"Talks a good game about freedom when out of power, but once he’s in – bam! Everyone's enslaved in the human-flourishing mines."

Book Review: Mount Misery

[Content warning: psychiatric abuse (especially around borderline personality), rape, spoilers for Mount Misery]

I.

Last month I reviewed Samuel Shem’s House of God. The sequel, Mount Misery, is about his time training in psychiatry. This is obviously relevant to my interests, so I picked it up.

It’s weird to accuse someone of writing a cheap knockoff of their own book, but Mount Misery reads like a cheap House of God knockoff. There are all the same elements – a young doctor, an incompetent system, cruel hospital administrators, a kind mentor. But in the first book, it all came together perfectly. In this one, it was more hit-and-miss. Sometimes the imagery clicked; other times, it just seemed like caricatures. Creepy magical realism alternated with guys who announced “I hate patients! Let’s just pump them as full of drugs as possible and leave them to die!” and then zoomed away in fancy sports cars they bought with pharma money. Maybe it’s just less funny when it hits closer to home? I don’t know, but it was less funny.

The book’s frame story follows Dr. Roy Basch, who has left his abusive medical internship to do a psychiatric residency at the Mount Misery hospital, lured there by the kind and decent Dr. Ike White. But Dr. White commits suicide Basch’s first month of the job, the hospital administration ineptly covers it up, and nobody wants to talk about it – something something metaphor even psychiatrists stigma something metaphor. Having lost his mentor, Basch is thrown back and forth among various attendings – the one who thinks Freud solves everything, the one who thinks drugs solve everything, the one who thinks a thinly-veiled parody of Otto Kernberg solves everything, et cetera. The only sympathetic character is Dr. Malik, who tells Basch to ignore the theories and try to connect with his patients as human beings; Malik is of course loathed by all the other doctors and ostracized from all the good positions in the institution.

The typical psychiatric treatment in Mount Misery works as follows: Take someone who has some awful stuff going on in their life but is pretty much functional. Declare them to be a perfect example of whichever theory is popular that week (“this person clearly is obsessed with the idea of sucking their father’s penis”), then insult any underlings who don’t buy-in as being ignorami who refuse to understand the complexities of the human mind. Ignore all of the patient’s human needs in favor of the theory – if they complain that their room is cold, tell them that’s a reflection of the coldness of their father. If they protest that no, they’re really cold, then mark them as “resistant” and double-down on your theory since they obviously need a lot of help. The angrier the patient gets, the more you’ve obviously hit a nerve and the better a psychiatrist you are. Repeat the process until they are curled up in a ball, completely nonfunctional, which you will call “successfully regressing the patient” and “revealing the repressed pathology”. Then keep them in hospital until their insurance runs out, at which point discharge them to be someone else’s problem.

When someone like Dr. Malik doesn’t do the typical treatment, the fact that his patients never get reduced to curled-up balls gets held against him. He’s so “superficial” that he just takes the patient’s complaints about being cold as a reference to real physical coldness in the environment! If his patients say they’re upset at losing their job, he’s so “superficial” that he just talks to them about their job and how they can support themselves financially! A janitor could do that! When his patients fail to be reduced to curled-up balls of rage, that obviously proves he’s not nailing their real emotional problems, not getting past their defenses, not successfully regressing people, and just generally incompetent.

The master of this kind of anti-treatment is Dr. Heller – the hospital’s specialist in borderline personality disorder – who believes that it’s psychodynamically important to bring out the latent negative transference in borderlines (ie make them hate you). When Dr. Basch, at Dr. Malik’s urging, tries being nice to a borderline patient instead, and gets much better results than Heller ever has, the expert lectures him on his mistake:

Heiler explained that his technique, “confrontation”, had evoked the anger that was hidden in each and every borderline. “She wasn’t angry at me“, he said, “it was her transference to me. She was distorting her real relationship with me based on early infantile experiences, with her bad mom, in the first year of life.”

“But she was angry at you,” I said. “Anyone would be.”

“Not that angry,” he said. “Not borderline angry.”

“How do you know that she’s a borderline?”

“Because of that incredible anger.”

“But she didn’t start out angry – you provoked it.”

“Who says?”

“I do! It was obvious.”

You? You, who’ve been a psychiatrist two whole months? You don’t know diddly-squat about treating borderlines. Your so-called ‘concern’ is going to be a real problem – you’re already overinvolved, imagining that you can rescue her. To you, what I did seemed cruel, right? […]

His voice softened, and he went on, “Look. I know that the first time you see it, this theory seems strange – it’s counterintuitive. If just being nice to borderlines worked, don’t you think I would do it? Of course I would! In fact, I tried, way back, at first. But it’s like dealing with difficult children: you’ve got to be firm. Everybody knows that if you don’t dig up the Latent Negative Transference in these gals, next thing you know you’ve got people killing themselves, or killing other people. For fifty years people have been trying to cure borderlines by being ‘nice and human’ to them. Everybody felt better, nobody got better. It’s easy to act nice, it’s hard as hell to stand firm and confront the rage locked up in borderlines. Borderlines are hell. There aren’t too many of us left who have the guts to treat ’em. I’ve specialized in borderlines for years and years, and I’ve seen what works: You go through that rage to the truth, to their miserable pain and suffering, and believe me, they get better.”

“But,” Solini said, “I mean, everyone agrees that the lady [did get better when we were nice to her]”

“In this case,” Blair said, “Better is worse. She’ll have to get worse – which is in fact better – in order to get better, which will still be worse. If she gets a little worse, she won’t get a lot better, but if she gets a lot worse, she may get a little better. Not smarmy-‘nice’ better. Borderline better…Don’t worry, Roy. Your overinvolvement with her is normal. Sick, but normal. Gals like her are experts at getting guys like you entangled. Read my paper, Rescue Fantasies In The Naive Resident

This speech could be a word-for-word transcription of something one of my attendings said to me during my intern year when I tried being nice to a borderline patient. There is a subtle sense in which this attitude can sometimes be helpful. But get the subtlety even slightly wrong and it devolves into being really evil, and Mount Misery brings out the worst in it.

Dr. Basch’s first therapy patient is a man named Cherokee, a rich WASP lawyer. He’s obsessed with the paranoid fantasy that his wife is having an affair with her psychoanalyst, a Mount Misery luminary named Dr. Dove. Basch tries everything with Cherokee – drugging him up, uncovering his latent homosexuality, suggesting he hates his father – but eventually Cherokee commits suicide anyway (“eventually he commits suicide anyway” will be a common theme among characters in this book.) In the aftermath, it is discovered that – surprise! – his wife was having an affair with her psychoanalyst, and also it was kind of coercive and bordered on rape.

Basch starts an investigation and learns that this same Dr. Dove is molesting a bunch of his female patients, and various other tangentially related people for good measure. He tries to expose Dove, but Dove denies everything, and he’s a bigwig who can get the administration to take his side.

The description of the ensuing investigation is beautifully done, precisely because it avoids some of the caricatures of the rest of the book. Dr. Dove isn’t portrayed as an ogre grumbling about “lying whores” or whatever. He sounds to all the world like a caring psychoanalyst, who understands that his patients are fragile and that stress of discussing sexual fantasies in psychoanalysis can sometimes break out into the patient’s consciousness and cause them to behave as if those fantasies actually occur. Yet all of this just serves to make him creepier and more hate-able.

In a particularly sharp scene, Dove capitalizes on the occasion to team up with a colleague and offer workshops about how to protect yourself from false accusations of assault in psychiatry:

The slide show ended. Dr. Shpitzer then made a heartfelt statement that patient-psychiatrist contact was absolutely off-limits. Touching the patient, but for a handshake, was off limits. A hug was totally out of bounds. Yet what was the psychiatrist to do when a female patient, maybe a borderline or dissociative or multiple, suddenly got up out of his chair and approached, intent on hugging him? Dr. Shpitzer asked Dr. Dove to demonstrate. Schlomo, ever the showman, popped to his feet.

First Shptizer said he would show us all what not to do, and told Shlomo to go ahead. Playing the woman patient, Schlomo started toward Shptizer, arms forward. Shpitzer crouched in a martial-arts stance and with a scream _ HYAH! – karate-chopped Schlomo’s hands down…The discussion then centered on variants of this technique. Dr. Shpitzer passed out his brochure, describing his video course – “Six Quick Steps To Avoid The Pitfalls Of Risk” – which we could all buy for $399.95. This would allow us to pass out risk-management requirements for state relicensure as shrinks in the comfort and privacy of our very own homes.”

A psychiatrist actually rapes a patient, he doesn’t get punished because he’s a very important guy who’s friends with all the bigwigs, but everyone has to feel like they’re doing something, so they ban all normal human contact with patients, and also sell $399.95 courses that you can use to prove you’re compliant with patient protection regulations. This may be the best metaphor for life that I have ever heard.

(it doesn’t hurt that I’ve had to go through courses on whether it’s ever appropriate to hug patients, or that I once had to finagle my way out of attending a conference that was basically this guy’s $399.95 video lecture)

II.

One of the main themes of this book is that psychoanalysis makes people worse.

The book doesn’t claim that psychoanalysis isn’t effective. It treats it as powerful and worthy of respect. The book’s psychoanalysts are consistently able to tell weird facts about a person from just a glance, to strip them down to their deepest insecurities in minutes. It’s just that people who are healthy and decent going into psychoanalysis end up cracked and nasty coming out of it. A lot of the worst doctors at Mount Misery were decent people before they started getting analyzed themselves. Of course, it would have helped if their analyst wasn’t a sexual predator, but the book treats the process as dangerous even aside from that.

When Basch asks his supervisor Dr. Lowell what to do about the man who believes Dr. Dove is having an affair with his wife, Dr. Lowell describes the analytic technique:

“But what about Schlomo fucking his wife? You don’t think it’s true?

“There is no truth, there is only the individual perception of experience.”

“Wait a minute. The truth is that I’m taller than you.”

“That’s not the truth, that’s your transference to me.”

“We can measure it. To see who in fact is taller.”

“You think ‘taller’ can be measured?”

I saw her point. She wasn’t only aware of the objective fact, she was also aware of the deeper meaning psychologically. “But I’m stuck,” I said. “I don’t know what to do.”

“You have to go deeper into his obsession, find the deeper meaning, the roots of it in his childhood, his past.”

This was exactly what Malik had warned me against doing. Suspicious, I asked: “How?”

“If he talks feeling, you talk thought. If he talks thought, you talk feeling. If he talks past, you talk present. If he talks present, you talk past. You the doctor talk constantly about what he the patient doesn’t want to talk about. This is the analysis of the resistance. Then, when he starts distorting his relationship with you and calling you a sonofabitch for not talking about what he wants to talk about, then you do the analysis of the transference, telling him he’s treating you like his father, his mother, his aunt Sally, whatever. On a deeper level still, you can analyze the resistance to the transference, and the transference to the resistance. Not to mention the countertransference to each – but that’s still way beyond you at this point.”

Finally I felt I was getting some concrete advice about what to do in therapy.

I highlighted this last line because this is seriously much more concrete and actionable advice than anyone has ever given me about psychodynamic therapy and I’ve been doing it for two years.

And a lot of this rings true. I remember one time one of my patients missed a session because his flight back from vacation was delayed. I told my supervisor this and he got angry with me, saying it was superficial to blame it on the flight instead of talking about which of my comments had triggered the patient and made him decide to miss his plane. I insisted that we’d had a perfectly good session the week before, that the delayed plane had just been a delayed plane, and me and my supervisor got angrier and angrier at each other for both missing what the other thought was the point. Finally I got on the Internet and managed to prove that my patient’s plane really had been delayed to the point where it was impossible for him to have made my appointment, at which point my supervisor switched the discussion to why it was so important to me to believe that his plane had been delayed that I would do an Internet search about it, and whether I was trying to defend against the unbearable notion that my patient might ever voluntarily miss one of our sessions. My supervisor’s treatment of whether planes ever get delayed seems a lot like Basch’s supervisor’s treatment of who’s taller.

And I don’t think these people are literally so stupid that they don’t understand that there are objective rulers that tell objective height. Trying to steelman this school of psychoanalysis, it’s a sort of as-if game, the professional equivalent of Crowley’s demand that the adept swear an oath “to interpret all phenomena as a direct dealing of God with his soul”. It’s an enforced fast from object-level discussion, where you treat everything as significant as an assumption. My first guess was going to be that this is so that you minimize the Type II errors where you miss something that really is significant, but after thinking about it more I wonder if it’s just that this is a bizarre and unnatural mode of thought that can get you places that normal thought can’t, sort of the same way some people have revelations on LSD not because LSD itself is magic but because it’s so different from normal thought processes that it can uncover things that are otherwise hidden. This could also explain the Freudian obsession with dreams – it’s not that they necessarily mean anything, any more than my patient missing his flight meant something, it’s that they’re a good source of noise to start scrying into.

(another Freudian technique is free association, asking the patient to just say whatever first comes to mind. In Mount Misery, Basch’s patient says “porpoises”, but has no idea why – something had to come to mind, and a porpoise was the first thing to pop into his head. This is a lot more like my own experience with free association than the textbook cases of people suddenly coming up with repressed childhood memories or something)

But this method also reminds me of something else. This is Christopher Hitchens:

“I think Hannah Arendt said that one of the great achievements of Stalinism was to replace all discussion involving arguments and evidence with the question of motive. If someone were to say, for example, that there are many people in the Soviet Union who don’t have enough to eat, it might make sense for them to respond, “It’s not our fault, it was the weather, a bad harvest or something.” Instead it’s always, “Why is this person saying this, and why are they saying it in such and such a magazine? It must be that this is part of a plan.”

The avoidance of object-level discussion in favor of meta-level discussion can get really nasty, really quickly. The book gives one example – if you psychoanalyze rape accusations (“what purpose is it serving in this person’s mental ecosystem to have them accuse their psychiatrist of rape right now?”) then you miss someone who is actually getting raped. This can be more insidious when complaints are less dramatic and less binary – I know a lot of psychiatrists who will respond to people saying their medication isn’t working (or is causing side effects), with analyzing their motives for wanting to piss off their psychiatrist or stay unhealthy. And finally, this is absolutely fatal to any kind of complicated social discussion – the thing where instead of debating someone else’s assertion, you bulverize what self-interest or privilege causes them to believe it.

Basch says:

I breathed in the cleansing sorrow of the rain and stared back up at the castle, and I saw clearly how through psychoanalysis you could know every nook and cranny of yourself and have no idea how to be with anyone, the seeming dazzle of the self blinding you to the connections with others…and I knew then I had once been in touch with people, and that it wasn’t inevitable that we are always shouting across an unbridgeable gap, but rather that the gap was in Freud and monstrous fabrications like [Dr. Lowell] herself who followed after, bereft souls floating untethered in pools of self like lilies in sepsis, the gap was in them, not in the essence of humans, nor in the essence of the whole world.

I stared up at the vigilant street lamp, the cone of glittering sleet in the winter night reaching toward me like a beacon, showing me as clearly as if it were the moment’s sun that the real perversion of Freud and analysis was to take the essence of something and reduce it to something eles – the present to the past, love to hate, joy to misery, life to death – and to do it under the guise of understanding and yet, let’s face it, all the while doing it to escape from what Malik kept saying life at heart actually is – being, without description of that being.

If the book is right about psychoanalysis being destructive, I wonder if this is why. Living on the object level is really good. That’s where all the problems are and generally where the solutions are. It’s a natural, healthy place to live.

III.

The last thing that really struck me about the book was its praise for Alcoholics Anonymous.

In the last chapter of the book, Dr. Malik is revealed to be a recovering alcoholic who relapses when he gets diagnosed with cancer. He ends up committed to his own hospital, where he is first pumped full of irrelevant drugs (of course), then subjected to random people telling him he is a bad person because only bad people would drink. All of this is finally contrasted with Alcoholics Anonymous, treated as a beautiful organization full of caring-yet-pragmatic people that tries to genuinely connect with people and give them what they need to stop drinking.

It’s pretty popular to hate on Alcoholics Anonymous these days. And not without reason – I did a sort of literature review about them a while ago, and while they’re no worse than any other treatment options, they aren’t any better either. Their insistence on acknowledging a Higher Power pisses some people off; their insistence on how they are the only way and if you abandon them you’ll just be a drunk for the rest of your life pisses off others. Yet there are some very smart and very compassionate people – apparently including Mount Misery author Samuel Shem – who absolutely love them. In fact, looking at the About The Author page in the back of the book, it looks like after finishing this novel, Shem wrote a hagiographical play about AA founders Bill W and Dr. Bob.

(I checked to see if Shem has ever been an alcoholic himself, sometimes a common feature of people who are really into AA, but it doesn’t look like it.)

There’s a link between AA and Shem’s constant theme throughout his books – people healing through relationships and human connection. But I was especially interested to see this quote, from an article on his AA play:

And what about God? At the time that the two of them met, neither one had much faith in a traditional, religious God. As Smith said, “I was forced to attend church four times a week. I vowed when I was free I would never darken the door of a church again—a vow I’ve kept, religiously, for forty-odd years.” Wilson, too, had more or less given up on God. Both men had pragmatic reasons: they had tried prayer to God, and it didn’t work to keep them sober. The key to their vision about “God” came from a man named Ebby Thatcher, an old friend of Wilson’s who said, “You don’t have to believe in God, you just have to admit that you’re not God. Use what you do believe in, whatever it is.”

Shem seems really into this. I can’t quite justify this from the text, but I get the feeling that he would even take this to the meta-level, something like “complaining about how AA is exclusionary because it requires you to acknowledge a Higher Power is a good sign that you haven’t completed the personal growth task that ‘acknowledging a Higher Power’ corresponds to.”

