believe in god, they just don’t want to be held responsible for this actions” or “you already have a love for God in your soul, you just have to accept it” or “how can you seriously believe there is just nothing out there, you must be completely deluded”. So perhaps theists have the same intuition about atheists? Maybe there is a universal form of the typical mind fallacy where you believe that no one could possibly really hold the beliefs that are in opposition to your own.

      I have also seen some people say “atheists say that theists are deluding themselves into a comfortable lie, but theists say the same about atheists, can’t we just say that everyone actually believes what they actually believe, after all, it’s kind of offensive to say otherwise?” I’m kind of sympathetic to this position as well. But then again some people really are lying to themselves, and sometimes that fact needs to be pointed out…

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      • Daniel H says:

        A lot of people definitely truly believe in [insert religion here]. And for most of those religions, there are people who profess belief but don’t act like they believe.

        A lot of atheists truly believe that there is no god. I would be surprised if no atheists were professing atheism but really did believe in a god.

        I think the policy to adopt would be “Unless shown otherwise, assume people aren’t lying to themselves about their beliefs. Keep in mind, though, that some people are lying to themselves, and be prepared to notice when this is the case.”

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      • Oligopsony says:

        I actually fairly often have the sense that I’m lying to myself about atheism being true, and that, contrary to my vainglory, God definitely exists and that I’m wrong to be an atheist. The fact that the external arguments for atheism are so strong mean that I don’t really put much weight on this experience when it comes up for all my other beliefs, which it does.

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      • One can look at whether people act as if their professed beliefs are true. Many people “believe in God” in a way that is so vague that there are no specific entailments. But if you claim to belong to a specific religion, there are things you would definitely do (and not do) on the basis of its beliefs.

        Reading books by Christian pastors for other pastors is interesting. They gripe a lot about the fact that their supposedly Christian flock do almost none of the things you’d do if you actually believed, and most of the things you’d do if you didn’t. Rick Warren (hugely successful Southern Baptist megachurch leader) says pretty nearly everyone who attends services at his church “is a pagan” in fact.

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        • a person says:

          That’s true, but at the same time a lot of people are very, very poor at realizing what the implications of their beliefs and desires are, especially if those implications beckon them to take an unusual action. I feel like a lot of the LessWrong literature documents this type of flaw. E.g. people want to do good, but don’t do effective altruism.

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          • @ a person — I agree with that too!

            Some people actually do believe crazy wrong things. Some people pretend to for signalling reasons, while knowing they are wrong. Many people simply don’t care about the truth of the things they claim to believe, and have no interest in evaluating them.

            For many controversial beliefs, there are no deductions that have significant implications for the average person’s life. Evolution is an example.

            It’s cheap to claim not to believe in evolution, because no action that follows from its truth or falsity would makes a difference for most people. So if you get a signalling benefit, there’s no point in having a grounded belief one way or the other.

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        • Douglas Knight says:

          Could you point to an example? I’m particularly interested in the Rick Warren example, but googling “rick warren pagan” only produces accusations.

          It is normal for Christians to say that they are bad Christians, so I wouldn’t be surprised if the pastors agree with them, though complaining is a bit surprising. I think it is more accurate to say that they aren’t Christian at all, but I am surprised that the pastors see that. Is that what the pastors mean, or is it only Rick Warren who goes that far? The early protestants, perhaps even Luther, complained that the Church hadn’t bothered to Christianize rural Germany. Maybe they were wrong, and it wasn’t that the old religion continued, but that the peasants had generated a new paganism.

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        • Anonymous says:

          It’s been ~7 years since I read that stuff, so my memory is a bit vague. The Rick Warren quote is (probably) from his The Purpose-Driven Church, which is excellent (apart from the fact that his religion is wacko).

          I think it is more accurate to say that they aren’t Christian at all, but I am surprised that the pastors see that. Is that what the pastors mean

          Yes, by “pagan” he means “non-Christian,” essentially. Definitely not Neo-Pagan. Perhaps also “having the same attitudes pre-Christian people did.”

          Example: If you are a Southern Baptist, you are supposed to believe that (e.g.) fornication will send you to hell, and most Southern Baptists fornicate.

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        • Whoops, that Anonymous was me!

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        • Douglas Knight says:

          I couldn’t find the relevant passages by searching for the word “pagan” on google books. It doesn’t cover the whole book, but I doubt he uses that particular word in those passages, and thus I think they will be hard to find. Would you recommend any particular chapter?