This was pretty close to what Dr. Basch decides is the essence of a good psychiatrist during his final-chapter epiphany: he realized that he had to get outside himself. The lesson is a little bit Buddhist, but it also ties in nicely to the condemnation of psychoanalysis – while he was being analyzed, he was focused on “his inner machinery”, focused on how everything he experienced was a reflection of his own mind and desires. The attitude Shem holds up as healthy is the exact opposite of that – being able to think about anything except your own problems and your own status, being able to connect to your patients because you’re experiencing them as human beings.

I’ve been trying to reread some of The Last Psychiatrist and better understand what he means by narcissism, something I haven’t been able to get a good feel for before. I think Shem’s idea of getting outside yourself and “admitting that you’re not God” is close to this, a kind of narcissism therapy, where you can work yourself out of narcissism which allows you to connect to your patients and maybe help them in the same way.

(it also sort of reminds me of C.S. Lewis)

It’s well-known in psychopharmacology that different drugs work on different people, for mysterious reasons. Prozac and Paxil are about equally good in general, but some people will hate Prozac and find Paxil a miracle drug, whereas other people will get better on Prozac and find Paxil does nothing. I wonder if there might be something similar for social interventions like Alcoholics Anonymous. Over the whole population, it won’t outperform any other form of rehab – but there will be a few people for whom it works miracles. Those people will go on to praise it to the skies in all kinds of books and plays and so on – not to mention starting the next generation of Alcoholics Anonymous groups – while everyone else watches bemusedly. Actually, now that I mention this it sounds obviously true and I’m not sure why I wasn’t thinking this way already.

IV.

One of the reasons the psychiatrists in Mount Misery are so bad is that they’re narcissistic, but it’s an understandable narcissism. Someone says “My mom just died”, and you say “I’m sorry for your loss” and let them talk about their memories of their mother? Anyone can do that! Why did they get borderline-tortured throughout their twenties and thirties getting a really prestigious psychiatry degree if they were just going to say “I’m sorry your mom died”? Being able to relate it all to wanting to suck your dad’s penis at least gives them some credibility for all their erudite Freud-knowledge and justifies their $200-an-hour fees. “I’m sorry for your loss” isn’t exactly $200-an-hour level insight.

But I don’t know if Shem has a good solution here. It doesn’t seem like he wants to destroy psychiatry as an institution – he is, after all, a Harvard psychiatry professor. But his fictional bigwigs are right. If all you do is be a decent human being and have one-to-one meaningful discussions with patients, then it doesn’t seem like there’s a point in having MDs for that.

I’ve had a lot of patients with this exact complaint – usually it’s about psychologists or therapists instead of psychiatrists. “She kept telling me to go to sessions, that she was going to help me, and all we did was talk about my problems. I could have had a friend do that. So eventually I just quit and I haven’t been back to see a therapist since. Bunch of quacks.” I hear this kind of thing almost every day. It’s a big fear of mine that somebody thinks it about me. Probably one reason I like psychopharmacology so much is that it makes me feel useful – prescribing imipramine correctly isn’t something that just anybody could do; my patients may or may not get better but at least they’re getting their money’s worth.

I don’t know if Shem thinks that well-trained psychiatrists have some kind of special ability to connect with other people. Based on how horrible every psychiatrist in his book is, plus his preference for self-help groups like AA, it doesn’t look like it. But his rejection of both official therapies and medication doesn’t leave him a lot of outs. Also, it seems pretty obvious even to him that a lot of conditions – like melancholic depression and schizophrenia – don’t just need a kind word and a smile, that they are really complex entities that need a lot of effort and probably a good biochemical understanding before you can do much to them.

If all that Shem is saying is that doing the complicated work of psychiatric treatment – therapies, medications, et cetera – has to be combined with actually caring about the patient and treating them like a human being, then fair enough. But the vitriol of his criticisms of therapy and medication make it hard to read that message. If he’s proposing something more radical, then I’m afraid I didn’t entirely get what it was.

This entry was posted in Uncategorized and tagged , . Bookmark the permalink.

211 Responses to Book Review: Mount Misery

  1. Randy M says:

    Interesting review, thanks. It’s kind of discordant when you start by calling it a cheap knock-off that often comes off as containing caricatures, but go on to say how true to your experience it was. I’d ask how much of it came off as true to life, but not having read the estimation wouldn’t mean much.

    Your comments on psychoanalysts are especially interesting, though I’ve no first hand experience with such. Do you think it is from missing the forests for the trees, or all due to narcissism when the therapist will gloss over the object level? Do they feel the patient understands that the doctor realizes 99% of the complaint is the cold room but suspects there is a deeper problem that the cold room could be used as a metaphor for, or are they actually refusing to consider the patients words could have a meta-level zero, “literally literal” meaning? Sometimes I’ll make a verbal pun by deliberately misunderstanding my wife; to coin a phrase, ‘A comic is never appreciated in his own home”; but at least she knows it’s a shtick. I’m surprised more psychoanalysts aren’t strangled for saying “When you say your room is cold, do you really mean” three times in half an hour.

  2. hnau says:

    Two C.S. Lewis references in the same SSC post? It really is Christmas. Fascinating book review!

    I’m currently working my way through the LessWrong Sequences, and the description of Stalinism / Bulverism / meta-level contrarianism in psychoanalysis reminded me of their tone somewhat. There’s very little discussion of actual object-level questions in there– it’s all about analyzing (and usually criticizing) one’s own thought processes. Which is all well and good on its own, but as applied to real object-level disagreements it starts to sound pretty sketchy, especially since it’s always one’s own thought processes being criticized and never the author’s. (The discussions of religion were the main place I noticed this. To be fair, a better explanation might just be that in such a forum the object-level case against religious worldviews is taken for granted.) I’m not sure it’s fair to compare this to the delayed-airplane psychoanalysis Scott described, though, so I’d like to hear what other people think.

    • Callum G says:

      Interesting connection! I see how the tone is similar. Maybe that’s why I have friends who see the rationalists as a elitist circle jerk of people who perform mental backflips in order to pat themselves on the back for said backflips.

      Which is all well and good on its own, but as applied to real object-level disagreements it starts to sound pretty sketchy, especially since it’s always one’s own thought processes being criticized and never the author’s. (The discussions of religion were the main place I noticed this.

      I see the section on religion as an accessible way to learn about some failings in thinking. Given there is no justifying body of evidence for these major religions, why do so many people still believe in them? What are the thought processes there? Religion is used as a teaching example. However, the critical awareness taught should absolutely be turned back on the author. I think EY even warns against this later on in the sequences.

      To be fair, a better explanation might just be that in such a forum the object-level case against religious worldviews is taken for granted.

      A rationalist idea is not just to have beliefs that best match the evidence, but to only have beliefs that best match the evidence. And so through updating based on evidence, Occam’s razor and making beliefs “pay rent”, religious worldviews fall out of favour.

      Unless I’m understanding you wrong and you’re wanting more examination of the evidence? In that case there are plenty of Dawkins style books that weigh into that whole debate. Yudkowsky is just looking at the thought processes behind belief.

      • Eponymous says:

        I see the section on religion as an accessible way to learn about some failings in thinking.

        The counterargument is that these sorts of examples make the work *less* accessible to religious people.

        Probably the optimal sequence of examples when teaching rationality would be:
        (1) Made-up or otherwise obvious examples, to illustrate the concept most clearly.
        (2) Beliefs held by previous generations (including scientific theories, like phlogistan and vitalism), but now universally rejected.
        (3) Currently highly controversial views. (e.g. MWI).
        (4) Extra credit: Explain what’s wrong with a currently widely accepted view.

        In the sequences, Eliezer treated religious belief as a preeminent example of (2), when it should be treated as (3), or perhaps avoided altogether as extremely distracting (for example, imagine if Eliezer had used global warming as a go-to example).

        • Deiseach says:

          Thing is, religious people are used to getting the “believing in religion is a relic of evolutionary psychological processes and mistaken semi-naturalistic explanations that people had to fudge up before they had real science, so I am now going to explain to you why it is stupid to be religious at this day and date and exactly in what way you are being stupid” treatment, so one more version of it is not going to be “Okay, this time it really convinced me!” except for a few cases.

          I suppose, though, if it does work on dispelling illusion for a few, it could be considered worthwhile. But most religious people are going to skip that sort of lecture on the assumption that it’s only going to be yet more “let’s all laugh at how dumb the religious are”, even if the laughing is only done up one’s sleeve.

          Also, religious people are used to religion being the easy, go-to target for “this is an example of clearly wrong thinking”. What is more convincing is when a non-religious “this is mistaken and this is what way it goes wrong” example is used because that has at least the appearance of being disinterested.

        • Callum G says:

          I wonder if EY views religiosity as failing of rationalism. As in, if religion does fit into (3) then it’s controversy comes from failing meta-belief systems rather than emerging evidence, disagreeing experts etc; things that make MWI controversial.

          In any case you’re right that it would be distracting. Religious people get attacked by nerdy elitists all the time so I wouldn’t be surprised if they read these sections, sigh, and dismiss much of the skills the book is trying to teach. If the example application of these skills apparently leads to invalidating your religion then of course you wouldn’t feel too positive about it.

        • harryjohnston says:

          The counterargument is that these sorts of examples make the work *less* accessible to religious people.

          But is the work aimed at religious people in the first place? Perhaps EY simply considered them a lost cause? (I’ve only read a few Sequences articles, and none of the ones in question as far as I can remember, so this is pure speculation.)

          • FullMeta_Rationalist says:

            I think LW’s intent was to inject lithium into the water supply. EY once wrote something about the dissolution of organized religion by raising humanity’s rationality above some abstract waterline.

          • Mary says:

            In which case it’s unreasonable to do something that will cause people to filter it out of the water.

          • FullMeta_Rationalist says:

            A few years ago, I met a guy irl who had never heard of LW or the Rationalist Movement, but namedropped Bostrom’s Superintelligence: Paths, Dangers, Strategies out of the blue. So I feel like it’s working as expected to at least a partial extent.

          • Spookykou says:

            I am not sure I follow.

            Is the idea here that LW has signal boosted Bostrom such that even people outside of LW have heard of Bostrom?

            In any case I agree with Mary, if the goal is to spread ‘rationality’, then wouldn’t the rational approach be to make ‘rationality’ as palatable as possible to as many people as possible?

          • Viliam says:

            if the goal is to spread ‘rationality’, then wouldn’t the rational approach be to make ‘rationality’ as palatable as possible to as many people as possible?

            The risk of not spreading the message sufficiently is balanced by a risk of diluting the message.

            Remove the “religion” part, because it could offend people. But what about “separate magisteria” and “beyond the reach of god”? What about “mysterious answers to mysterious questions” or “ignorance is a fact about the state of the mind, not a fact about the thing”? What about “privileging a hypothesis” and “a map is not the territory”? Are you going to remove all of this, or only the parts that are too obviously connected to the topic of religion? Where exactly to make the cut; and what are you going to do if someone asks about the next step?

            “People often believe that what happens in their heads must also necessarily exist out there. For example, if they don’t understand something, and don’t know anyone who does, they are likely to conclude that the thing is inherently unknowable. But there are no inherently unknowable things, there is only a lack of specific knowledge in specific minds. By the way, history shows that many of the formerly inherently unknowable things are taught at elementary schools today.” “But isn’t like God inherently mysterious? Or is that another instance of confused thinking?” “Uhm… no comment! There is no rational answer to this question, nor shall there ever be; now please go away.”

            Atheism per se is cheap. It means getting the right answer on a yes-or-no question, usually for the wrong reasons. Flip a handful of coins, half of them will become atheists; that doesn’t make them smart. History shows that all kinds of stuff that atheists usually associate with religion, also happens in nominally non-religious societies. (Sometimes because they are engineered by former theology students, but anyway.)

            Sequences go beyond atheism as a “teacher’s password”. Sequences teach stuff, which — if understood properly — would make you invent atheism even if you never heard about it before. (In theory, of course. Ratonality goes against too many human instincts.) Map is not the territory, and Solomonoff induction is not a human — you must thoroughly research this.

            Limiting rationality to “we need some smart people to think really hard about constructing a superintelligent AI” would not be even enough to make smart people think really hard about constructing a superintelligent AI. I mean, why do they even need to be smart, and to think? Maybe they actually need to be virtuos, and to pray. Please explain why that would be a bad strategy, without disparaging religion. I mean, asking the friendly super-superintelligence to protect you from mere superintelligence seems like a smart move; especially in the absence of better ideas. Or maybe we are meant to be all killed by the AI and go to Heaven; who really knows?

            I suspect that what will really happen is that the “rationality movement” will get diluted anyway. Similar things already happened in the past. We had the Science-and-Sanity guy, who used to be famous and now is just an obscure footnote. We used to have Rational Therapy, the ancestor of today’s CBT which is mostly known for curing phobias by gradual exposure. Meh. Cybernetics? Something something obscure, probably about machines. So, I expect fifty (or maybe just twenty) years from now to be like: “Rationalist movement? Oh, you mean the Bostrom guy, who said machines will become dangerous. Yeah, the World War 3 proved him right; we got punished by gods for our sins. What, cognitive biases? Nah, never heard about that.” But I don’t want to make this happen faster.

          • FullMeta_Rationalist says:

            From hanging around HN, I get the feeling that the optimal strategy is to: A) appeal to a core userbase of over-zealous power-using hipsters; B) distribute a watered-down product that will appeal to filthy casuals.

            I think EY regrets taking swipes at religion though.

          • Harry Maurice Johnston says:

            My personal impression of LW and the sequences is that they were intended to help develop the concepts and to assist those who were already part of the community, rather than to try to persuade anyone to adopt rationality who didn’t already want to do so.

            Outreach seems to be centered more around CFAR and/or MIRI. At least, those are the links I found from HPMOR. On the other hand, MIRI does contain a compendium of the sequences, which might or might not include the same religion-unfriendly material we’re discussing.

          • FullMeta_Rationalist says:

            Reminds me of worse is better.

            TLDR there’s often a trade-off between virality and correctness.

          • Spookykou says:

            I assumed that any number of similar belief structures could be used in lieu of main stream religion, but maybe this is not the case, I have not actually read the sequence.

            Given my belief that the messages of the sequence could be conceived without any direct reference to religion, let me clarify my position,

            1.) The purpose of the sequence is to help other people find ‘rationality’ of the form described in the sequence.

            2.) Some number of people will read the sequence.

            3.) Some number of those will be receptive to the ideas in the sequence such that they will change at least some of their behaviors or thoughts in a way that is viewed as being desirable by EY.

            4.) Some number of those will be religious.

            5.) Some number of the religious will be turned off by the openly atheistic messages in the sequence and as a result stop before step 2.

            So, as to your first question, you just cut out direct reference to main stream religion.

            Basically everything else you wrote seems to be assuming the sequence is some sort of conversation you are having, and not a document.

            In fact, you even claim that understanding the meta concepts in the sequence would lead you to atheism without ever having heard of the concept, so I am very confused why you would then also think that the sequence would need to directly explain this.

          • FullMeta_Rationalist says:

            analogy

            Don’t tell neophytes about Vegetarianism’s ban on fish. It might scare them off.

            Vegetarianism and fish-eating are too closely related to ignore. Eventually, someone’s gonna ask about fish. One can either: A) be upfront; B) “Don’t Ask, Don’t Tell”; or C) lift the fish ban for the sake of Vegetarianism’s popularity.

            I’m not saying theism and rationalism are incompatible. Just that – by default, an upstream topic should influence a downstream topic.

            Which incidentally is the point of LW’s Semantic Stopsigns, Separate Magisteria, Universal Fire, etc. (So EY, can we eat fish or what? “Never ask that question.”)

          • Viliam says:

            In fact, you even claim that understanding the meta concepts in the sequence would lead you to atheism without ever having heard of the concept, so I am very confused why you would then also think that the sequence would need to directly explain this.

            If we lived in a universe where the only obstacle on the way to rationality would be individual irrationality (cognitive biases), maybe it would be enough to explain the machinery of thinking in general, and let smart people connect the dots. It wouldn’t be the most efficient way — thinking takes time, time is a scarce resource, this is why we have schools instead of letting kids reivent the whole civilization from scratch — but maybe having thousands of people explore the path independently could be worth it.

            But we don’t live in such universe. Besides individual irrationality, there is also group irrationality. Religion is the obvious example of a formal institution devoted to spreading irrationality, but belief in homeopathy also usually comes from outside. It’s not just the mistakes you make spontaneously because you are an imperfect human; it’s also mistakes you make because your social environment would punish you for not making those mistakes. Individual mistakes you can try to reduce by slowly teaching people how to think better. Organized mistakes will fight back. You invent a rationality curriculum, they invent an anti-rationality curriculum. (Someone already wrote a “Bayesian proof” of Jesus.) So, publishing only the first half of the way to rational thinking, and then staying quiet, is not going to end well… someone will fill the vacuum with some insane twist of the original idea. Don’t give up the first-mover advantage.

            Religion doesn’t play fair at the marketplace of ideas. Religion is an organized child abuse. If anyone objects against me saying this, please give me another example where you would consider it ethically okay to threaten little kids with eternal torture? (And that’s already a mark of a secular society that we mostly rely on verbal threats that an invisible sky monster is supposed to fulfill in the unspecified future. In less secular society, parents sometimes cut their children’s throats for blasphemy, completely unmetaphorically.) Religion takes care to implant the seeds of insanity before the children are capable of independent though; and tries to cripple them emotionally to make them unable to undo the damage later. It’s an imperfect process, but the important thing is that it works on average.

            This is a huge elephant in the room. I’m not saying that religious people are horribly immoral. I’m saying that even people who say things like “we should treat religion with respect” are already horribly immoral. Please taboo the word “religion”. Should we treat child abuse with respect? Should we treat emotional torture with respect? Should we treat insanity with respect? (I mean, insane people do deserve respect, but not the insanity itself.) Uhm… why? Because it allows one to “pretend to be wise”, if one refuses to say the obvious, and pretends it doesn’t exist? I am sure it signals some social skills, but… eh.

            In vacuum, if A implies B, and B implies C, and you teach people how A implies B, and you give them the tools to make the “B implies C” connection for themselves… it is reasonable to expect that they will.

            In real world, teaching people that A implies B, and stopping there, still means teaching people who were taught, at the age of 3 or 5 years, that even thinking “maybe C” makes them deserve to be tortured forever. And then you have people who have literally studied at universities how to make and keep other people insane, and who have millenia of such dark knowledge at their disposal, to write a conclusion that “A implies B, but B totally implies not-C”. If a sufficiently smart person writes that in a sufficiently complicated way, the reader is not going to examine it too deeply, because a part of their brain fears that that would be a way to receive eternal torture. So they will just read “yeah, A implies B, B implies not-C, so now I know that rationality proves God” and sigh with a relief, subconsciously knowing that they just dodged a bullet.

          • The original Mr. X says:

            You invent a rationality curriculum, they invent an anti-rationality curriculum. (Someone already wrote a “Bayesian proof” of Jesus.)

            That would be the Rev. Bayes, I assume.

            It does seem a bit odd to portray this as an “anti-rationality curriculum” made up in response to LW’s arguments, when the Rev. Bayes pre-dated LW by two and a half centuries and LW’s main shtick is taking the Rev. Bayes’ argument for Jesus and applying it to other things.

            Religion doesn’t play fair at the marketplace of ideas. Religion is an organized child abuse. If anyone objects against me saying this, please give me another example where you would consider it ethically okay to threaten little kids with eternal torture? (And that’s already a mark of a secular society that we mostly rely on verbal threats that an invisible sky monster is supposed to fulfill in the unspecified future. In less secular society, parents sometimes cut their children’s throats for blasphemy, completely unmetaphorically.) Religion takes care to implant the seeds of insanity before the children are capable of independent though; and tries to cripple them emotionally to make them unable to undo the damage later. It’s an imperfect process, but the important thing is that it works on average.

            And yet religiosity is positively associated with mental health and reported wellbeing. It’s a pretty odd kind of “abuse” that leaves its victims happier and more psychologically healthy than they would otherwise be.

          • Nancy Lebovitz says:

            Viliam, not all religion teaches children about hell. I’m not sure what the proportion is.

            I realize Judaism is a small religion, but most of the many variants have little emphasis on an afterlife.

            To be fair, there are Chasidim who teach that Nazism was a result of secular Jews. I don’t know how that works out emotionally for children, though it sounds a lot like a threat of hell to me. On the other hand, Chasidim are a minority within a minority.

            Do you have an opinion about how much opposition non-hell religions should get?

          • Jiro says:

            If anyone objects against me saying this, please give me another example where you would consider it ethically okay to threaten little kids with eternal torture

            “If you go cross the street without looking both ways you may get run over by a car and suffer horribly”. Technically it isn’t eternal, but I think it satisfies most of the requirement.

            We believe all the time that certain acts have horrific consequences out of proportion to the seeming inconsequential nature of the act. “Don’t get run over by a car.” “Don’t fall of the ladder and get a concussion.” “Don’t play with the wood chipper and get your hand agonizingly chopped to bits”. If the parent actually believes that Hell is real, warning the kids that if they do X they get eternally tortured is no more unethical than warning the kids that if they do X to the woodchipper they get finitely tortured.

          • Nancy Lebovitz says:

            Jiro, that’s one of those intent/effect issues.

            If a parent believes a well-tested medical procedure is dangerous, doesn’t let their child get the procedure, and the child suffers serious damage as a result, should this be considered abuse? Even if not abuse, should the parent still have custody?

          • Viliam says:

            And yet religiosity is positively associated with mental health and reported wellbeing. It’s a pretty odd kind of “abuse” that leaves its victims happier and more psychologically healthy than they would otherwise be.

            Didn’t read the original study, so I have no idea whether it controlled for confounders such as “how are the openly nonreligious people treated by some of their religious neighbors in predominantly religious societies”. You know, stuff that can make people report worse wellbeing, or have worse mental health, without being a direct consequence of their own behavior.

            To put it bluntly, I believe that e.g. in Taliban territories, atheists live significantly shorter and worse lives than the rest of the population. But I wouldn’t interpret this statistical fact as a social problem of atheism.

          • Viliam says:

            @Nancy Lebovitz

            Do you have an opinion about how much opposition non-hell religions should get?

            With limited resources, one must make priorities.

            In a perfect world, I would prefer to not have any kind of organized irrationality targeting defenseless children. Even lying about Santa feels creepy.

            But in the world we have here and now, we should prioritize disarming of memes that turn people into suicide bombers. Moving away from bloodthirsty supernatural beings, towards more benign supernatural beings, is an improvement. Just like replacing Miracle Mineral Supplement with homeopathy would be an improvement in healthcare.

          • FullMeta_Rationalist says:

            And yet religiosity is positively associated with mental health and reported wellbeing.

            Likewise, patriotism is also positively associated with well-being. Apatriotism might be… bad for one’s health. Isn’t that right, comrade?

            In case I’m being too subtle. Sweeping generalizations about religion are like sweeping generalizations about governance. Some governments are great; but some governments will send you to the gulag for sneezing. It’s unproductive to lump them together.

            I suspect that in the West, religions have been neutered by Freedom Of Religion. But without Freedom Of Religion, religions were confident to behave nastier toward infedels because religions had greater bargaining power. Especially if a particular religion were a regional monopoly (cough MONOTHEISM cough).

            I was raised Roman Catholic. My pastor was hilariously laid-back. “Just be a good person.” The polar opposite of fire and brimstone. This mostly reflects the personality of the pastor. But it’s sufficient to prove there’s a lot of variance. Therefore, we need to be more specific about which parts of religion are good or bad, and why.

            Incidentally. I might be totally off base, but I get the feeling that heaven & hell is an invention of the comparatively newer religions. E.g. the Celts didn’t have a concept of the afterlife. Is it just me? (Everytime I’ve looked at religion historically, I’ve been fed contradictory accounts. I’ve mostly given up at this point.)

          • Harry Maurice Johnston says:

            Incidentally. I might be totally off base, but I get the feeling that heaven & hell is an invention of the comparatively newer religions. E.g. the Celts didn’t have a concept of the afterlife. Is it just me? (Everytime I’ve looked at religion historically, I’ve been fed contradictory accounts. I’ve mostly given up at this point.)

            Is the Greek underworld (see Wikipedia article of the same name) an example of what you’re asking about? Or are you making a distinction that I’m missing?

          • The original Mr. X says:

            @ Viliam:

            Didn’t read the original study, so I have no idea whether it controlled for confounders such as “how are the openly nonreligious people treated by some of their religious neighbors in predominantly religious societies”. You know, stuff that can make people report worse wellbeing, or have worse mental health, without being a direct consequence of their own behavior.

            AFAIK the correlation holds in secular regions like Europe as well as more religious ones. I don’t think “My neighbours refuse to speak to me now that I’ve stopped going to church” is going to be a situation many Europeans find themselves in.

            @ Full Meta:

            Likewise, patriotism is also positively associated with well-being. Apatriotism might be… bad for one’s health. Isn’t that right, comrade?

            Yes, and if somebody claimed that raising your children to be patriotic is a form of child abuse, I’d think that they were being stupid too.

          • Nancy Lebovitz says:

            FullMeta_Rationalist

            I’ve been told that the ancient Celts believed in non-karma reincarnation. You might be affected from a geas from a former life, but there was no justice, just life after life.

            I might be able to track down a source, if anyone cares.

          • The original Mr. X says:

            I’ve been told that the ancient Celts believed in non-karma reincarnation. You might be affected from a geas from a former life, but there was no justice, just life after life.
            I might be able to track down a source, if anyone cares.

            Caesar mentions this belief in De Bello Gallico.

      • Jaskologist says:

        Given there is no justifying body of evidence for these major religions, why do so many people still believe in them?

        Because that’s not actually given. There are justifying bodies of evidence. Not everybody finds them convincing, but they do exist.

        • RicardoCruz says:

          Surely he was referring to mainstream religions, where the only evidence is that the holy book says so. No archeology has ever supported a narrative from a holy book. In many cases, archeology has refuted them. Not to mention astronomy and other claims made on such mainstream holy books.

          • The original Mr. X says:

            That is an extremely cartoonish understanding of the situation.

          • Mary says:

            “where the only evidence is that the holy book says so”

            What is your evidence for this assertion?

          • Spookykou says:

            I have fought through my fear of looking stupid.

            Would you be willing to explain the situation in more detail Mr. X?

          • The original Mr. X says:

            Well, his assertion that “the only evidence is that the holy book says so” is wrong, and his assertion that “[n]o archaeology has ever supported a narrative from a holy book” is also wrong. So basically, he’s made two sweeping statements without backing them up, and both of his statements are wrong.

          • Spookykou says:

            Well, yes I agree with that, I was mostly looking for examples of good if controversial evidence, sorry I wasn’t clear.

          • The original Mr. X says:

            Well, one example would be the Pilate Stone, which inter alia confirms that Pontius Pilate did indeed hold the rank of prefect, as the Gospels suggest (previously there had been some debate over this, as Tacitus calls him a procurator). Plus, the archaeological evidence of 1st-century Jerusalem is consistent with what the New Testament reports, and the titles given to local governors in the Book of Acts are AFAIK all confirmed by inscriptions from the places in question.

          • Spookykou says:

            I know that many claims from the bible are generally considered to be accurate historically, but these tend to be the less miraculous claims, that is what I assumed this was all about, evidence for a great flood event, things like that you know?

          • The original Mr. X says:

            I think, in general, it’s difficult to use archaeology to confirm or deny most miracle stories, because it’s not clear how, if at all, miracles should show up in the archaeological record. Although I suppose the reports of strong electromagnetic disturbances at the tomb of Christ could be taken as evidence of the resurrection, insofar as they indicate that something strange has happened there.

  3. CatCube says:

    I remember one time one of my patients missed a session because his flight back from vacation was delayed. I told my supervisor this and he got angry with me, saying it was superficial to blame it on the flight instead of talking about which of my comments had triggered the patient and made him decide to miss his plane. I insisted that we’d had a perfectly good session the week before, that the delayed plane had just been a delayed plane, and me and my supervisor got angrier and angrier at each other for both missing what the other thought was the point. Finally I got on the Internet and managed to prove that my patient’s plane really had been delayed to the point where it was impossible for him to have made my appointment, at which point my supervisor switched the discussion to why it was so important to me to believe that his plane had been delayed that I would do an Internet search about it, and whether I was trying to defend against the unbearable notion that my patient might ever voluntarily miss one of our sessions.

    I hope you’re not telling the truth here, but I fear you are. This probably isn’t the most dysfunctional supervisor interaction not involving outright criminal behavior I’ve heard of, but it’s at least in the top 10.

    • Mary says:

      He generally changes details to conceal cases. So the basic principles are probably true.

      • Mary says:

        hmmmm. . . .

        One supposes one would have to be a colleague to start asking about the childhood trauma that leads every comment about a missing session to trigger a paranoid assumption that it was something the doctor did.

    • Winja says:

      Utterly infuriating.

  4. Azure says:

    This explains the couple therapists I’ve talked to who seemed to go out of their way to make me miserable and on-edge the whole time I’ve talked to them. I never understood /why/ and it almost felt like they were going out of their way to be nasty. I only had them briefly since I’m not going to put up with that nonsense from people, but I had never realized it was a Doctrine in the profession.

    I have a theory that the therapists who have listened to me talk and gave common sense advice were helpful precisely becaue I was paying $140 an hour so I was predisposed to follow their recommendations more. Also, not being my friends, I was more inclined to be open with them about some things I was otherwise embarrassed about.

    I wonder if the general love for AA is why Havenwyck uses a weird twelve-step program for mental illness, or if it’s just that, since they’re doing addiction treatment anyway, they may as well just throw the non-substance-abusing psychiatric patients in, too.

    • ADifferentAnonymous says:

      > I have a theory that the therapists who have listened to me talk and gave common sense advice were helpful precisely becaue I was paying $140 an hour so I was predisposed to follow their recommendations more.

      Compare to Robin Hanson’s theory of corporate consulting.

  5. Robert L says:

    Other things about AA:

    On the positive side, it often works and can be forgiven a lot for that.

    On the negative, it notably tries to extend its reach beyond its natural constituency, which consists of actual drunks and former drunks in danger of a relapse. In particular, if you live with a drunk, if you tolerate the drunkenness you are an enabler and a co-dependent, but if you try to do something about it you get an AA mantra about how you can neither cause nor cure it (or something). If you are a drunk and stop drinking, then unless you continue to attend AA meetings for the rest of your life you are a dry drunk. And it has no mechanism for turning away people who come along because they occasionally drink almost a whole bottle of wine in one day and who obviously have major problems which they have completely misdiagnosed as alcoholism.

    • wintermute92 says:

      On the negative, it notably tries to extend its reach beyond its natural constituency, which consists of actual drunks and former drunks in danger of a relapse.

      This is my main problem with AA and American alcohol discussions in general. Alcoholism-as-disease is a dependency pattern that has to be treated at the consumption level. People-pushed-into-AA covers not just dependency, but frat brothers who party too often, people drinking to deal with bad situations, people drinking as self-medication for mental health issues, and people forced into treatment by the legal system. Trying to cover all of those people with the same treatment plan is basically hopeless.

    • Walter says:

      AA is a thing that HAS to exist, just because of how certain accusations work.

      “You are an alcoholic!”
      “No I’m not!”
      “See! Denial, obvious sign!”
      “I swear I’m not”
      “You sound just like the bad guys on tv.”
      “Shit, I do.”

      When there’s an accusation that can’t be refuted, there needs to be a way to surrender. Rehab, AA, sensitivity training, whatever. Organizations based around this niche will thrive.

      • Spookykou says:

        I am not sure I follow.

        AA is a thing that HAS to exist

        Rehab, AA, sensitivity training, whatever.

        You seem to be contradicting yourself here.

        Also, I don’t really agree with even the weak version of your position, that something like AA is born out of a need for people to surrender to accusations of being an alcoholic.

        Why do people go to AA?

        I can’t imagine the situation you present above actually results in someone going to AA very often.

        Forced: Court ordered.

        Coerced: Ultimatum(go to AA or i’m taking the kids and going to my mothers)

        Voluntary: I’ve hit rock bottom.

        The accusation structure you are presenting would only be relevant in the second case. However if the need to resolve these interpersonal ultimatums could create whole industries as large as the Rehab industry, I might expect some room on the margins for ‘cleaning up after yourself’ camps, and ‘doing the dishes’ seminars to fill this supposed niche.

        Of course maybe those things already exist in some significant way and I am just ignorant of them?

  6. Deiseach says:

    Going solely off what is in this review, perhaps what Dr Shem was objecting to was how patients were being sacrificed to theory – the objective was supposed to be to help the patient get better, for whatever value of “better” that was, but instead everyone had their pet theory and the patients were being forced to conform to that, regardless of what affect it had on them in reality.

    And if the theory was causing them harm, that was not recognised, that was re-interpreted to fit with what the theory said. So instead of helping people, they were harming people, and thinking that they were doing what was right.

    The part about the risk training is blackly humorous because it is so like what came in with child protection in the wake of child abuse cases: in no instance can or should you ever touch a child unless completely necessary and never be alone with a child, etc. You need police vetting if you’re working in any place where there are children/vulnerable adults; I’m purely clerical support staff and I’ve had to get it. I’m very dubious about the actual efficacy of this, but it’s “something has to be done and seen to be done”.

    And to do some justice to Dr Heiler and his “cruel to be kind” school of therapy, in some cases that is necessary. I know that if I got a counsellor who was all sympathy and niceness and “there, there” to me, it would do me no good at all. I only ever make changes when absolutely forced to, and fear is one of the few motivations that work on me. Somebody who will challenge me, make me change, and be harsh if I don’t follow up with the agreed plan is the only therapist who would work.

    • carvenvisage says:

      Somebody who will challenge me, make me change, and be harsh if I don’t follow up with the agreed plan is the only therapist who would work.

      In terms of professionals, I think that’s more the purview of ‘personal trainers’ and ‘lifecoaches’. Doesn’t square with the word ‘therapist’ at all, in my mind.

    • So, in Ireland, nightclub bouncers have to be approved by the National Vetting Bureau?

      • Deiseach says:

        It would seem so. I have no idea why that would be, unless it was expanded to cover cases of “we really don’t want somebody six foot six, eighteen stone, covered in tattoos and who has done a stretch in the Joy for assault and battery working as a bouncer where it’s fairly likely they’ll get drunk punters taking a swing at them and yelling personal abuse on a regular basis. We can cope with the tattoos and looking like a shaved gorilla, but a conviction for bodily harm is not the thing”.

  7. antimule says:

    Scott, what do you think about this interview with Jordan Peterson, an anti-SJW Canadian professor of psychology? He talks a lot both about the origins of SJW and problems of psychology:

    https://www.youtube.com/watch?v=04wyGK6k6HE

    • Viliam says:

      Should Scott really watch three hours of video just to reply on a blog comment? I hope there is a shorter version. Or a transcript.

      • antimule says:

        Well, I thought this might be relevant to his interest. The guy is the highest rating academic (from Harvard) so far to speak against SJW and he also talks about it from psychological POV.

  8. HeelBearCub says:

    On the linked AA effectiveness review, I note that Scott seems to make no note of how the “brief intervention” study identified people who were “alcoholic” and it seems like a very large confounder.

    Second, assuming that these are actually people for whom alcohol is actually causing problems more than just the physical ones that come with excess alcohol consumption, then I really wonder how many of the people in the Brief Intervention category then went off and joined AA. This is not mentioned and seems like a big problem for reaching the conclusions that are tentatively reached.