          Yes, his flock fornicates. My impression, as I tried to indicate above, is that they repent and would say that this makes them bad christians. I think that is very different from approving of fornication, even if it’s hard to tell the behavioral difference. I’m surprised that the pastors would emphasize behavior, rather than agreeing with me about attitude.

          I would be interested if by “pagan” he meant “having the same attitudes pre-Christian people did,” but I don’t see it in his few uses. I think he means people who do not identify as christian, or at least not as members in good standing. Thus I do not think he would say that his flock consists of pagans. He merely says that pagans come to services occasionally, testing the water, and that much of evangelism consists of being as inviting as possible for those opportunities.

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          • I read the book many years ago, I don’t have it anymore, and apparently I misremember it. It may be that I’m confusing it with another author who I read about the same time, or it may be that my memory is just entirely false! In any of the above cases, I apologize for misleading you.

            My impression, as I tried to indicate above, is that they repent and would say that this makes them bad christians.

            Anecdotally, I don’t think this is true. That is, if asked “do you think fornication is a sin,” they’d say “yes, of course”; but if asked “do you think Beth was wrong to do sleep with Harry,” many would at least prevaricate. Some might give different answers to different questioners; some might say “well, the pastor would say … but I feel …”; some might say “no, that was OK, because they truly loved each other, even if in general premarital sex is a sin.”

            This is strictly anecdotal, though; to go further, we’d need proper evidence. I vaguely remember reading some (about the sexual attitudes of professed evangelicals), but again it was a long time ago!

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        • Douglas Knight says:

          No need to apologize! This was all very interesting.

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    • MugaSofer says:

      Hmm. I don’t know about that. I’ve heard it suggested a lot, sure, but I’ve never seen any evidence.

      I’ve been saved from acting on false beliefs by Akrasia, sure … but then, I’ve also reacted exactly as if they were true on occasion, often to my personal detriment – and acted similarly invisible-dragony about things that are really true.

      And, to pick a concrete example, people who think the world is going to end certainly *seem* to actually think that, as the media constantly shows us (it acts as a pretty effective Cowpox of Doubt.) If it’s a signal, it’s a damn costly one.

      And this “awareness” that it’s a delusion … well, Scott has written about the Presidential Ward in DC, filled with people who came to warn the President, and as he noted then … they seem to be reacting just like you would if there were really aliens invading. Including being worried people will think you’re crazy, worrying you might really *be* crazy … and trying to persuade the people who can do something about it.

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    • ChristianKl says:

      On this blogs comments are formatted with html and not with markdown. That means that you can quote with (of course you remove the ‘.’) instead of ‘>’.

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  2. Anonymous says:

    >The lecturer, who was a very prestigious psychiatrist of some sort, said that his standard response was “I believe that what you are seeing and experiencing is real to you.” [...] If I was that patient it would enrage me.

    I thought it was common knowledge that that kind of response enrages *everybody*, to the point where it’s jokingly referenced in mainstream movies like The Santa Clause (IIRC), delivered by unsympathetic psychiatrist characters.

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    • Scott Alexander says:

      It’s common knowledge that there is a form of psychiatrist-response that enrages everyone. I’m not sure how you’d be sure that particular answer is an example of it.

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  3. Anonymous says:

    As a person who suffered from Reduplicative Paramnesia and Capgras delusion from the ages of 7-15, I should probably speak up here.

    For background, memory and familiarity are governed by different processes. Both disorders are caused by a broken “familiarity” sense – Capgras for faces, and Reduplicative paramnesia for places. So I’d see my mother’s face, but have a strong gut sense intuition that it was a very similar-looking stranger…or enter my home, and have a strong sense that it was an identical copy of my home.

    > deluded people know in the back of their head that their delusions are wrong

    I had a strong intuition telling me one thing. and my childish brain automatically generated multiple plausible scenarios in which my intuition would be true (conspiracy where people are stolen and replaced with copies, weird physics where I kept getting transferred to parallel universes, etc). I would constantly be testing – staring into people’s faces looking for small discrepancies (my mom got her hair done without telling me once…it was stressful) or asking them questions only they would know.

    >“If you were me, would you believe it?”

    At the same time, it was *quite* obvious to child-me that other people would believe that these ideas were crazy, and with good reason. No one in my life could tell that anything was wrong, because I kept it hidden. So one day I sat my parents down and told them: “I’ve keep having weird thoughts, I keep thinking that you guys are getting replaced by identical copies, and that I keep getting swapped into parallel universes whenever I go around a large object or enter a room through a different door than I exited. I know that it’s not true.”

    They were understandably upset, thought I was reading too much science fiction, blamed themselves…so I never brought it up again (until a few years ago, to confirm that their memory of the conversation matched mine). And I continued to avoid going around objects, and peering into people’s faces and occasionally asking them questions … just in case I was right all along, you know?

    Then sometime around 7th grade I … guess I grew up intellectually? I grasped ideas of parsimony and Occam’s Razor, which basically removing all niggling doubt that I was right all along. I vaguely grasped how habits work and how conditioning works. I actively forced myself to go around objects and forced myself to stop peering into faces or asking questions. And the intuition of certain things being unfamiliar just sort of died and went away, and I basically went on as a normal teen. I never realized what was actually going on until picking up a psychology textbook several years later.

    So, I dunno. Maybe my brain just healed with age. Maybe I was just suffering from that “asynchronous development” that some children supposedly have. Maybe all children are actually a little insane but most aren’t articulate enough for us to notice…my sister used to be afraid of the night sky (because space is too big, we are too small) and tales of monsters frightened her, but she lost those fears just a year or so before I lost my delusions so maybe there’s just an age when most people learn the difference between what’s true and what’s all in our heads. Maybe some combination of intelligence and culturally acquired rationality training allowed me to self-modify from crazy to not-crazy. Maybe it’s only a small subset of the population who can consider the idea that their intuitions are totally wrong. I don’t know to what extent I can generalize from myself to people who have “real” delusions that they *actually* believe.

    I had a schizophrenic house-mate once. In her thought process I could sense my younger self’s thought process – basically, hyper-connected. Making connections without filtering out the bad ones, making too many inferences at once. My brain *still* sort of works like that, but when I grew up I acquired a good filter.

    She accepted she was schizophrenic and had delusions, but there were episodes or “breaks” she started to more and more act on her delusions and seemed to believe them. (she also had hallucinations sometimes, so perhaps those were feeding her bad evidence)

    She also had some scary intellectual fears which branched off belief in souls. The way madness works in my experience is that you start with one wrong belief, and then you use it to logically conclude other wrong beliefs. Hoping to be of help, I told her my experience, taught her about parsimony and Occam’s razor and got her to admit there was no evidence for souls, and that the physicalist view was probably right.

    I was quite surprised by her ability to process what I told her, immediately understand that it made sense, and change her opinion about reality…many neurotypical people can’t do that. I was mentally prepared for religious-level resistance, and instead just got a few perceptive questions followed by calm agreement. She actually laughed and said, “Oh, I guess I can’t actually justify my beliefs, huh?”

    In conclusion, I’m telling you that in my experience your intuitions are spot-on. People with clinical-style delusions often know that other people find them crazy, and why. However, they have strong intuitions telling them to believe the crazy thing, rather than what everyone else believes. At least some of them will respond well to “If you were me, would you believe it?”, “Do you have a rational explanation for why you believe that” and the like.

    The “standard practices” you are mentioning, which seem to consist of simple refusal to actually engage with the internal logic of the delusional belief seems like absolutely the wrong thing to do. In my experience, it was a huge relief to disprove and kill my delusions.

    Then again, it’s possible that they are dealing with patients who become violent when confronted, or something…in which case it seems like careful diplomacy is necessary on a practical level.

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    • ozymandias says:

      I have a similar experience with a different illness (borderline personality disorder). My intuitions inform me very strongly that I am a bad person, that my friends secretly hate me, that my partners are going to leave me, etc. I intellectually know these things aren’t true, but it takes a lot of work/rationality to process it. And yeah it is generally helpful to me to point out that my brain is lying to me, as long as the person *also* communicates that they agree that my brain lying to me is a serious problem and it makes sense to them that I am upset. Sometimes people convey “well that’s obviously wrong, so why are you making such a fuss?” which feels really invalidating and upsetting.

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    • ShardPhoenix says:

      >Maybe some combination of intelligence and culturally acquired rationality training allowed me to self-modify from crazy to not-crazy

      I’d guess this is actually common, I did something similar with a lesser condition (sub-clinical OCD).

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    • Scott Alexander says:

      I think it is probably different from disorder to disorder and patient to patient. I have met many people who refuse to budge at all, or who even make up events that if they really occurred would be evidence for their delusions but which I can’t believe actually did (I am not accusing them of making them up consciously).