    Scott mentions a “brief intervention” on smoking cessation that he does. Does he think these people (who do quit) then go out and quit cold turkey? Or does he assume that there will be a range of possible responses? And that some/many of them will try, say, nicotine gum? In other words, we don’t know what further actions would have led to any successful smoking cessation, so we definitely wouldn’t be able to conclude how effective the brief intervention was vs. nicotine gum. And we definitely, definitely wouldn’t conclude that we could eliminate nicotine gum as a treatment option and have as good a results with an hour talk on how to stop smoking.

    • AnonEEmous says:

      “On the linked AA effectiveness review, I note that Scott seems to make no note of how the “brief intervention” study identified people who were “alcoholic” and it seems like a very large confounder.”

      I don’t doubt that this could be true, but how? Is it a self-identifying thing? I went and read that entire post and I couldn’t figure it out.

  9. yossarian says:

    Another bit of personal anecdata to study – in the past, I’ve had somewhat severe problems with depression, alcoholism and so on, after a bitter divorce, job loss and such. I’ve gone to a psychiatrist (a very nice one, too), got anti-depressants and the rest of the nice stuff one usually gets in that sort of situation. But, seriously, if I could go back in time and pass a message to myself, it wouldn’t be “go to a psychiatrist”, it would be something like “dude, forget what your degree was in, you’ve spent 3 (paid) years coding in C++ in Linux, read this book about SQL and databases and this book about algorithms and go knock on the doors of every IT company nearby, you’ll make it as a junior programmer (’cause many actual CS graduates haven’t done as much as you have), and everything will be fine.” Sometimes you do just need someone who can give you a good life advice, not someone who would analyze whether you’ve ever wanted to suck your father’s penis.

    • Walter says:

      I have a pet theory that you could get a lot of the benefit of therapists by just buying a ps4 for every patient who walks in. Lots of people are just lonely, and just need something to do with their time.

  10. mbeaver says:

    Thanks for this piece. I appreciate how you struggle with offering something of actual value to your patients. A friend of mine who has issues that could perhaps be treated by non-md therapists will only see psychiatrists because he respects their medical background and this has worked well for him. I hope that you continue to be faithful to your questions as you join a system that makes it hard to be uncertain.

  11. Mary says:

    It’s weird to accuse someone of writing a cheap knockoff of their own book

    What’s weird about that? It is notorious that books in a series tend to degenerate after some time, and that after that point the later books start to read like pallid imitations of the earlier books. Like someone who had read the first books but couldn’t understand what made them click.

  12. scriptifaber says:

    This is an amazing review, in the literal, old-fashioned meaning of the word. I am rather horrified of the stories Scott highlighted, which show professionals whose purpose is to aid and help people, instead harming them, in some cases irreparably. And society pay lots of money for their services rendered, the damage inflicted! My visceral reaction is to call for an immediate halt to this sort of behavior, anywhere.

    My more tempered internal dialogue counters that this reaction would be akin to throwing the baby out with the bathwater; that surely psychiatry does help many people, and while some few are hurt, more do receive the results they sought. The end result is another piece of evidence for my opinion that the medical establishment is dangerous to most people. A hospital is the most dangerous place in a city. Amusingly, I still retain my faith in pharmacology; I trust big-pharma to know what their medication does, but not the doctors or psychiatrists who might prescribe them. I wonder if this is the opinion Scott intended to cultivate in his audience.

    • Walter says:

      Well, say this for psychiatry, it isn’t OBVIOUSLY harmful to the extent that people stop going. Like, it is mostly voluntary, yeah? People who go…tend to go back? So classify seeing a shrink as “weird stuff other people get up to but it’s their free choice so I can’t hassle them about it”?

      • carvenvisage says:

        Well, say this for psychiatry, it isn’t OBVIOUSLY harmful to the extent that people stop going.

        Like scientology

        • Spookykou says:

          I always thought that cults had certain commonalities about them that contribute at least in part to the nominally irrational behavior of being in a cult, I am not sure that they make a particularly strong general case for people being irrational. Unless you think psychiatry and or therapy have some things in common with cults that would promote such behavior?

          • Linvega says:

            I’m not the guy you were commenting on, but I’d say that *bad* therapy/psychiatry definitely has mechanics to keep the people coming similar to cults. If you read about all the atrocious therapy styles that have existed at one point or another, you often see how they have some things in common: Not only do they make the victim just as or even more miserable than before, they always purely blame the victim for its problems and tell it the only way out is to continue to follow the therapy.

            It’s already shown in this post from scott: If people point out they got worse, then they’re told they just have to stay put and they’ll get better eventually, or that being worse is actually better somehow.
            If people disagree or do anything that therapist doesn’t like, it’s analyzed until the therapist ends up at some kind of personal flaw he can point out, and the only way to battle that flaw is to … follow the therapy, of course!
            This is even done when the therapists does something clearly wrong and gets critized for it, like the rape example: Obviously, the patient had some mental reason for it that needs to be therapied!
            All these techniques are also used by the gurus/followers of cults to keep people inside and to shield the cult from criticism.

            In psychiatry, the classic example is people who have been slightly disfunctional before getting so over-drugged that they become completely non-functional… which obviously necessitates them staying in the psychiatry. Even this has similarities to cults, which often use drugs to keep people complacent.

            In general, imo the biggest problem of any kind of mental health institution is separating the people who actually have some interest in helping the patients from those who are more interested in power over/extorting money from helpless victims or, to a lesser degree, who want to prove their pet theory at any cost, etc. . Again, these three motives are also very common in gurus of cults.

          • Spookykou says:

            This is interesting and depressing. This morning I listened to a rather sad story about the relatively recent abuse of cognitively challenged laborers by a company based out of Texas which seemed thematically similar to what you are talking about here.

            I have always assumed that one of the bigger issues with conspiracy theories is that they rely on the complicit behavior of too many nominally good people, yet this example/story seems to call that belief into doubt.

            I don’t want to believe!

          • Moon says:

            “In general, imo the biggest problem of any kind of mental health institution is separating the people who actually have some interest in helping the patients from those who are more interested in power over/extorting money from helpless victims or, to a lesser degree, who want to prove their pet theory at any cost, etc. . Again, these three motives are also very common in gurus of cults.”

            People often need to shop around for a good therapist. Sometimes one has a friend who was helped to make positive changes by a particular therapist. There are lousy therapists and good ones. But if people don’t shop around, they may never realize that.

          • carvenvisage says:

            Yes I do but I intended to comment primarily on the form of the argument:

            There are lot of things which are harmful but which people find it diffuclt to walk away from. Food, alcohol, drugs, Abusive spouses, team fortress 2, working, not working, not eating.

            And especially for someone who is -speaking imprecisely-, ’emotionally vulnerable’, almost anything can become something which a person will continue to lean on, just because they happen to be leaning on it right now, not because it’s a healthy support.

            ‘well people don’t seem to stop’ is not just an argument in favour of most things which are bad for you in an insiduous way.

            Which is one of the two main ways people who are against psychiatry say that it goes wrong, (the other being that it’s undignified or obviously ridiculous).

            So while I do think psychiatry is a bit cult like, the more fundamental point is that ‘whether psychiatry is (always/generally/often) unhealthy in an insiduous way’, is one of the main questions in question here.

          • AcademicianZex says:

            Linvega above is talking about psychiatry, but nearly everything there is very applicable to AA, particularly in refusing to notice that the “patient” is getting worse, attributing every success to the program, and presenting every failure of the program as personal moral failing.

  13. Placid Platypus says:

    Living on the object level is really good. That’s where all the problems are and generally where the solutions are. It’s a natural, healthy place to live.

    This was a somewhat surprising couple sentences to find in an SSC post.

  14. moridinamael says:

    This isn’t the first time you’ve mentioned that somehow nobody ever taught you how to do psychoanalysis, but you’re still expected to practice it. This causes me to imagine a hypothetical world where engineering lectures are purely theoretical with few worked-out practical examples; engineering homework is all reading assignments with no problems to be worked out and graded; and tests are all essay-form with no numbers. Academic understanding of engineering would be purely theoretical and you would have no idea where the holes in your practical understanding were located. Obviously in that world, engineering would be a thing that you learned practically nothing about until you got your first job, which seems to be what psychoanalysis looks like.

    Luckily for engineers, it’s fairly easy to construct artificial homework problems and examples that have clear solution methods and correct answers. In psychoanalysis, and psychiatry in general, if you want to be rigorous, you’re limited to using case studies of psychiatric interventions that actually worked in real humans in the past, and even then, you can’t prove that something else wouldn’t have worked. There is nothing like the ease of constructing artificial problems to use in training intuitive skills found in the science and engineering disiplines.

    Perhaps I’m saying very banal, obvious things, but if so, that’s just an expression of the degree of my disbelief that people even expect this system to work effectively.

    • Viliam says:

      Imagine that a software engineering lecture would go like this:

      > Today, let’s talk about Facebook. Facebook is an important example of a successful software engineering. Facebook was launched in 2004 by Mark Zuckerberg. Mark Zuckerberg was born in 1984 in White Plains, New York, USA…

      …and so on, 90 minutes of random trivia about Facebook and Zuckerberg’s life, without ever mentioning any technical issue. The next lesson would be in the same style, about Google; then Microsoft, Apple, etc.

      At the end you are declared an expert software engineer, because you know tons of trivia about more internet companies than most people even heard about. Without having ever written a line of code, but that’s considered okay, because you are supposed to learn it by getting a job, sitting at a computer and pressing random keys, observed by a supervisor who learned software engineering the same way you did, only 20 years ago. He or she might give you some good advice, such as not to press Ctrl+Alt+Del too often, because overusing this powerful tool seems to have negative side effects in long run.

      Predictably, your computer usually doesn’t do what you want it to do. But that’s considered acceptable, because everyone knows that computers are really really complex, and it is reasonable to spend a few years before getting them print “Hello World” correctly. — Okay, once in a decade a genius is born, who can write “Hello World” in a few weeks. You know these people’s names, you learned about them at school, and you worship them properly. But it would be crazy to expect to become one of them.

      …that’s how many of my psychology lessons felt like…

      Like, seriously. I knew hundreds of details about Freud’s life: when and where he was born, where he lived, and whether he had a pet (sorry, it’s a few years, I forgot since then). Yet, most of my classmates couldn’t give a specific example of what e.g. “reaction formation” was. But it was important to be familiar with the idiom, and to attribute it to Freud.

      (To be clear, I am not trying to make a point about whether Freud’s theories were good or bad. I am trying to make a point that people who learned about Freud’s theories, actually didn’t even learn what those theories were. They just learned the keywords, and the year when Freud was born. And it was similar for Jung, or Maslow, or Rogers, or Skinner, or other celebrities.)

      Some of these things seemed like they would be trivial to fix. I mean, what would be difficult about writing 5 cartoonishly simple stories, and letting people fill in which one of them is “reaction formation”, which one is “transference” or “counter-transference” or “denial” or “sublimation”? It could be done in 10 minutes. It’s just… probably no one ever realized that something like that actually could be useful. That there is such a thing as fake understanding, guessing the teacher’s password etc.

      Maybe just my school was exceptionally crappy, though.

      More generally, I suspect that this is a good heuristics for when people are teaching stuff they don’t really understand — they talk less about technical details, and more about trivia. Like, when someone starts teaching you which year 486 processor was invented, don’t walk away, run! It’s not that there is something intrinsically wrong with the fact, it’s just that there is something very suspicious about a person who chooses to focus on this fact, as oppposed to… thousands of more important things. Chances are, the person doesn’t really know about those more important things.

  15. bbeck310 says:

    “Someone says “My mom just died”, and you say “I’m sorry for your loss” and let them talk about their memories of their mother? Anyone can do that! Why did they get borderline-tortured throughout their twenties and thirties getting a really prestigious psychiatry degree if they were just going to say “I’m sorry your mom died”? Being able to relate it all to wanting to suck your dad’s penis at least gives them some credibility for all their erudite Freud-knowledge and justifies their $200-an-hour fees. “I’m sorry for your loss” isn’t exactly $200-an-hour level insight.”

    But if the patient’s only problem is “my mom just died and I’m grieving,” they probably shouldn’t be seeing a psychiatrist! Most other professions find it unethical to take clients who don’t actually need their services; for example, I’m an IP litigator, and when someone came to me the other day wanting to sue Yahoo because some twerp was lying about his trademark on a forum, my advice wasn’t “OK, let’s go to court,” it was “Here’s a link to Yahoo’s form for requesting a takedown based on trademark infringement, no need to pay me.”

    And for people with real problems handling life for reasons not adequately explained by the human condition, medication and CBT seem to offer somewhat effective treatments not available through talking to a friend.

    Though my therapist (firmly on the CBT & meditation side of the profession) once explained to me that a lot of people, especially men, simply didn’t have a friend to confide in and release pressure, or at least a friend they felt safe talking to freely, and a therapist can end up being quite useful as effectively a paid friend. And that matched my experience pretty well.

    • Deiseach says:

      Though my therapist (firmly on the CBT & meditation side of the profession) once explained to me that a lot of people, especially men, simply didn’t have a friend to confide in and release pressure, or at least a friend they felt safe talking to freely, and a therapist can end up being quite useful as effectively a paid friend.

      Which is why it doesn’t work for me. You tell a friend you feel bad about something, all they can say is “Wow, that sucks, sorry for your troubles”. A therapist who responds “That must have made you feel bad?” to something – what good is that, when it’s twenty years or more in the past? If I want to relieve pressure by venting, I can do that at home by talking to myself about how ill-used I was and indulging in self-pity. It happened, it’s done, people expressing sympathy or support (even genuine sympathy and not “you’re paying me to listen to this”) are not going to change what happened.

      Unless, I guess, the therapist says “You’re stuck on this, move on, it’s twenty years ago and it’s the unchangeable past, stop obsessing about it” 🙂

      • bbeck310 says:

        Well, that’s where the CBT comes in–sometimes you need someone to rant to about the unfairness of the world, and sometimes that goes too far and a good therapist can help you work on techniques for moving past that. Presumably a useful part of training for therapists is learning how to tell the difference between “normal response to bad stuff” and “abnormal response requiring new tricks.”

    • onyomi says:

      Isn’t there an extent to which thinking you should see a therapist is proof enough that you ought to see a therapist? (Not that you have to be crazy to think you should see a therapist, but that, if you’re experiencing enough psychological unease that you think you need professional help, then that unease is itself the proof you might benefit from it).

      • Moon says:

        That’s the way the profession of psychotherapist is structured. The person decides whether they need/want help with their issues. If they think they do, they call and make an appointment. Sometimes their family doctor or someone else may suggest it, but it is still up to the prospective patient to decide if they want it.

        Some people don’t go to psychotherapy unless they feel like they are in a huge crisis. Others go for personal growth purposes. Just to grow and expand their psychological, professional, social etc. skills and horizons.

  16. AnonEEmous says:

    this is plainly obvious and thus I don’t like to say it

    but the story about your supervisor’s reaction to your patient’s missed flight, and other similar reactions in the field, sound like stuff you read in catch-22. In fact I’m pretty sure it is, actually, mined for humor in catch-22. How is it reflective of reality? This seems intensely cancerous, even if it happens to produce good results in some cases.

    • pneumatik says:

      I have no experience with psychiatry but I don’t find this behavior surprising at all. If anything good comes from the rationality movement it’s that a few more people will be able to detect this terrible terrible behavior of believing things that no only have very limited support but actually have plenty of evidence that they don’t work or produce results that are opposite of what’s intended.

  17. wintermute92 says:

    Charles Duhigg praises Alcoholics Anonymous with similar fervor, and given my respect for his work I expected it to have uncommon success rates. I was pretty surprised when that didn’t pan out at all.

    On further consideration, I think the “great for one specific class of alcoholics” thing makes a lot of sense. Duhigg praised AA for breaking the “want to drink, have a drink” habit loop, and replacing it with a healthier “want to drink, get social support for not drinking” loop.

    That seems to be really effective for some people, who love the program for being exactly the cure they needed. These people seem to find that AA not only helped them quit drinking, it reshaped their entire relationship to drinking and themselves.

    That pattern also seems near-useless for people drinking too heavily on other grounds. Someone who goes home from a shitty job to a shitty marriage, and drinks because they’re bitterly depressed, is unlikely to turn their life around by not drinking. “Believe you don’t need alcohol” isn’t going to stop them from being miserable all the time, and so they need to break their habit loop one step above what AA deals with (at “be sad, want to escape” rather than “want to escape, drink”).

    I also suspect that AA’s focus on rock-bottom produces some extra fanaticism. People paying for fancy outpatient detox while they continue to work high-powered jobs might get well at equal rates, but have much less dramatic redemption stories than people likely to end up in AA.

    • HeelBearCub says:

      As near as I can tell, there are zero “good” treatments for alcoholism. AA has the benefit of at least being essentially free, other than your time.

      Given that, there will be a subset of people who really do hit rock-bottom (whatever that is for them). And then they may finally turn to AA and get help from it.

      Given the absence of any sort of other treatment that would turn a heavy “problem” drinker into a non-drinker or a light-social drinker, what else would we have people who have been helped via AA do?

      I think so often it is very misunderstood that AA itself never engages in promotion. They take no stance on any issues outside of AA. They simply accept “everyone” at there meetings who comes. Arguably any mandated attendance at an AA meeting is contrary to the spirit of AA, but if a court requires you to go to AA, they won’t kick you out.

      Now, there are certainly individuals who have promoted AA, but that isn’t the AA organization itself.

      As to the person who goes home every day from a shitty job to a shitty marriage and is depressed, being an alcoholic isn’t going to do any good for that person, and will also prevent them from doing anything to get out of or make better the job/marriage/depression.