      I am very surprised by your Capgras, since I associated it with something that mostly happened in people with brain damage or stroke. Looking back I think I remember one other similar story but I bet it was just you in a different venue. Did you ever figure out why you had it?

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  4. Daniel Speyer says:

    I wonder how “I neither believe nor disbelieve, but will gather evidence as we talk” would go over. My actual guess is not well outside our community, but maybe.

    It will serve you well if you ever run into a patient the FBI actually is after, though. Must happen sometimes. They do go after people.

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    • a person says:

      The more natural way of phrasing this would probably be “I haven’t decided yet”.

      I don’t think this would work very well, it would make the patient feel like he is being tested and has to prove himself to the therapist, leading to nervousness and discomfort.

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    • Daniel H says:

      Not only do the FBI go after people, but there have been societies where political prisoners were kept in psychiatric institutions. If I believed the FBI was wrongly after me, and I found myself in a psychiatric hospital, I am not sure I’d be able to assign a high enough probability to “I’m here because I’m crazy and the FBI aren’t after me” vs. “I’m here because the FBI caught up to me”.

      I think if I had whatever psychiatric condition caused this specific kind of paranoid belief, it would be the CIA or NSA that was after me, but that’s beside the point.

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    • MugaSofer says:

      …is that really true, though? Presumably Scott sees a lot more people who are, well, in need of his help. So the prior is low, right?

      Actually that might work. “Most of the people I meet here are mistaken – although it feels like they’re not. But I always keep an open mind, just in case.”

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    • Scott Alexander says:

      I don’t want to lie, especially since I think it would be pretty obvious that it was a lie. Of course I’ve decided most of these things aren’t true.

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  5. ShardPhoenix says:

    My preferred answer to “Do you think I’m crazy?” would be something like, “I think you may be suffering from psychosis which we can treat etc.” which is basically saying “yes” but only after reframing the question to less insulting terms.

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    • MugaSofer says:

      To be fair to the cliches, I think this is the intention behind “crazy isn’t a technical term.”

      But, since we’re being fair … that’s really very poor.

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  6. Kiboh says:

    The statements the prestigious experts suggest – and the statements that Scott wants to replace them with – all have a benefit that hasn’t been explicitly stated in the main article or in the comments yet. Namely, they deny that the psychiatrist thinks the patient is making it up for attention, or that the psychiatrist thinks the patient is exaggerating evidence in order to construct a more convincing case for their Jesus-hood. I don’t think this is unimportant: there’s more than one way to not believe someone, after all, and in the patient’s position I’d be worried about all of them.

    (Actually, the few times I went to a psychiatrist, almost the ONLY thing I worried about was whether they’d think I was lying to them, though that’s pretty specific to my personality and to the things I wanted to talk about.)

    If you’ll permit me to speculate wildly (despite my lack of background in any relevant field): the prestigious answers might have a hidden advantage because they aren’t as direct in their denial of the possibility that the patient is lying. Scott’s more honest answers more immediately imply that the doctor doesn’t think the patient is lying, which might make the patient more suspicious that the doctor is lying about whether they think the patient is lying. The fuzzier, more general answers might be more convincing on this front because of their vagueness, in the same way that “There isn’t any fruit in the house” is a less suspicious statement than “There DEFINITELY aren’t EXACTLY THREE APPLES in the house”.

    In fact, if I take this line of reasoning far enough, the prestigious statements might also be better because they communicate different information to the patient. Scott’s statements communicate “I don’t think you’re lying” and “I am empathic to you” and “I understand your situation” and “I respect your intelligence”. The prestigious statements communicate “I don’t think you’re lying” and “I am empathic to you” and “I understand your situation” and “I am trying to hide the fact that I think you’re delusional” and “I am really bad at hiding the fact that I think you’re delusional”, with the implication “If I suspected you were lying, you’d know because I’m so bad at hiding things”, and with an added bonus of “whether or not you’re lying isn’t even a concern, the focus of this conversation is whether or not you’re delusional”. The prestigious statements might be more convincing specifically because they make the person making them look bad.

    I’m probably reading too much into this, though.

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  7. Ialdabaoth says:

    In a similar vein, how should a patient deal with certain communications with their doctor?

    For example, this morning I stumbled into one of my more terrifying landscapes: I had to communicate with my therapist that I was having not-necessarily-founded doubts regarding their expertise and competence, and needed them to help me overcome those doubts before any further progress could be made.