      • Loquat says:

        Have you ever heard of the Sinclair method? One takes naltrexone prior to drinking, and it suppresses the reward the drinker would otherwise experience. Repeated enough times, it gradually trains the brain to stop associating alcohol with intense pleasure, thus reducing cravings.

        My husband tried AA multiple times and it never worked for him, but with naltrexone he’s been quite successful at cutting his alcohol consumption to “social drinker” levels, and he would heartily recommend it to any other alcoholic who needs a hand.

        • HeelBearCub says:

          I’ve seen the Sinclair method mentioned.

          It seems like if it actually worked very well (as in, using the Sinclair method had positive outcomes for a large percentage of patients) that this would have shown up in the literature review.

          This obviously doesn’t mean that it didn’t work for your husband. Just that “working for your husband” is only a single point of data.

          • Loquat says:

            Well, the clinics Sinclair founded in Finland claim about a 75% success rate, with success defined as reducing alcohol consumption to a “safe” level, and former actress/recovered alcoholic Claudia Christian has several more points of data she’d like to share. I can’t speak for the literature review, but I see enough n=1 success stories to think it should at least be offered to any alcoholic who wants to change and can’t or doesn’t want to go cold turkey.

          • Loquat says:

            My first reply seems to have been eaten, so no links this time.

            Former Babylon 5 actress and recovered alcoholic Claudia Christian would like to share several more points of data via her foundation’s website, C Three Foundation dot org. If you go to About the Sinclair Method > Explore the Science, they’ve got links to some peer-reviewed papers about the effectiveness of naltrexone, and of course the site has plenty of testimonials as well

          • HeelBearCub says:

            When I do a google search for c three foundation I only get links to c three foundation websites (and lots of different ones). That seems like a bad sign.

            In any case the Wikipedia article on Naltrexone says this:

            A naltrexone treatment study by Anton et al., released by the National Institutes of Health in February 2008 and published in the Archives of General Psychiatry, has shown that alcoholics having a certain variant of the opioid receptor gene (G polymorphism of SNP Rs1799971 in the gene OPRM1), known as Asp40, demonstrated strong response to naltrexone and were far more likely to experience success at cutting back or discontinuing their alcohol intake altogether, while for those lacking the gene variant, naltrexone appeared to be no different from placebo.

            So naltrexone might work for some people, but for the large majority it would seem it does nothing.

          • Loquat says:

            What? C Three Foundation is their name and with a .org it’s their web address, “links to c three foundation websites” is exactly what you should get. I tried googling, and got that, plus: C Three Europe which is their European partner, a reference to them on LinkedIn, and ClaudiaChristian.net which, being the founder’s own website, not surprisingly has information about her foundation.

            Anyway, let me try links again and see if it gets through: this is one of the studies linked from their website, and ends with

            Thus, the results of the COMBINE study demonstrated that a pharmacotherapy, like naltrexone, when given with medical counseling that emphasizes taking medications as prescribed, can yield clinically significant outcomes (reduced drinking/increased abstinence) that are either as compelling, and under some conditions, more compelling than those observed with specialty behavioral therapy. One important implication of the COMBINE results is that naltrexone with MM [medical management, aka doctor’s oversight] can be delivered in healthcare settings where traditional specialty treatment is unavailable. Receiving treatment directly from their primary healthcare provider could greatly expand treatment options for persons with an alcohol disorder.

    • Walter says:

      I feel like a lot of ‘alcoholics’ (scare quotes to differentiate them from other alcoholics who have other stuff going on), are people who fall into the (want to drink, have a drink) lap when they are bored. The miracle of AA is that it breaks the loop in a way that gives them something else to do.

      What I mean is:

      A: I want a drink SO
      B: I resist taking a drink SO
      C: I’m thinking about taking a drink SO
      D: go to A

      Only way this loop breaks is when I take a drink.

      But with AA
      A: I want a drink SO
      B: I call my sponsor, SO
      C: We talk about football.

      The cycle is broken.

      AA probably works miracles for people who are trapped in this pattern, but this isn’t all alcoholics. For the rest of them the AA program might not help.

      No proof of this, natch, just a thing I’m thinking.

      • AnonEEmous says:

        which suggests a really positive and heart-warming idea that we may need to find a way to fit the approach to the person and can derive heavy benefits from doing so.

        this post i suppose doubles as a call to do that, but i’m not the right person to do this at all so gg on my end

  18. Thorium says:

    So what’s the deal with “borderline”? What goes wrong if you try to be nice to “borderline” people?

  19. jooyous says:

    I feel like, as a general rule, the things you need a professional to do are things they’re going to do on YOUR time. So, sure, you could have had a friend listen to your problems, but if you’re in the middle of a crisis, all your friends might be busy and/or having problems of their own. And, like, if you’re acutely suicidal, your friends might not realize, for example? Or not know what to do. And it kinda isn’t their job to. So you pay a professional and set up an appointment to which they’re going to show up AND put their problems aside for yours.

    So, I guess, my point is: while I understand feeling like you need to justify your professional status and taking $$ for something that a friend could do, I think the $$ payment is actual justified by the structure of the professional visit and not necessarily by the … internal … contents.

    This argument applies to paying for sex also.

    • bbeck310 says:

      Also, if your friends and family are involved, you can’t go to them that easily. Who do I share most of my problems with? My wife or my mom. Who do I talk to when my wife, mom, and sister are fighting and it’s stressing me out? The professional I pay to keep everything I say confidential 🙂

    • FullMeta_Rationalist says:

      I noticed a while ago that psychiatry sounds awfully similar to hostessing. Placebomancy works in mysterious ways.

  20. carvenvisage says:

    Is the dad’s penis illustration necessarry?

    Serious question- can you get across the idea of sick bizarre shit (or whatever the idea more specifically is) without actually having me read sick bizarre shit? (that I’m somewhat but not totally desensitized to, and which others may not be at all) If so I think it would objectively improve the article.

    Please feel free to delete or edit my comment.

    • baconbacon says:

      @ Scott,

      I think this is what TLP is talking about when it comes to narcissism.

      • Scott Alexander says:

        Totally confused by this comment.

        • baconbacon says:

          TLP’s writing on narcissism is largely about how individuals twist their responses and expectations around their own importance. This is an example.

          Is the dad’s penis illustration necessarry?

          Totally reasonable response, he read something that got to him and mentioned it.

          Serious question- can you get across the idea of sick bizarre shit (or whatever the idea more specifically is) without actually having me read sick bizarre shit?

          Tone is a little aggressive, no one actually made him read your writing, but it upset him so a strong reaction isn’t unusual.

          (that I’m somewhat but not totally desensitized to, and which others may not be at all)

          Bolsters his statement by including others who feel the same or worse reading this.

          and then

          If so I think it would objectively improve the article.

          A big leap it suddenly goes from “I didn’t like this” to “your writing would be objectively better if you catered it to my tastes”.

          • FullMeta_Rationalist says:

            I was confused too. Because another interpretation was that Scott was the narcissist for not including a trigger warning.

          • baconbacon says:

            I guess I am the narcissist because I didn’t even consider that as an option when I replied.

          • Viliam says:

            Not that it matters, but to me the baconbacon’s comment seemed quite obvious.

            I disagree with it on factual level, because I think a narcissist would be unlikely to add “please feel free to delete or edit my comment” (specifically the “please” and “or edit” parts); but the previous paragraph resonated with what I remember from TLP.

            I guess we probably shouldn’t make too large conclusions from three lines of text.

          • baconbacon says:

            I disagree with it on factual level, because I think a narcissist would be unlikely to add “please feel free to delete or edit my comment” (specifically the “please” and “or edit” parts); but the previous paragraph resonated with what I remember from TLP.

            TLP would never have called a poster a narcissist based on a single quote like this, and I didn’t either*.

            What TLP emphasizes it that narcissists think about small things in distorted ways which emphasize their individual importance. “Does she like me?” vs “how can I make her like me?”, and eventually this type of thinking becomes habitual.

            *Almost any phrase can be indicative of a narcissist, because it is all in how he/she interprets the reaction. “you can delete this if you want” can be followed up by “it wasn’t deleted, my opinion is validated” or “it was delete, I must have struck a nerve”, but we can’t witness this and tell if it is true or false modesty when it was written.

          • carvenvisage says:

            ‘Sick bizarre shit’ is a delineation, not aggression. If you can find a more delicate and flowery way to describe it, I will apologise to Scott, and to your hurt feelings too if you’d like.

            And yes.. it may objectively improve an article if you can make the same point in a less unpleasant way.

            That is an objective statement. And I said that ‘I think’ it would, not just that it would, which you either deliberately, or in a fit of dishonesty (and/or narcissism), chose to obviate in your pretend translation. I’m not even going to get into how you compound this aggressive mischarecterisation by saying that I’m appealing to my tastes rather than e.g. good writing (which is implied in any reading with the least entry level smidgen of generosity or basic parsing ability).

             

            Like, did it even occur to you to consider the literal meaning of my statement, or did you just jump straight on board with your emotional reaction?

            And how else would you have me phrase it? It’s not like I can come out and literally ask, ‘have you consider the possibility that…’ because that will certainly be read as aggressive sarcasm rather than literally.

            And I’m not just going to assert that it’s the case either, so the compromise I came to, in the two seconds I spent thinking about phrasing, is to say that I thought, what I thought.

            And again, do you even have a better way? You really should, because you have all the time in the world to find a better way to put it than I offhandedly happened to, but I don’t think you even do.

             

            What’s funny is that your comment is a totally feelings based and projected interpretation, as well as overanalysis, of my literal and direct 30 second comment, -which may have less less than perfect phrasing.

            And yet here you are accusing other people of narcissism. It’s hard to believe.

          • FullMeta_Rationalist says:

            The accusation of narcissism stems solely from your use of the word “objectively”. Tastes are subjective, even if popular. E.g. some people like shock-value. Some people dislike euphemism.

    • Serious question- can you get across the idea of sick bizarre shit (or whatever the idea more specifically is) without actually having me read sick bizarre shit?

      In my experience, this is the way mental health professionals habitually talk to each other, and even to friends and family, using words and examples that might shock outsiders.

      I assume it’s not unique to the field, just a byproduct of constant exposure to how horrible many people’s lives are. Probably among police officers and ambulance drivers, casual references to gruesome auto-crash carnage are just as prevalent.

    • Scott Alexander says:

      The example is taken from the book and I think gets across how bizarre some of these techniques are.

      • carvenvisage says:

        Yeah it definitely gets it across. The question was where it could be got across without using actual ‘sick bizarre shit’.

        That’s an entirely literal, serious question. -The answer could well be no. I’m neither as good a writer as you nor literally you yourself so I wouldn’t know, but it wasn’t a rhetorical question.

    • Callum G says:

      It’s a reference to Freudian Theory which was the birth of psychoanalysis. I suppose the Electra complex was more the daughter developing penis envy of her father, not exactly wanting to perform fellatio. Either way the theory feels Freudian.

      The book has gross bits in it for a reason, it’s not just shock value. It’s real life history.

    • houseboatonstyxb says:

      In the multi-meta context Scott has explained, I think the shock value is the message. The narrator of Mount Misery wanted to shock; so did the author of MM; and so did Scott in quoting that phrase.

      For other purposes a writer might soften the shock effect with a euphemism. Or with a dysphemism (a slang or obscene term), or with a vulgar tone throughout the immediate context (or both) — which could act as a trigger warning, at least for some readers.

  21. Moon says:

    Some schools of psychotherapy that are not very evidence based or research based, are not that different from religion. You have a belief system. You believe it without evidence and/or you make up the evidence as you go along, in the way that you interpret events in your (or your patient’s) life within the framework of your belief system. And you are clueless as to how subjective this all is.

    Belief systems seem rational to people. But really they are just big security blankets, or life preservers, to satisfy one’s needs for emotional security, and for certainty. Through them, you know exactly the right or virtuous action to take in any situation. You know exactly how to be an expert in your profession, even if you just read your very first book about it.

    It’s an accident of history that the highest status psychotherapists are psychiatrists, in the current system. Although there are exceptions to the rule, the average psychologist or social worker usually knows more about how to do psychotherapy than the average psychiatrist does, for a number of reasons. These reasons include not suffering much from sleep deprivation during training, as psychiatrists do; not having most of their training be about medicine rather than psychology; and being more grounded and sensitive, on average, due to having lower status and less power.

    There are some advantages that psychiatrists do have though, such as knowing how to prescribe medications when needed, and being able to recognize it more easily when the supposed mental disorder is actually a physical disorder.

    Belief systems must be very necessary for humans, because they are everywhere, and some of them even successfully charge super high prices for entry.

    There is the rationalist belief system. Rationalists really think they are being logical and rational while they nit pick, cherry pick, lemon pick etc.

    There is the Right Wing ideological system so common on this board when politics comes up. To me this looks and feels exactly like a Right Wing Safe Space and echo chamber bubble. But to most participants on this board, who are Right Wing themselves, I am sure that the board appears to be rational and objective.

    It’s hard to see a belief system objectively, when you are inside of it.

    One giant overarching belief seems to be a belief in black/white thinking. And there is lots of that in our culture. E.g. if you think the job of psychotherapist has to never require an M.D. or always require one. If you have to always talk at the object level or always at the meta level. Or if you have to always piss off your patients, or always be nice to them. If you have to only be open to a patient and connect with them as a human vs. if you have to always be practically a robot in your dispensation of medication or advice or response to patient’s words with particular techniques.

    Some therapists, and patients, seem to be caught within such black/white frameworks. But psychotherapy is actually as large as human life, human needs, and the meanings humans give to their lives, and the traumas and other experiences that humans have and their effects. That’s why so many therapists run screaming and then look to find their certainty in rigid belief systems.

    And the great variety of things that different patients need mean that it can be difficult for a patient to find a good match in a therapist. If the therapist is all empathy, and you need direction or challenge—or vice versa—then you need to find someone who is a better match.

    Sometimes you can do this by phone by asking what kinds of interventions the therapist does to help their patients. And of course, some therapists can both challenge a patient and give empathy, as needed. But there is an interpersonal chemistry involved, where some therapist/patient duos are great matches, and others do not work at all.

    The same for therapy groups and support groups. AA is some people’s wonderful solution, and other people’s pointless exercise in futility, depending on their needs and also on the other personalities present in the group. Interestingly, some of the best AA groups contain people who have been through a lot of psychotherapy themselves.

    One psychology professor I once had, asked me “How can you be aware of what’s not there?” When he asked me, I didn’t know the answer, nor did he. But now I think I know. You are aware of what’s not there, from experience– your own, your patients’ experiences, the experiences of the people around you. You can tell what is missing when things aren’t going well for a patient, by observing what is present when things ARE working well for people in their lives.

    Cognitive distortions come into play in schools of psychotherapy, as in much of life. There are interesting books written about cognitive distortions, like

    You Are Not So Smart: Why You Have Too Many Friends on Facebook, Why Your Memory Is Mostly Fiction, an d 46 Other Ways You’re Deluding Yourself Paperback – November 6, 2012
    by David McRaney

    https://www.amazon.com/You-Are-Not-So-Smart/dp/1592407366/ref=sr_1_2?s=books&ie=UTF8&qid=1483029059&sr=1-2&keywords=you+are+now+less+dumb

    You are Now Less Dumb: How to Conquer Mob Mentality, How to Buy Happiness, and All the Other Ways to Outsmart Yourself Paperback – August 5, 2014
    by David McRaney

    https://www.amazon.com/You-are-Now-Less-Dumb/dp/1592408796/ref=sr_1_1?s=books&ie=UTF8&qid=1483029059&sr=1-1&keywords=you+are+now+less+dumb

    One of the distortions covered in this latter book here is deindividuation, through which, despite our best intentions, we pretty much disappear when subsumed by a mob mentality.

    People think of mobs as big angry crowds outdoors. But the group of people in one’s professional training program can be a sort of mob– and indeed is more powerful, for a longer time, over the individual than your typical mob. You can’t just walk away and go back home in an hour– not if you really want the degree or the professional license you are pursuing.

    Many schools of psychology are religion and are also power politics– due to the power that supervisors have over trainees, and the power that trainees and other therapists have over vulnerable and sick patients. To use power appropriately and for good, rather than for evil, or rather than for getting hopelessly lost with your power and not having any idea what the impact of your own behavior is, is a challenge that few humans seem to be capable of dealing with well.

    Not going along with the prevailing belief system can put one in a really bad position. So many people just chime in and go along to get along– patients, psychotherapist trainees, people whose families or friends or colleagues or favorite Internet board all lean the same way politically etc.

    My favorite book that I have read in a long time proposes an overall framework for therapists, parents, teachers, spouses, leaders of all kinds etc., in their work. I am seldom impressed by a book, but this one has some good points. The writer uses Bowen’s family systems therapy as the basis for his theories, explained here below in wikipedia. Although I do not believe every word of Bowen’s theory, I find much of it useful.

    https://en.wikipedia.org/wiki/Murray_Bowen

    The book I mentioned above, that is based on Bowen’s theory, is A Failure of Nerve: Leadership in the Age of the Quick Fix Paperback – February 1, 2007 by Edwin H. Friedman. The author is dead, but somehow a new edition of the book is coming out in May of this year, so there must be people thinking it is still relevant, and apparently editors adding something to it. I don’t agree with everything in the book, but do with a lot of it. Even where I disagree, it stimulates my thinking.

    https://www.amazon.com/Failure-Nerve-Leadership-Age-Quick/dp/159627042X/ref=sr_1_1?ie=UTF8&qid=1483030635&sr=8-1&keywords=A+Failure+of+Nerve

    From the summary on Amazaon: “he argues for strength and self-differentiation as the marks of true leadership. His formula for success is more maturity, not more data; stamina, not technique; and personal responsibility, not empathy.”

    That quote makes it sound more black/white than the book really is– and definitely more black/white than the way I apply what I learned from the book. But it does give you an idea of the areas of emphasis in the book. Anyway, I highly recommend it for psychotherapists, teachers, leaders and everyone who wants to be more aware of the impact of your behavior on others.

    • Spookykou says:

      Are all these books you are recommending not just more examples of

      You have a belief system. You believe it without evidence and/or you make up the evidence as you go along

      • Moon says:

        There is plenty of research evidence to show that cognitive distortions do exist.

        And the Failure of Nerve book is one I find to be useful, as a trained psychotherapist.

        So I guess you can have the opinion that Scott and I and all psychotherapists, whenever we do psychotherapy, just have a belief system, and we believe it without evidence and/or we make up the evidence as we go along.

        But I have had a lot of success helping people to get better as their psychotherapist. If you are a psychotherapist, you have to do something, and I do what has worked for people.

        • Moon says:

          Cognitive distortions article for people who are interested but who don’t want to read a whole book

          8 Common Thinking Mistakes Our Brains Make Every Day and How to Prevent Them
          https://blog.bufferapp.com/thinking-mistakes-8-common-mistakes-in-how-we-think-and-how-to-avoid-them

        • DrBeat says:

          You being a psychotherapist is frightening to me, because you constantly do this exact behavior the post you are replying to decries — fixating on one explanation and interpreting everything as evidence of that explanation, and nakedly asserting that anyone who disagrees with your explanation is too stupid and wrong to see the obvious truth.

          You are doing that exact thing. You are Scott’s supervisor who simply cannot accept that a patient might have actually missed a flight. You continually act as though your pet theory explains every single thing in your zone of perception and is conclusively proven — with no need of evidence — and anyone who disagrees is just refusing to see the obvious. You do this every single time you post. Every time. Every discussion you get involved in is you proclaiming that everything you see is because of Bad Right-Wing Stupid, and people telling you that isn’t true, and you responding that this proves how Bad Right-Wing Stupid they are because they can’t even see how right you are.

          You proclaim everyone is held in the thrall of biased thinking, and never show the capacity to stop and go “Wait, am I experiencing biased thinking as well?” I have never seen any evidence that you are capable of separating your beliefs from reality, or of entertaining the notion that not everything you believe must be automatically true.

          This is why people get so upset at you. Because you are so nakedly hypocritical and so consistently exhibit the flaws you accuse others of.

          • Moon says:

            Right of Center people do the things you describe me as doing, constantly on this board. What, so you folks can dish it out but you can’t take it?

            I am certainly not any more the way you describe than the average Right of Center person on this board.

            I know, a Left of Center person who stands up for themselves is automatically a target, in our polarized society– especially since so few Left of Center people do.

            I am a very good psychotherapist, but I am not your just listening non-confrontational type therapist. I have helped numerous people attain their goals in psychotherapy. But I am no doormat liberal, as most liberals are. And I am sure that none of my happy former patients are the least bit concerned about what some angry guy on the Internet thinks of me.

          • Deiseach says:

            I know, a Left of Center person who stands up for themselves is automatically a target, in our polarized society– especially since so few Left of Center people do.

            For once, I am going to agree with Moon. I wish left of centre people would stand up for themselves – not by ranting in futile anger about all the traitors and bigots who voted the wrong way, and not in the way that made me steam with anger myself when I came across it today.

            Somebody vaguely arty, I think a novelist, plainting and handwringing over what oh what can art do in the days we are now in (that is, post-election, with the Unmentionable being president-elect). What good is there now in any pursuit of the imagination when the dreadful things are going to happen? They had decided to engage in activism instead as some kind of feeble fighting back. But luckily a fellow-artist urged them to continue because of the vital necessity to keep the struggle alive and get the word out. And the self-pity and self-centredness just dripped and oozed out through the screen.

            And I wanted to slap them hard across the face and shake them until their teeth rattled and yell at them “Have you never heard of Primo Levi, you insufferable little toadstool? Do you think no-one has ever before questioned the power or use of art in the face of tragedy and horror? What on earth makes you think that your little crisis of egoism has any right to dare raise its head in the company of the great questions of this nature, when the worst thing you can complain of is while sitting at a café table and talking about how you’re donating to Planned Parenthood?”

            If they had as much resilience as a jellyfish, that would at least be something. But this marshmallow boo-hooing over an injury that has not yet happened, and then daring to compare their notions with the terrible questions that arose in the wake of the Second World War – Adorno’s agony that “Writing poetry after Auschwitz is barbaric” – no, not even to compare, the idea of comparison has not crossed their empty, narcissistic minds because they are all full of me me me!

            For the love of God, can you not at least take a lesson from La Pasionaria – “Better to die standing up than to live kneeling down!” – and at least get up on your hind legs and turn your face to the sky like a human being, instead of weeping and wailing over the prospect of somebody being mean to you in the near future?

          • Moon says:

            Oh, and if my behavior is so awful, but Right of Center people here are, by comparison, such beacons of fairness and light, then that must be why there are just as many liberals who feel comfortable commenting here as there are conservatives…….oh, wait.

          • Moon says:

            LOL, if only the Left were not full of me, me, me. If only we were like those altruistic Right of Center folks.

            So Diesach, it’s okay for Left of Center folks to stand up for ourselves– as long as we do it precisely in the way that you approve of?

            Well, at least your comment to me had some interesting stuff about artists, and was not 100% hostile like several here were, which I do appreciate. Thanks for that.

          • DrBeat says:

            You’re doing it again. You cannot stop doing it. You are not capable of seeing anything and not thinking “This happened because Bad Right-Wing Stupid”. You excuse your behavior by saying right-wingers do it (not nearly to the extent you do, you are really unusual in your naked hypocrisy), and then decry right-wingers for doing it, and then claim you never do it.

            Stop it. Stop it. Stop it. Stop it. Stop it. Stop it.

            Stop it.

            Stop fixating on how everything in your zone of perception is due to Bad Right-Wing Stupid.

            Stop fixating on how everything in your zone of perception proves Bad Right-Wing Stupid.

            Stop fixating on how everything in your zone of perception is the perfect opportunity to bring up Bad Right-Wing Stupid.

            Stop fixating on how everything you do is justified because Bad Right-Wing Stupid.

            Stop fixating on Bad Right-Wing Stupid.

            Stop blaming other people for your own behavior, regardless of political alignment.

          • lvlln says:

            DrBeat, taking as true your assertions about Moon (which seem 100% true to me), do you believe that telling her things like

            “Stop it. Stop it. Stop it. Stop it. Stop it. Stop it.

            Stop it.”

            is helping to change her behavior? Maybe it helps your internal state to vent like that, and that’s not nothing, but I suspect it’ll just cause more and more intensity of the same behavior that made you want to vent in the first place. Kinda reminds me of someone yelling “Murder all cis white men!”

          • Deiseach says:

            So Diesach, it’s okay for Left of Center folks to stand up for ourselves– as long as we do it precisely in the way that you approve of?

            Yes, and I agree that’s my bias, and that only shows that I am at least capable of passing for human since we all have biases 🙂

            Moon, I much prefer “Now God stand up for bastards!” than “Mommy, Mommy, there’s a scary monster in the wardrobe!” in an opponent – though I’d rather think “interlocutor” than “opponent”, it’s very few that I do actually want to get into a verbal fight with, as distinct from an argument.

            Part of why I like you is that, despite the fact you think this site is full of us right-wingers lying back in the snipe grass waiting to pounce on you, you come back and you come out swinging.

            I think I disagree with you on just about everything past “water is wet” and sometimes you do make it harder for yourself by putting it up from the start that you are going to be attacked before ever you get into the main body of your comment, but you’re still around rather than flouncing off in a huff or running off crying that the big boys and girls were mean to you. A lot of the left-leaning types online are much soggier than the sponge fingers I used for the Christmas trifle. The me me me person I was angry with was not someone likely to be suffering under the oppressive jackbooted regime, being a middle-class white woman of the chattering class (if you have the luxury of wondering should you continue writing, you are not relying on that as your main income source). Her concern was ostensibly on behalf of the minorities who would bear the brunt, but it was all about her and her self-importance (I very much doubt if she stopped writing this minute that it would make a straw’s worth of difference to the state of the nation).

            The most frustrating thing about your comments is that you do seem (and please, this is me saying “it seems to me”, not me saying “this is what you are“) to operate by “if we disagree on this point it is because Bad Right Wing”, not that someone might disagree with you because they came to a different conclusion by a different interpretation of the facts and this was in good faith, not out of kneejerk conservatism.

            I think (and again, this is “it seems to me”) that what is most frustrating for you is that the majority of us on here elevate reason over emotion, so if someone says “This makes me feel bad” (to take a very simplified version of it), most of us tend to respond “So what?” That sounds hard-hearted, but it arises out of “Can you construct a factual, reasonable argument that does not arise out of, or depend on, subjective emotional states for its rationale?” So it seems like we are ignoring what you are saying and nit-picking and cherry-picking and demanding impossible levels of rigour, when instead that’s the kind of detail-oriented, fussing over dotting the i’s and crossing the t’s that our mindset does.

            Often that approach is lacking, I have to admit. But it is the default of a lot of us on here (we wouldn’t be hanging around rationalism blogs if we didn’t have a large contingent falling somewhere on the autism scale) and we do often tend to react with unconscious hostility to emotionally-based appeals because it feels like an attempt to manipulate us in an area we have been found lacking in before or have bad experiences from (autism scale, not being good at reading people, not being good at understanding what is and is not deemed offensive, getting burned for this when we genuinely don’t understand what we said/did that was so bad, and in future responding defensively to emotional, rather than intellect-based, statements or arguments).

            tl; dr: most of us on here don’t mind the “you damn fool, here’s a bullet-list with links as to why your argument is a pile of horse manure” approach as long as the counter-argument is something solid we can get our teeth into and if it’s correct, we’ll say “yeah, I am a damn fool, you’re right”.

            Others stall at the first hurdle of “you called me a fool? where do you get the right to insult others?” and don’t see the argument as the most important thing, it is the perceived attack that occupies their attention so that is what they concentrate on in their reply, and of course to the first party that looks like “so you haven’t any facts to back you up, you’re evading the question and trying to turn this around on me”.

            We both should perhaps be more polite to each other.

          • FullMeta_Rationalist says:

            Moon doesn’t participate despite perceived conservative bias. Ze participates precisely because of the perceived conservative bias. Few things will change Moon’s behavior because victimhood and bravery are exactly ze wants. If Moon genuinely wanted to reduce hostility toward libs, there exist tactics which are far more productive than inciting a partizan flamewar over a book review about psychiatry.

          • Deiseach says:

            Moon doesn’t participate despite perceived conservative bias. Ze participates precisely because of the perceived conservative bias.

            To be fair to Moon, we do tend to jump at the bait when she dangles it in front of our noses. If we could ignore “but you’re all right-wingers waiting to dogpile on me”, then it’d be better for our collective blood pressures, and we wouldn’t dogpile on her (because five comments in a row about her doing what she always does is a dogpile, unfortunately. No, I haven’t counted exactly how many responded to her, I’m being rhetorical here).

            She feels that she is one of the few voices sticking up for liberal values, and that liberal/left voices are few and far between in the conservative/right dominated media landscape, society and culture as a whole, and online.

            Moon is very important as a representative of that point of view – if we’re castigating the press for not getting off their urban backsides and going out and talking to people in the rustbelt and elsewhere, so they would not have been blindsided by Trump’s victory, we should also be careful to hear the point of view from the other side, instead of going off abstractions of what we think they think (which is all too easy to do, after the umpteenth rage and tear-filled “white middleclass women betrayed Hillary!” opinion piece; then you start arguing with the Condensed Spirit of Such Thinkpieces, instead of real people expressing those views in their own particular interpretation).

            Moon has a voice that needs to be heard, even if we don’t agree with what she’s saying, because knowing what representative people who hold down responsible jobs and are not wandering the streets with placards are thinking and saying and believing on the left/liberal/Democrat/fill in your own blank side is very, very important if we are not to be simply talking past one another for the next four years of Trump’s administration.

            As I said, that writer’s post made me want to slap them silly for their presumptuous self-importance. I don’t want to slap Moon, even if sometimes I am reduced to “But good God, woman, how can you think this in the teeth of the evidence?” And as I said, I have to grant this to Moon – even if she thinks she is going to be used as a chewtoy, she comes back and sticks around. I think we had a couple of drive-by left-ish commenters who sniffed about the state of the place and how they were shaking the dust of it off their sandals, instead of hanging around and being willing to have a fist-fight* argue it out?

            *See Maureen O’Hara:

            Annoyed by both her co-star and director while filming The Quiet Man, she struck Wayne with great force in a fight scene.

            “I really went for it. But he saw it coming and put his hand up. My hand snapped off the top of his fingers, and I broke a bone in my wrist.” Wayne complained that she had almost broken his jaw, and she assured him that that had been her intention.

          • Aapje says:

            @Deiseach

            Moon has a voice that needs to be heard, even if we don’t agree with what she’s saying,

            My issue with Moon is not that I believe that her standpoint doesn’t deserve to be heard, but that she presents her argument extremely poorly.

            Basically, she never gets concrete in a way that can result in a decent discussion. It’s always extremely abstract stereotyping that is so obviously extremely simplistic compared to the truth or simply false, yet so vague that there is no way to address it without asking for specifics, which she doesn’t provide.

            Instead, she goes ‘aggressively victim’ at the slightest criticism, which just leads to a bunch of insults being lobbed at her opponents who then give up before long.

            Rinse & repeat. It never goes anywhere interesting.

          • Moon says:

            “Moon doesn’t participate despite perceived conservative bias. Ze participates precisely because of the perceived conservative bias. Few things will change Moon’s behavior because victimhood and bravery are exactly ze wants. If Moon genuinely wanted to reduce hostility toward libs, there exist tactics which are far more productive than inciting a partizan flamewar over a book review about psychiatry. ”

            Full Meta, marriage proposal rescinded due to your not being a rationalist after all, given your being unable to resist dog piling on. Thanks for telling me exactly why I do what I do. It would be more rational to ask me, rather than to tell me, why I do what I do.

            My primary goal in participating has not been to reduce hostility toward libs. It has been to tell the truth. I am indeed aware that no one wants to hear certain truths, and that the messenger is usually shot. You would be aware of that also, if you had any interest in telling the truth.

          • Moon says:

            I have so many people I ignore now that I can’t tell. But I imagine that your response was to another dogpiler, not to me, as you did not address me directly. I find it odd that you consider this “a partisan flame war”, as all this kind of situation usually is, is me making a comment and then tons of people dogpiling on to rage at me. One person making a comment, “partisan” or not, and a ton of people jumping onto them and trying to tear them to shreds is not a “war.” Perhaps you need to consult a dictionary.

          • baconbacon says:

            I find it odd that you consider this “a partisan flame war”, as all this kind of situation usually is, is me making a comment and then tons of people dogpiling on to rage at me

            TLP would say “the common theme in all your flame wars is you”

          • Moon says:

            Almost every liberal you meet, with the exception of a very few SJWs, is trying to reduce hostility toward libs. That’s what got Trump elected. Liberals being nice and kind and not wanting to offend people– whether Trumpsters or SJWs.

            Liberals silently put up with insults from Trump and others like him. Taking abuse and almost never dishing it back out in return. Being good door mats. I figure, as long as I am getting trampled on anyway, I may as well tell the truth. If I am going to be a door mat, at least I won’t be a silent one.

          • Moon says:

            “TLP would say “the common theme in all your flame wars is you”

            They are not wars. I am alone and others attack me for what I say. One individual vs. a mob. There is no one on my side but me. I am perhaps the only liberal here willing to call things as I see them. No one dares support or defend me, because they don’t want to be dog piled onto like I am. I can’t blame them for that.

            People don’t kill the messengers (plural) of bad news. Only the messenger (singular.) Seeing that person killed, no one else wants to take over and deliver the message, true though it may be.

            Life is interesting. Sometimes people will pay you well to tell them the truth. But try and tell it to them for free, and they may kill you if that truth is not fun and pleasant and comforting to them.

          • carvenvisage says:

            @DrBeat

            I partially agree with you, and you’re one of my absolute favorite posters here, (top 3ish) but I reported your stop stop stop stop stop stop x stop y stop z comment, for what are hopefully obvious reasons.

        • Spookykou says:

          So I guess you can have the opinion that Scott and I and all psychotherapists, whenever we do psychotherapy, just have a belief system, and we believe it without evidence and/or we make up the evidence as we go along.

          That is not what I am saying, that is what you are saying.

          Some schools of psychotherapy that are not very evidence based or research based, are not that different from religion. You have a belief system. You believe it without evidence and/or you make up the evidence as you go along, in the way that you interpret events in your (or your patient’s) life within the framework of your belief system. And you are clueless as to how subjective this all is.

          I am not aware of any form of psychotherapy as being really stand out in terms of the evidence based research supporting it in comparison to the other main stays of psychotherapy. Even the ‘anti scientific’ Freudian psychoanalysis actually performs comparably to CBT, etc. Your confidence that your particular brand of psychotherapy is uniquely true however, is, well you said it yourself,

          Belief systems seem rational to people. But really they are just big security blankets, or life preservers, to satisfy one’s needs for emotional security, and for certainty. Through them, you know exactly the right or virtuous action to take in any situation. You know exactly how to be an expert in your profession, even if you just read your very first book about it.

          • Moon says:

            If it works and people get better and attain their goals, then it works.

            Lots of people wanting to argue with me tonight and find various reasons to criticize me– just criticism, not any kind of real discussion. You’ll be on my list now of whom to ignore.

          • Spookykou says:

            If it works and people get better and attain their goals, then it works.

            I am not saying it doesn’t work, I think all forms of psychoanalysis work to some extent.

            I was just trying to call attention to the particular claim that any form of psychoanalysis as being objectively better than any other, which as far as I know, is not a claim supported by the evidence.