    I attempted to communicate this clearly and compassionately, and enumerate the reasons why. I said something very similar to, “I’ve been given very bad advice in the past that sounds remarkably like what you’re saying. Also, I’m used to being the smartest person in the room, so I have a natural tendency to filter everything everyone says through a ‘does this person even understand the topic half as well as I do?’ lens. I’m not specifically accusing you of being incompetent or stupid, but I’m saying that that’s how my subconscious wants to judge the situation, and I need help overcoming that.”

    Their voice became VERY tense and sharp, and the rest of the conversation consisted of all the ways I’m dumb and don’t know what I’m doing emotionally / socially (which I completely copped to, since that’s the whole damn point of my going to therapy).

    Is there a better way to communicate those concerns? Because if I don’t say them, I just keep on subconsciously assuming that they don’t know what they’re talking about, so I don’t invest fully in their advice. (Or worse, I just take it “on faith” that they know what they’re talking about, invest in their advice naively, and then fail because I deliberately shut off my normal sense of what parts are good and what parts are bad.)

    I would LIKE to acknowledge that I have trust issues without being made to feel like I am a strictly inferior person to my therapist until they feel better about themselves enough to continue giving me advice.

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    • Shmi Nux says:

      > Their voice became VERY tense and sharp, and the rest of the conversation consisted of all the ways I’m dumb and don’t know what I’m doing emotionally / socially

      IANAT, but regardless of whether this is really what happened (quite likely) or is only your perception, it seems like you need a different therapist, as you have no connection with this one, and without it there is little chance of any progress. It’s not your job to “communicate this clearly and compassionately”, it’s theirs, and they clearly failed at it.

      I hope Scott chimes in.

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      • Ialdabaoth says:

        It’s not your job to “communicate this clearly and compassionately”, it’s theirs, and they clearly failed at it.

        This seems clearly false on the face of it. If they fail to help me / I fail to be helped, I’m screwed; they suffer no consequences whatsoever. In what sense, then, is it their job to help me?

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        • orthonormal says:

          The sense that you’re paying them money to help you, and that you can change therapists if you decide that your current one isn’t working for you.

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        • Ialdabaoth says:

          Well, this is a work-appointed therapist (HR has one of those “wellness programs”), so I’m not actually paying them; further, if their advice were to get me fired, they would no longer have to deal with my presence anymore (they’re an employee at my work, which makes them a co-worker and which means we occasionally interact outside of sessions). So in a real sense, failing at their job in this particular case would have a net benefit for them.

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        • Jim says:

          In the literal sense that it’s actually their job, and it sounds like they’re not doing it very well (at least in this situation).

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        • Shmi Nux says:

          > if their advice were to get me fired, they would no longer have to deal with my presence anymore

          Ah, that’s a different story altogether. You are not the therapist’s client, your employer is. Then you are absolutely right to treat this like a performance evaluation, not a doctor’s appointment.

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        • Ialdabaoth says:

          Ah, that’s a different story altogether. You are not the therapist’s client, your employer is. Then you are absolutely right to treat this like a performance evaluation, not a doctor’s appointment.

          Certainly. But it’s been made VERY EXPLICITLY CLEAR that it’s a doctor’s appointment intended to GET ME HELP, and not any kind of performance review or anything like that.

          And since the whole problem that I’ve been referred to her for is basically that I take diirections at face value instead of figuring out which inferred social/political meaning I’m supposed to be following, I kinda think I might be screwed.

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        • Scott Alexander says:

          It sounds like this person is not a very good therapist. I’m starting to think that the (often terrible) advice that therapists are supposed to be passive and avoid showing emotion or having human interaction is a Schelling fence because a lot of therapists are terrible and will act like this.

          I don’t think it’s necessarily personal, but I do think a lot of people aren’t very good at complex layered ideas, and interpret them as microaggressions or as trying to put something by them.

          If you can’t get a new therapist, then evaluate how honest your workplace is in saying it’s about you getting help and not something they’re making you do for legal reasons or signaling reasons or whatever. If you have to do it, see if you can just keep things on a simple level that the therapist can understand (I realize this is unusually hard to do when the other person is both too dumb to have a normal conversation with and things they’re condescending to YOU) – and squeeze whatever you can out of a bad situation, I guess.