            I personally have been through CBT and did not find it helpful for my depression, but I am still interested in trying other forms of psychoanalysis precisely because the evidence I have seen is that psychoanalysis does seem to work.

          • Mary says:

            But then, if it doesn’t work, and people get better and attain their goals, then it doesn’t work. The reason we conduct double-blind experiments is to work out what really works as what happens to be done at the same time as a problem that resolves for other reasons.

      • FullMeta_Rationalist says:

        Spookykou, is your comment not a textbook case of Bulverism?

        (By going full meta, I attain Nominative Determinism.)

        • Spookykou says:

          I am not sure!

          The textbook examples I have seen are, simpler, but might still be essentially what I was doing.

          I think I was agreeing with Moon’s argument and assuming it is true (with regard to beliefs) and then trying to draw attention to the fact that Moon also seems to hold beliefs. However this second claim assumes that the books Moon is recommending are not particularly more evidence based then other forms of psychoanalysis. Which is not a position I actually provided any arguments for! BUT in my defense, I left the door open for Moon to prove me wrong by providing that proof.

        • Moon says:

          Wow, Full Meta, you must be a real live genuine rationalist– analyzing what you are reading–rather than a “rationalist” trying to win points with other people here, by dog piling onto the same person everybody else is dog piling onto.

          If I weren’t already married, I might ask you to marry me, Full Meta. Do you get a lot of marriage proposals?

          I often think about “rationalists” the way Gandhi thought about “Western civilization.” When asked, he said “That would be a good idea.”

          • Viliam says:

            I often think about “rationalists” the way Gandhi thought about “Western civilization.” When asked, he said “That would be a good idea.”

            This is a good point. But I believe that trying and doing the thing imperfectly is better than not even trying.

            (For the purposes of stereotyping me correctly, I grew up in a communist regime, my both parents were party members, and as a kid I was a member of the Pioneer movement. Would that be a sufficient evidence that I have seen things outside of the right-wing bubble?)

          • Mary says:

            Could go either way. Things that would be nice if done perfectly can be disasters if done imperfectly, and waste resources in the process.

    • AnonEEmous says:

      i can’t decide what makes me angrier

      that your first stuff after a ban is more of this

      “There is the Right Wing ideological system so common on this board when politics comes up. To me this looks and feels exactly like a Right Wing Safe Space and echo chamber bubble. But to most participants on this board, who are Right Wing themselves, I am sure that the board appears to be rational and objective.”

      or that you use the propaganda technique of presupposing this conclusion and using it to try and prove something greater or different, without acknowledging that there is serious debate on the issue (example: the despicable Scott Adams, master of persuading people that he should be tossed from a helicopter)

      i might have to use that ignore button people were talking about…shit is lit folks

      • Moon says:

        What?

        Please do use the ignore button. Feel free not to ever read my comments.

        So you are sure that this board is not a Right Wing Safe Space and echo chamber bubble? Fine. Each to their own opinion.

        I said what it looks and feels like TO ME, using that exact phrase. I did not presuppose what it looks and feels like to you.

        I presupposed no conclusions, used no propaganda techniques, and tried to prove nothing.

        But if I persuaded anyone of anything here, that they did not believe before reading my comment, please let me know. I would be quite surprised if I did.

        And what does Scott Adams have to do with my comment? Oh, perhaps you have a grudge against me for having said something negative about Scott Adams months ago. Well, if so, that would explain your reply to me. Are you his best friend or what?

        • AnonEEmous says:

          Frankly, I plan to. So enjoy my last reply roasting your nonsense:

          “I said what it looks and feels like TO ME, using that exact phrase. I did not presuppose what it looks and feels like to you.”

          dude

          “There is the Right Wing ideological system so common on this board when politics comes up. To me this looks and feels exactly like a Right Wing Safe Space and echo chamber bubble. But to most participants on this board, who are Right Wing themselves, I am sure that the board appears to be rational and objective.

          It’s hard to see a belief system objectively, when you are inside of it.”

          in a post talking about “cognitive distortions” and “evidence-free beliefs”. Yeah, but the guy who constantly talks about how this is obviously a Right Wing Safe Space, was taking a moment to be objective and admit that actually, that’s an evidence-less belief that he has. It’s…not that this couldn’t be the case, but nothing I’ve seen from you in this post or previous posts would indicate that level of self-awareness. If you have it, you purposely push past it.

          “I presupposed no conclusions, used no propaganda techniques, and tried to prove nothing.”

          “there are lots of cognitive distortions based on zero evidence. Like, for example, this one, which I will drop as an example, saying that something “appears” to be something, but really it’s not (I FEEL!). And we’ll just leave it at that and move on to explaining other stuff about cognitive distortion”.

          Coincidence?

          “Well, if so, that would explain your reply to me. Are you his best friend or what?”

          was “the despicable Scott Adams” not clear enough for you? It’s his primary technique, and probably the only reason he writes his posts.

          • Moon says:

            There is really no point in my reading about your rage at me. Yes, let’s just ignore one another’s comments. If you want someone to rage at, you’ll have to choose someone else, because I will not be listening.

          • Moon says:

            On second thought, please do not rage at anyone else either. Please seek help with your rage. I am not your enemy. I’m just another human being, with my own problems.

            I have not read Scott Adams’ blog in a long time. But Adams doesn’t know much about propaganda. He mainly knows about supporting Trump.

            So any time Trump said “Hello”, Adams would write some long blog post about how Trump was skillfully using complex persuasion/propaganda techniques. Trump was not doing that. Trump does not even read books. How would he even know what such techniques are?

            Trump was just saying whatever came into his head, and his supporters loved it because they love alpha male type billionaire celebrity reality TV star successful business men— no matter what they say.

            Again, I used no propaganda techniques and I am sure that I did not change anyone’s mind. I asked people above, to tell me if I did change their mind. And no one has replied.

          • nydwracu says:

            Trump was not doing that. Trump does not even read books. How would he even know what such techniques are?

            Bruh the Austronesians sailed everywhere from Madagascar to South America without literacy and you’re asking how Trump learned SOCIAL SKILLS from anywhere but books.

            William the Conqueror, Genghis Khan, and Muhammad were all illiterate, as is one of the richest men in Britain.

          • Sandy says:

            So any time Trump said “Hello”, Adams would write some long blog post about how Trump was skillfully using complex persuasion/propaganda techniques. Trump was not doing that. Trump does not even read books. How would he even know what such techniques are?

            Look, I think Scott Adams is a hack, but it’s entirely possible some people have talents for persuasion that they didn’t pick up from books.

        • Aapje says:

          @Moon

          So you are sure that this board is not a Right Wing Safe Space

          My objection is that you are are making vague sweeping claims, that seem little more than pejorative declarations, but have little to no substance. And most importantly, you are doing nothing to create positive change.

          If there is bias in the forum about certain topics, then one can try to change that by pointing out the bias for those topics, preferably with strong arguments. Or one can initiate a debate about ignored topics. What doesn’t work is to simply complain about bias in general. Doing that is mere emotional debating, where you trade on feelings that people already have or alienate people who don’t have those subjective feelings.

          But if I persuaded anyone of anything here, that they did not believe before reading my comment, please let me know. I would be quite surprised if I did.

          The most irritating part is that you wallow in victim-hood, presenting your inability to engage with people productively as a badge of honor.

          It’s like the activist who declares that he is doing the right thing because he gets arrested by the police, while ignoring that he got arrested for setting a car on fire. There is a perversity in defining your success by the anger you create in others, rather than how well you are able to convince people.

          To me this looks and feels exactly like a Right Wing Safe Space and echo chamber bubble?

          I have never seen a forum that didn’t have certain biases, which seems inevitable, if only by the language used (which keeps out certain people). To me, this isn’t disqualifying.

          I also don’t particularly care if things are technically right wing or left wing. Something can be ‘right-wing’ and correct or ‘right-wing’ and wrong. Something can be ‘right-wing’ and an intellectually interesting thing to discuss or it can be vapid nonsense. The same thing goes for ‘left-wing’ things. I’d rather see people focus on making good arguments, than to seek some silly left/right wing balance relative to some society (which then is totally unbalanced compared to other places, where left and right mean different things).

      • Harry Maurice Johnston says:

        Personally, I dropped Scott Adam’s blogs not long before this debacle, because it seemed to me that he’d pretty stopped working as a comic writer and taken up a full-time position as Trump’s spin doctor.

        Mind you, I also had a personal grievance so I guess I’m biased. And yes, I have reason to believe that was aimed specifically at me. : – )

      • Scott Alexander says:

        Wait, there’s an ignore button here?

        • AnonEEmous says:

          i was told that there was.

          Come to find out that there wasn’t, but google served up a nice chrome extension clicking auto-hide

          which, having seen 4 scott alexander posts, I proceeded to disable momentarily to see if moon caught the ban, but come to find out just a warning

          think it’s the last time I’ll do so, even though it hides responses I might like to see. life is life, nothing more nothing less and everything in between.

    • Scott Alexander says:

      Warning that it was really annoying and unnecessary to bring up “this blog feels like a right wing safe space” on a previously perfectly nice post about psychiatry books, and next such infraction will result in a ban

    • phil says:

      Thanks for writing this post,

      this is actually really thought provoking

      ———-

      the bias towards black and white thinking, is really pervasive, I see it in myself all the time (as well as in others)

      I’ve been reading Michael Lewis new book about Daniel Kahneman and Amos Tversky, there was a line that really stuck with me, I believe it was Kahneman (though it could have been Tversky, I might be mixing that up) talking about his early work, and he made a quote about (I’m paraphrasing from memory) “People focus on ‘is this true or not?’, what they should focus on is ‘when is this true?'”

      I’m not sure I interpreted this the same way that Lewis or the original speaker did, but I sort of feel like my misinterpretation is almost more interesting (to me at least, lol)

      it strikes me that we through a lot of babies out with the bathwater in out thinking, we see something that’s a really like shade of gray, and declare ‘THat’s not White!!!’, and feel really proud of the rigor of our thinking for recognizing something as not absolutely true, and miss the vast range of instances in which it is true

      —-

      anyway, I think your comment added usefully to the discussion, and wanted to say so

  22. Andy B says:

    It seems to me that the true art of psychiatry is figuring out which treatment will work best for a given patient. (Drugs? Talk therapy? AA? Specialized trauma therapy? Just carrying the hair dryer?) If a doctor’s premise is that their favorite treatment will work for every patient, they are immediately a bad doctor. If their attitude is patient-centered and their mind is open, they’re at least trying. If on top of that their judgment is good, then they’re worth their fee.

    • Moon says:

      Yes, the art of psychotherapy for all psychotherapists has a lot to do with figuring out what treatment will work best for a given patient. I do that. I am eclectic. But it’s not necessary to be eclectic. One can specialize, and then refer patients out to other psychotherapists, if what you do is not right for a particular person’s needs.

      “If their attitude is patient-centered and their mind is open, they’re at least trying. If on top of that their judgment is good, then they’re worth their fee.”

      Yes, that’s generally true.

  23. blarglesworth says:

    “I’ve had a lot of patients with this exact complaint – usually it’s about psychologists or therapists instead of psychiatrists. ‘She kept telling me to go to sessions, that she was going to help me, and all we did was talk about my problems. I could have had a friend do that. So eventually I just quit and I haven’t been back to see a therapist since. Bunch of quacks.’ I hear this kind of thing almost every day. It’s a big fear of mine that somebody thinks it about me. Probably one reason I like psychopharmacology so much is that it makes me feel useful – prescribing imipramine correctly isn’t something that just anybody could do; my patients may or may not get better but at least they’re getting their money’s worth.”

    I have a lot of experience with depression and the med-go-round, and I have to say I think something similar about psychopharmacology. It seems to consist entirely of just kind of guessing and throwing stuff at the depression until something sticks. And it’s usually me who suggests each new thing to try, after looking stuff up on Wikipedia or Google Scholar – the doctor’s role is pretty much just writing the prescriptions. I don’t see why this requires someone to have gone to med school – a few months of learning about drugs and interactions is all it should take. I seriously think I could be a more competent outpatient psychiatrist than the median one, armed with nothing but Wikipedia and the medical literature. Literally the only thing they’ve ever been good for is that they have the ability to write prescriptions.

    If this were Libertopia, or if it weren’t so expensive to just import the drugs I need myself, I would just cut the middleman out and get the medication myself. I get why we don’t do it like that, because most people can’t or won’t learn enough about drugs to know what they’re doing, and a lot of people would screw up and die. But that’s really the only use I see for most psychiatrists.

    And it would be one thing if they were just dartboarding, but they don’t even play with a full set of darts! The three most effective things I’ve tried have been ayahuasca (once), kratom (daily), and phenibut (every few days). None of those are things psychiatrists can even prescribe. The ayahuasca trip, while a very difficult experience, gave me an ~80% reduction in suicidal thoughts from a single dose; nothing that can be prescribed is anything like that effective. Kratom provides me a motivating kind of stimulation, and phenibut greatly reduces anxiety while also having a bit of a mind-opening effect, although of course it can’t be taken for more than a few days at a stretch. Effexor is in a distant fourth place to those drugs, to say nothing of all the other crap I’ve tried.

    I have a lot of respect for Scott because he goes far beyond the norm and really does his homework, even finding out about bizarre Russian drugs and whatnot. But he’s literally the only psychiatrist I’ve ever known that I actually think is a real doctor who puts his medical school training to good use.

    • Spookykou says:

      I have had a similar experience with treating my depression, and am currently on Venlafaxine without much in the way of results. Could you recommend any resources where I could find more information about the three alternative treatment options you have listed here?

    • Deiseach says:

      I seriously think I could be a more competent outpatient psychiatrist than the median one, armed with nothing but Wikipedia and the medical literature. Literally the only thing they’ve ever been good for is that they have the ability to write prescriptions.

      I have complained about doctors on here before, but I will say this: when I was leaking blood like a sponge* the blasé “yeah this is a thing that happens, here’s an injection and a prescription, if the bleeding hasn’t stopped in three days call back” attitude from two different doctors was really reassuring when (a) I was mildly freaking out over leaking blood like a sponge (b) looking it up on the Internet helped a bit but didn’t set my mind at rest (“it’s been over two hours, the website said it’s supposed to stop after two hours, why isn’t it stopping?”)

      So yeah – doctors having seen the thing before (or at least heard of it) can help calm down the anxious patient 🙂

      *A “women’s problems” thing, I hadn’t cut off a limb or anything like that!

  24. baconbacon says:

    4 basic types of substance abusers that I have met in my lifetime (not a huge sample).

    1. Decent people who find drugs/alcohol at the wrong time in their life when they have no direction and no meaningful work to do (i.e. high school/college).

    2. People with serious issues that pushes them toward drugs/alcohol (i.e. depression/childhood abuse) to cope.

    3. Shitty people who use drugs/alcohol as an excuse to act a certain way.

    4. People who absorb it as part of their identity (Hemmingway drank, and I’m a budding writer/I don’t play by society’s rules).

    Overlap is common, #2 becomes #3 (my dad drank and beat me, now I’m 37 and I drink and beat my kids), #1 becomes #4 (my life feels pointless but alcohol makes me feel something, now I drink because I suffer silently and no one understands me).

    These categories are also total bullshit. If I reflect on my life to date I can slot a different age me into each category, the reality is I felt different things at different times, but it resulted in very similar behavior (in my case heavy drinking).

    This is how I interpret TLP’s definition of narcism- everyone else see’s how you act, you see how you feel. If you get hammered because you feel lonely and isolated you have one perspective, everyone else sees an irresponsible drunk. If you get hammered because your father molested you, you see your own demons, everyone else sees an irresponsible drunk. The narcissistic tendency is to overvalue how your feel and undervalue how everyone else feels. Get to far to into this habit and all you are left with is how other people effect you with no understanding of how you effect them.

    • Moon says:

      True. Narcissistic personality disorders are very hard to treat. Occasionally it’s possible though, once they have been smacked around by life a few times– or, more accurately, once they have smacked themselves around a number of times, by being so self-centered that they never notice their impact on others.

  25. Moon says:

    Alcoholism can be treated. I’ve treated it successfully in people. Of course, like any therapist, there have been some people I could not help. I think alcoholism is best treated by people who have training in both alcohol/addictions treatment and also in basic psychotherapy. The people I was able to help, I found out what sorts of situations triggered their drinking, and helped them come up with a plan for what else they could do instead of drink, when that situation came up.

    Some people drink for opposite reasons. I had one patient who thought he was always right and everyone else always wrong and that everyone else should do things his way. When people wouldn’t agree with him, he’d get terribly angry and go drink. Eventually he was able to come to terms with the fact that other people are not obligated to agree with him, and that it’s not so end-of-the-world if they don’t. He became easygoing, actually, over time.

    Another guy was very passive and felt obligated to go along with whatever other people wanted. But he didn’t like doing that, and he’d get depressed about it and go get drunk. With him, I helped him work on his assertiveness and self expression. He became able to stand up for himself and express his opinions and ask for what he wanted.

    If people are trying to get certain needs met by drinking, but they really don’t like being drunks, and are motivated to change, then if they can get those needs met in another way, they can often stop drinking.

    People who want to be drunks, tend to stay drunks though, no matter what kind of treatment program they are put through. And some may want to change but for whatever reason are not able to.

  26. IvanFyodorovich says:

    My one big gripe with House of God was the ending. The main character, disgusted with how ineffectual so much of modern medicine is . . . becomes a Freudian psychiatrist. I’m glad to know at least that Shem realized the error of his ways, even if it meant he wrote the same book twice.

    • Moon says:

      Most psychotherapists and most psychiatrists are not Freudians. It’s considered an idea whose time has come and gone, by most psychotherapists.

      • IvanFyodorovich says:

        I know, but the Basch character at then end of House of God starts reading Freud, analyzing people using Freudian terminology, and switches to a psychiatry residency. It seems that he is turning into a Freudian psychiatrist.