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        • Ialdabaoth says:

          *nod* yeah, that’s sort of the mode I’m in now. What’s frustrating/terrifying is that “evaluate how honest your workplace is in saying it’s about you getting help and not something they’re making you do for legal reasons or signaling reasons or whatever” is explicitly part of what I need help with – my natural tendencies are somewhat cynical and paranoid due to early childhood trauma, so I tend to either under-correct or over-correct (which therapists and armchair-therapists usually declare as “black and white thinking” in an accusatory and condescending sort of way, but it feels subtly different than that from inside).

          As it is, I just need to find another good therapist in the middle of rural Idaho, AND convince the work therapist to actually give me a referral (since apparently no one in this town takes walk-ins).

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        • misha says:

          Not a lot you can do about the problem of a therapist being less smart than you apart from switch therapists. You’re good enough at verbal self sabotaging that I don’t think an insufficiently skilled therapist could get around the barriers you put around yourself. If you were going to a therapist simply for access to hormones or whatever I might say just play along and get what you need from them but I think what you need is ACTUAL therapy.

          I have a very smart friend who had a similar problem: she described it as feeling like if her therapist couldn’t even get past/see through the regular screen of bullshit conversation she could effortlessly maintain with him, how could he dig into any real problems?

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      • MugaSofer says:

        … hmm. So the problem – social cues – also interfered with the solution. Tricky.

        Well, have you tried explicitly acknowledging that you have trouble with social cues and need their help to overlook that, in order to get therapy? Since that sounds like a solution people would ignore because of … social cues … that may well have already occurred to you.

        If the therapist is incapable of controlling their reaction … I would seriously advise you to find another therapist on your own time. Galling, but better than trying to fix your psychiatrist before they can fix you.

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    • Anonymous says:

      This is one of the reasons I wouldn’t see a therapist – by all accounts they seem to be more-or-less baseline humans who are no more empathetic or emotionally grounded than anyone else, and aren’t any more likely to give me insight into a problem. If I wanted to talk to some random human about a problem, I’d speak to a friend, not a therapist.

      Maybe I’m overestimating myself / underestimating them, or maybe I’m fundamentally mistaken about the extent to which a therapist needs to be more emotionally intelligent than the client in order to help them at a level above and beyond what a simple friendship would do.

      I’m sufficiently convinced that the majority of people can be helped by therapists. I’m just not convinced that a friend wouldn’t fulfill the same function. (Of course, not everyone has that close of friends, or maybe wouldn’t want to burden the friendship with it)

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      • Ialdabaoth says:

        Well, in most cases, most of my friends don’t really WANT to talk to me about my problems, and talking to them about my problems causes them to become ex-friends. Which leads to a kind of cascade failure where I wind up talking to near-strangers about my problems, which means I never actually acquire friends.

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        • Doug S. says:

          I’ve found the internet to be a good venue for talking about one’s own problems. People who aren’t interested will usually just ignore it and read something else rather than turn into ex-friends…

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      • Doug S. says:

        There’s some evidence that no specific type of talk therapy is any better than any other, and that in comparison studies, untrained laypeople tend to be as effective as professional counselors. (I’ve also heard that keeping a diary is also as effective as talk therapy.)

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        • Doug S. says:

          Incidentally, the source I read did say that there are *individuals* that are consistently better therapists than others, but their training had nothing to do with it.

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    • peterdjones says:

      Here’s a rule that you can apply in any circumstance: never tell someone you are smarter than they are whether its true or not.

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    • peterdjones says:

      Your employers probably see themselves as doing the nice thing jn not just firing you, and probably now see you as biting their hand. Maybe you should have smiled and nodded and thanked the therapist and not worried about the quality of the advice.

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    • JustMe says:

      It sounds to me like your problem is in your presentation (although I’m not an expert).

      For example, instead of saying what you quoted (” ‘I’ve been given very bad advice in the past …’ “), you could start out a therapy session by saying “So, Dr so-and-so, I very much appreciate the advice which you’ve been giving me. I think I’ve not been very eloquent in stating what I want out of our discussions. I apologize for that. What I have been trying to say to you is that I am a skeptic. I think it would benefit me, greatly, to discuss any suggestions we come up with, as we go through our sessions. This might include discussing the ideas behind them, and the possible outcomes therefrom. Do you think we could do this?”

      Make sure to thank your therapist, immediately afterwards, if he/she says “yes”. If the answer is “no”, then I would say to get a better therapist ASAP. You can always tell work that the therapist whom they assigned for you isn’t a good match for you, and that you’d like to find a therapist outside the workplace with whom to discuss matters.

      I suggest presenting yourself as a “skeptic” because this is both a very natural thing and something which is viewed positively in most of North America. Analysis is a positive thing. Furthermore, it sounds like a skeptic is exactly what you are.

      However, in response to your comment about generally finding yourself to be the “smartest person in the room”: I do find that often people are actually intelligent and do good work. It took me a while to truly recognize this. Now, I know to just seek what each person is good at: each person’s world-view and analysis helps to contribute to mine, in some way. Sometimes, it’s just via comparison in that I see their sloppy logic. Most times, however, I find something useful in our conversations.

      I just saw the date on your post, so I’m not sure whether this is still relevant to you. Nevertheless, I will share it, just in case.

      As one final note, “taking things at face value” is also what I would consider to be a good thing. There is no way to know what other people are thinking, and social/political cues vary from person-to-person. Therefore, expecting another person to act on your “hidden intent” based on social or political cues is simply poor communication. Taking statements at “face value” is the only safe way to go. (Even body language does not translate well between cultures.) In short, I would say that you could ask your work for clearer communication about what needs to be done. They probably do not want you to change what you perceive as your instructions based on your interpretations of the social and political currents. Perhaps speaking with them about this, and laying out some ground-work of expectations for communication, would be beneficial. This might involve, for example, explicitly listing which set of tasks accompanies a specific instruction. (Here is an example of this listing: if the instruction is to “deliver the internal mail”, the explicit listing of tasks might involve “Deliver the mail according to the following employee hierarchy, starting at the top: CEO, senior executives …. Then, place inter-departmental mail in the appropriate folder. …”).

      Good luck.

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  8. James Miller says:

    I had a friend at work who was in his 70s. He seemed to be exactly the kind of person who should signup for cryonics. He loved life, didn’t much care what other people thought of him, was (I think) an atheist, could afford cryonics, and understood the technological implications of a world economy that would likely keep growing at least 3% a year for a very long time. So I invited him to lunch and suggested he sign up for cryonics like I had done.

    He nicely said he wasn’t interested, but I could sense he thought cryonics was crazy. I was unable to discuss cryonics with him because he wouldn’t engage in a real discussion on the topic with me because (I think) he didn’t want to insult me. It was frustrating. I would much rather he had been honest with me.

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    • Shmi Nux says:

      > He nicely said he wasn’t interested, but I could sense he thought cryonics was crazy.

      He might react differently to a more oblique approach, where you do not stake out your position in advance. For example, if you say something like “I signed up for cryonics, but am having second thoughts on whether this is a good use of my money, and I’ve come to rely on your piercing analysis of technology in the society (or whatever he is good at), so I would appreciate your opinion on this topic, if you have one and are willing to share”. If you are not willing to be convinced, why should he be?

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  9. Ryan carey says:

    Yeah, I also don’t say ‘I believe it’s real to you’. I usually say I’m not sure’ and often say ‘I believe you’ and then clarify that I don’t really believe them, I only trust their subjective experiential story if they press me, unless I feel they’ll physically threaten me, in which case I lie more. In the ‘do you think I’m crazy case I think ‘no’ is just the straightforwardly untruthful but correct response in basically all scenarios.

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  10. Leo says:

    Ooh, I know the “Am I crazy?” one! Thing is, “crazy” doesn’t mean “psychotic” or “unable to function” or any of those things that happen to real people who can complain about them. It means “stops counting as a person”. In tragedies and roleplaying games, characters stop steering the plot when they die or go insane. A book or movie may be told from a character’s point of view then suddenly jump to third-person when they go crazy, because crazy people don’t have a subjective life. There’s no point trying to remain friends with someone crazy, the best you can do is to talk at them like you would to someone in a coma.

    I don’t know if that happens to anyone, but it certainly is not what is happening to any of your patients. Sinc explaining that this concept of “crazy” and actual mental illness are very different would take too long, “Of course not” is a perfectly accurate answer to the question – of course they’re not crazy in that sense.

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    • Douglas Knight says:

      Could you give examples of books or movies that do that?

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    • Scott Alexander says:

      I don’t think anyone who hasn’t been inculcated with a lot of social justice memes would ever think that way.

      I take my patients at their word. I think when they ask “Am I crazy?” they are not worried about whether other people are going to oppress them or whether there’s going to be stigma about them, but about the terrifying fear that they can’t control their own mind. I think it’s just as legitimate and just as heartfelt a question as “Do I have cancer?” and comes from the same root – this fear of losing control of yourself, that whatever your symptoms are now are only going to get worse. Keep in mind that a lot of these people are poorly educated and can’t ask something like “So do I have bipolar disorder?” “Am I crazy?” is the best they can do at inquiring after a real disease state.

      Also, the book thing seems extremely wrong.

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      • Doug S. says:

        Your Wikipedia link is broken.

        Here’s a TV Tropes link.

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      • Leo says:

        I have no idea whatsoever how you get to “worry about oppression and stigma” from “Am I not a real person anymore?”.

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        • Scott Alexander says:

          I was interpreting you as saying society doesn’t treat them as a person (hence why people won’t write books from their perspective), in the same sense as people say “Under patriarchy women aren’t people” or something like that.

          If you’re saying they are worried they are literally becoming not a person, I am confused and you will need to explain further. Do you mean they think they will become p-zombies?

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  11. Jimmy says:

    I agree with most of your analysis and like your clever responses, but I think there’s an important nuance missing here.

    It’s important to understand why they’re asking at a deeper level than “wants to know the answer”. If they already feel like you’re on their side then they might just be testing to see whether you’ll be real with them – and in that case a simple “no, I don’t” is enough. If they sound like they’re challenging you, then they probably feel like you’re not taking them seriously and think you are more focused on “this dude is crazy/delusional, what PC answer can I give that won’t enrage him?” – and if that’s the case, recovering will be tough because you’ve already dug yourself a hole.

    Say you’re the patient and you hear the engraging “I believe that what you are seeing and experiencing is real to you”. It’s not enraging because {he disagrees with you about your FBI-chasee status}, and it’s not because {you disagree about how important it is that whether there is a fact-of-the-matter} or {whether it’s important} – or even {whether it’s important that he believe you}. The enraging part is that it feels important *to you* and that he doesn’t feel like that is enough to make it worth addressing – like “crazy guy think’s this is important, but I’m just gonna ignore him because he’s not an actual agent worth taking seriously – and he won’t notice that I’m pulling this one over him”

    I think that as long as you explicitly address it, it’s okay to say that you don’t find it to be important whether you believe him. Imagine instead of saying “I see that it’s real to you”, he shrugs, looks mildly confused, and says “whether or not I believe you is so unimportant to me that I haven’t given it much thought” – and he says it so sincerely that you actually *believe* him. I bet your response is a lot more “confused/intrigued” than “enraged”. (kinda hard to believably say for the “I’m Jesus!” case, but less so for the “people are after me!” cases)

    Good empathy is about focusing on understanding their point of view to the exclusion of irrelevant obstructions (e.g. “if I had to decide now, is he right?”, “can I classify him as ‘crazy’ and switch to my ‘how to deal with crazies’ look-up-table so I don’t have to actually consider what he says?”, etc). Not caring about whether (given your current information/understanding) you think he’s right comes automatically. The hard part is actually keeping your attention focused empathetically.

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  12. Minstrel says:

    I think the answer I’d like to give is, “Let’s talk some more so I can properly understand the situation and then I promise I’ll come back and answer your question.”

    It’s a stall for time, obviously, but with a purpose: to allow a chance to ask questions to gauge some things about the person: how smart he/she is, what their personality is like, whether they have other reality-based thinking (as you put it) going on, etc. That would better allow me to craft a response that would be reassuring (and maybe even helpful) without being dishonest.

    I might re-craft the original question slightly, but the intention is to be neutral…like, from the phrasing, maybe the guy really is being pursued by the FBI (not that I believe that, but leaving it as a possible outcome) and I’d just like to hear more about what’s going on. That would, hopefully, avoid the patient feeling like they were being studied as a “crazy person” who’s situation needed to be figured out.

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  13. Laura says:

    On my last psych rotation I got hit with the question of ‘You don’t believe me, do you?’ and was unprepared. I said something along the lines of ‘No, but I don’t think that means I can’t help you with your situation… And I think we can come up with solutions that would make sense for both of us.’ I am sure this was not the right text-book answer, and I might have done better, but I think the patient, who both very intelligent and very paranoid about people playing games with her, was relieved to know where I actually stood. I also feel like if I had tried to give the evasive answer I would somehow have broken report. That might just be my lack of experience at this point, but I don’t think my answer caused harm, even if it was not ideal.

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