        I realize I just told the end of the book, but reading this review does the same thing.

        • Moon says:

          A lot of books and movies have the characters do the most outrageous things they can think of, in order to entertain readers.

          That practice makes me think of the book, The Dice Man, also about a psychiatrist. But definitely just for fun– not showing any real world situation.

          https://www.amazon.com/Dice-Man-Luke-Rhinehart/dp/0879518642/ref=sr_1_1?s=books&ie=UTF8&qid=1483065410&sr=1-1&keywords=The+Dice+man

          • IvanFyodorovich says:

            Yeah, but Basch’s transition is portrayed as wise and compassionate, probably because Shem wrote the book after he was burned out on medicine but before he was burned out on Freudian psychiatry. The author makes a whole big deal about how psychiatry provides the possibility of “cures” whereas the rest of medicine doesn’t. Forty years later, it reads ridiculous.

          • Moon says:

            Interesting. Your comment made me wonder what Shem thinks now. I went to his wikipedia page. He has a new book, At the Heart of the Universe, (Published by Seven Stories Press) that came out on May 17th of 2016.

  27. nope says:

    Ah good, discussion of TLP. Has anyone been able to extract clear, unambiguous meaning from his writing? He’s obviously quite good in some sense, and his writing is entertaining, but I’ve found it’s left me hopelessly confused as to “narcissism”, and it sounds like I have company there.

    In at least some contexts, TLP’s “narcissism” simply refers to inadequate theory of mind, but deficiencies in theory of mind are accounted for by other disorders, most prominently autism spectrum disorders, which don’t always or even often manifest clinically narcissistic behavior. Then, unrelatedly, narcissism also seems to be about valuing projecting a certain image over actually being a thing, and it’s unclear to me when and how these two aspects are supposed to overlap, and why they’re both called narcissism. Furthermore, TLP asserts that “his” narcissism is different from grandiose or “textbook” narcissism, and then I’m completely lost.

    Adding to that confusion, a lot of his writing is incredibly easy to pattern-match to oneself or one’s friends and acquaintances, and seems to promote paranoia without actually suggesting a course of action, and so I’m left wondering what the utility of his writings or the diagnosis in general are.

  28. FullMeta_Rationalist says:

    Shem is proposing to drink more rum.

  29. jsw says:

    “I’ve been trying to reread some of The Last Psychiatrist and better understand what he means by narcissism, something I haven’t been able to get a good feel for before.”

    Scott,

    I think he expresses it in two ways, very clearly.

    1) “Narcissism doesn’t mean you’re bad, just that you think you’re the main character in your own movie.” That comes up multiple times.

    2) The whole Narcissus piece is good, but to pick a representative graf, “You think Narcissus was so in love with himself that he couldn’t love anyone else. But that’s not what happened, the story clearly tells it in the reverse: he never loved anyone and then he fell in love with himself. Do you see? Because he never loved anyone, he fell in love with himself. That was Narcissus’s punishment.”

  30. cvxxcvcxbxvcbx says:

    Typo: eles -> else

  31. Nancy Lebovitz says:

    Thanks very much for this, especially the parts about focusing on motivations being destructive, and that description of psychoanalysts *always* changing the subject that the patient is trying to convey. I count my blessings that I’ve never had to deal with a therapist like that.

    I’d noticed the problem with motivation and SJW, though it might be safe for people to explore each other’s motivations as equals. The deadly thing is when one person’s motivations are up for question (funny how people are never suspected of being more benevolent than they appear) and the other person’s aren’t.

    From memory: The Brain that Changes Itself is written from the point of view of a sort of humble and sensible psychoanalysis which looks for patterns of thought, but isn’t trying to make brilliant/offensive leaps of intuitiion. I’m betting it’s a lineage which didn’t get famous because it isn’t emotionally weird enough to get people’s attention.

    Unbroken Brain— I’ve read most of this. Part of the premise is that addiction is more like a learning disorder than a moral failure or a disease. Like anyone else, addicts learn better when they’re treated kindly– and part of addiction is loss of sensitivity to bad outcomes, so punishment works less well on addicts than most people.

  32. Swimmy says:

    A lot of this really reminds me of Murray Rothbard’s Psychoanalysis as a Weapon (1980). Mostly it’s a quick summary of some of Szasz’s presentation of Karl Kraus’s criticism, with Rothbard’s typical Rothbardiness. Not 100% endorsed, but entertaining. Representative passage:

    It is no accident that the psychologizing of the psycho-historians has been used mainly against uncongenial people and groups. In the twentieth century, Adolf Hitler has been the most subject to this treatment, so much so that until recent years it was hard to find an American historian who did not dismiss him as a neurotic, psychopath, or psychotic. One of the problems with this analysis, of course, is that not only Hitler and his immediate followers, but also the entire German nation must then be treated as neurotic or psychotic. Not only does this strain the limits of credulity, but it must then be explained why the Germans suddenly became neurotic in 1933 and shucked off their alleged collective neurosis rather quickly twelve years later. Presumably their child rearing methods, or whatever, did not change radically before or after this time period. Three decades ago, there was a rash of psychoanalytic anthropological “explanations” of the allegedly totalitarian character of all Russians and Japanese, “explaining” such by their toilet training or their being swaddled in early childhood; but since then, the Japanese, at least, seem to have made a remarkable recovery from their toilet training.

    • Nancy Lebovitz says:

      Excellent essay.

      For Your Own Good: Hidden Cruelty in Child-Rearing and the Roots of Violence claims that there was a fad for very authoritarian child-rearing in Germany– it affected both how Hitler was raised and people who found an authoritatian leader attractive.

      This isn’t wild Freudian leaps, but I don’t know how solid it is. I will say it was educational for me. Until I read it, I’d never considered the possibility that people offering advice might be just making things up.

      • Deiseach says:

        It wasn’t just in Germany, though; strict regimes to train children from newborns onward was the rule of the time. The reason Dr Spock’s childcare book got the reputation of being the hippy idea of child-rearing was because his methods were a reaction against this and since his first book was published in 1946, this could be seen as leading to the generation of the 60s who reacted against everything.

        If authoritarian child-raising produced Hitler, then you would have to say it also produced Mussolini, Franco, Salazar, and Mosley – it can certainly make the argument, but it’s a bit of a “one-size-fits-all” explanation. The Germans were subjected to strict child-rearing which prepared them to follow Hitler, the British were subjected to strict child-rearing which prepared them to follow Churchill instead of Mosley?

        • Nancy Lebovitz says:

          As I recall, the strictness started much younger for Germans than the English.

          Another angle might be that there was already something going on in Germany that made parents receptive to advice to be very strict.

        • Steve Sailer says:

          My vague hypothesis is that the 1960s hippie movement grew out of the encounter of Northern European, especially Germanic, culture with the California climate, creating a culture of perpetual May Day.

          Maybe it seems paradoxical that Germanic authoritarianism can flip into Germanic hippieness, but I’ve seen it in my extended family, and up close it makes more sense than it sounds like on paper.

          • psmith says:

            Jungian unconscious racial memories of tropical PIE urheimat–ancient Nordic kingdoms in Hawaii, Tahiti!

    • Steve Sailer says:

      My impression is that German-speaking cultures around 1900 were kind of manic in terms of the various “life reform” fads they inflicted on their families. My Swiss-German grandfather, for example, was a health food nut. He worried that he was being poisoned by store-bought food the way Hitler worried that he was being poisoned by impure blood. So he moved from Chicago to California and had his kids grow all sorts of fruits and vegetables.

      On the other hand, this kind of “You must change your life” obsessiveness that peaked in Vienna and Berlin sometime around 1900 seems like the flip side of that era’s Germanic dynamism. Health food, for instance, isn’t a terrible idea even if my grandfather took it a little too far.

  33. benquo says:

    Just because a tool is powerful doesn’t mean it should be used:

    The book doesn’t claim that psychoanalysis isn’t effective. It treats it as powerful and worthy of respect. The book’s psychoanalysts are consistently able to tell weird facts about a person from just a glance, to strip them down to their deepest insecurities in minutes. It’s just that people who are healthy and decent going into psychoanalysis end up cracked and nasty coming out of it. A lot of the worst doctors at Mount Misery were decent people before they started getting analyzed themselves.

    Seems like the straightforward interpretation of Shem is that psychiatry is engaged in a massive campaign of gaslighting and emotional, psychological, physical, and sexual abuse against patients, that it turns psychiatrists into the sorts of people who should do this, and that it should stop. This is a straightforward description of overtly optimizing for bad outcomes:

    “In this case,” Blair said, “Better is worse. She’ll have to get worse – which is in fact better – in order to get better, which will still be worse. If she gets a little worse, she won’t get a lot better, but if she gets a lot worse, she may get a little better. Not smarmy-‘nice’ better. Borderline better…Don’t worry, Roy. Your overinvolvement with her is normal. Sick, but normal. Gals like her are experts at getting guys like you entangled. Read my paper, Rescue Fantasies In The Naive Resident“

    This speech could be a word-for-word transcription of something one of my attendings said to me during my intern year when I tried being nice to a borderline patient. There is a subtle sense in which this attitude can sometimes be helpful. But get the subtlety even slightly wrong and it devolves into being really evil, and Mount Misery brings out the worst in it.

    I don’t see how it’s a plausibly moral response to this sort of thing, to try to see what the true hidden wisdom is and how to twist yourself into a form that can obey it. If a Power looks like it’s trying to hurt people, and tells you it’s trying to hurt people, and you can verify this with your own experience, then the right thing to do is not to decide that hurting people must somehow secretly be good.

    • Spookykou says:

      I have never had my shoulder dislocated and I am not actually a doctor, so I will instead use a hypothetical dislocated shoulder that behaves exactly as I want for my example.

      A patient has a dislocated shoulder, and they want their doctor to treat it. Their doctor is training a young doctor at the time who watches. The patient tells their doctor that it hurts a little bit and they can’t use their arm very well. So the doctor walk over and grabs their arm, and tells them to look out the window and count to three, on two the doctor pops the patients shoulder back in, who cries out in pain, the young doctor looks on in horror. The patient then tells their doctor that their shoulder is sore and hurts worse than before, and the doctor just smiles and nods and sends them on their way. The young doctor stands aghast at what has just transpired, the doctor took a person with a mild discomfort, hurt them intentionally, and left them worse off then before.

      Should the young doctor simply assume that the doctor training them is a spiteful mean person, or should they try and figure out why the doctor assaulted the poor person with the dislocated shoulder?

      • baconbacon says:

        Student: Why the hell did you wrench the patient’s arm like that!

        Doctor: Here is a study on reducing dislocated shoulders, over 90% of those we treated this way reported a reduction in pain in the following days, and a return to near full range of motion.

        Student: oh, so there is a ton of evidence that the patient will get better? Thanks, that makes sense.

        —————————-

        Student: Why the hell did you wrench the patient’s arm like that!

        Doctor: (smirking) sometimes you gotta hurt the patient to make em feel better (walks off humming)

        One of these is acceptable, one totally unacceptable.

        • Spookykou says:

          Hey now, you don’t know that there is any research showing anything at all about dislocated shoulders as they are a made up illness I used for my example.

          But seriously.

          I believe there is at least some evidence that all forms of psychoanalysis have some positive effect?

          I was not trying to say that it is the height of evidence based medicine, I was simply pushing back on the idea that it is obviously wantonly immoral.

      • benquo says:

        I think there’s actually a huge and extremely relevant difference between those cases. With a dislocated shoulder, there’s easy to verify evidence pointing towards the procedure being good for the patient on net. You can immediately verity that the shoulder’s back in the normal place. There’s a very strong, intuitive model for why the physical location of the shoulder joint matters, based on simple mechanics.

        I agree that “patient experiences pain” isn’t strong evidence against the treatment being appropriate. And in fact one of the distinguishing marks of an expert, in a culture that hasn’t started to optimize for bad outcomes, is that they’ll often know that some painful solutions are appropriate. But once you start using that as a proxy for experthood, it can be trivially gamed by optimizing for self-righteously inflicting suffering on others.

    • cuke says:

      I just read Mount Misery as well and like how you said this:

      Seems like the straightforward interpretation of Shem is that psychiatry is engaged in a massive campaign of gaslighting and emotional, psychological, physical, and sexual abuse against patients, that it turns psychiatrists into the sorts of people who should do this, and that it should stop.

      I found the book both cartoonish and disturbing, though Malik I thought a great character, and how through him Shem ultimately comes down on the side of kindness, not pretending to know more than we do, and tearing down the expert role that so many mental health professionals get to play. I hear about a lot of misuse of authority by mental health professionals that seems entirely for the ego fulfillment of the clinician.

      There is indeed very little of what most scientists would consider to be good evidence for anything that happens in mental health treatment. It doesn’t mean that it doesn’t work; only that the process of finding what works for any one person is often more art than science (whether that’s prescribing drugs or doing talk therapy). At this stage, a clinician can pretty much find evidence for almost anything they want to do (that’s not overtly prohibited by ethical codes). The DSM/medical model and all the science-y language used in psychology obscure this reality in a malignant way.

      To me, the bulk of what we do in treating “mental illness” (and I’m a professional in the field) is telling good stories to each other. We organize meanings and intents around good stories, both patients and clinicians, and if we do it well, we harness a patient’s motivation to change in ways they want to.

      The “want to” part is central, and so getting consent is really important — and that’s the horror to me of Shem’s story, all the ways that all these patients’ consent is repeatedly violated. If you don’t know what manner of nonsense you’re participating in, you don’t have the capacity to consent to it. And if the whole field obscures how deep the nonsense goes, then no one can meaningfully consent.

      It’s hard to tell in mental health treatment if the pain that’s being caused is in the service of healing (as relocating a dislocated shoulder would be) or if it’s entirely unnecessary. We used to think that dredging up all of a person’s traumatic material was essential to trauma recovery, and our research, such as it is, now tells us that’s not so. There are still schools of addiction treatment that use heavy doses of shame to get people to stop using/drinking, but pre-existing wells of shame often fuel addiction and there’s no good evidence that shaming people further helps.

      A huge amount of what goes on in mental health treatment I’d categorize as various forms of shaming people (patients as well as trainees), now that I think about it. That’s probably one of the most prevalent ways that harm gets done, when ironically a lot of mental health problems seem to be caused by prior regimes of shaming.

  34. Steve Sailer says:

    “I wonder if there might be something similar for social interventions like Alcoholics Anonymous. Over the whole population, it won’t outperform any other form of rehab – but there will be a few people for whom it works miracles.”

    And maybe it’s bad for about as many people as it’s good, so in a rigorous study it comes out as having zero effect. But if people for whom it is bad quit quickly in real life and those for who it is good persist, than it could have a positive real world effect even if that doesn’t show up in gold standard experiments.

    • AcademicianZex says:

      Or it could monopolize treatment through vast swathes of the country (people in this thread are contrasting AA and rehab, but nearly all rehabs are 12 step based), seriously psychologically abuse those who it doesn’t work for, and keep people who would have gotten better on their own because they’re good at inflicting Stockholm syndrome.

  35. I find it annoying that “The Last Psychiatrist” is seemingly mostly known for writing about narcissism.

    Its one of the most important blogs in all of psychiatry blogging…and everyone is talking about these essays on narcissism, ignoring the most important parts he blogs about mental health care.

    (I really like his posts that don’t revolve around narcissism
    )

    On another topic…I think that AA, if mandated by a court, comes dangerously close to a violation of separation of church and state.

    • FullMeta_Rationalist says:

      I asked SSC what they thought about TLP’s narcissism posts a few weeks ago. So it’s probably my fault.

      I’ve also seen a few of Alone’s more technical posts. But they seemed obviously sound and important, so it didn’t seem worth discussing. Chalk it up to toxoplasma.

    • The Obsolete Man says:

      The Farewell Depression post of his is top notch-got it saved in my favorites folder. I think the narcissism stuff is so ‘hot’ because he talks about it frequently in the context of society and generations. My favorite post related to that is where he explores The Matrix and talks about ‘The Schizotypal State’:
      http://thelastpsychiatrist.com/2009/03/what_was_the_matrix.html

      • Nancy Lebovitz says:

        That piece about the Matrix could be useful for me– I’ve got a tendency to be hypnotized by a sense of possibility and paralyzed in the real world. Maybe this is a kinder description of being schizotypal?

        This being said, it’s also a good example of what I don’t like about TLP– his focus is on inventing people to hate and making wild leaps about what’s wrong with the culture.

        So far as the Matrix is concerned, I’ve never been able to stay awake through it– for some reason, I see the beginning and then wake up when Neo is slowing time.

        My impression is that he isn’t a prince in disguise, he’s a nebbish who’s handed the keys to the kingdom. Have I missed something?

        It could be that this is a really important (male?) fantasy because too many boys/men have been told they’re nothing special that it seems like the only hope is a miracle. It isn’t (just?) an aren’t-the-narcissists-awful thing, it’s a Moloch thing.

        Farewell Depression is from 2007. He made a bunch of predictions about the direction of psychiatry. Are they panning out?

        • The Obsolete Man says:

          I think TLP looks at ‘narcissism’ as something that was rare then become widespread-starting right after WWII and then continuing to increase. He says that it is nothing more than an alternative personality structure.

          He may be spot on about all of the stuff he talks about wrt to narcissism, but what if it is nothing more than an *evolution* of society that’s somewhat inevitable – a moving target that’s always changing that few people can do anything about? Something akin to yelling at glaciers advancing?

          One of the things that I remember that he used to distinguish a narcissist is that they define themselves by what they believe rather than what they do. And crucially, in the link above he mentions that we don’t believe in anything outside ourselves anymore. Maybe that’s the crucial differentiating thing?

          • trevormmurphy says:

            Let H be the hypothesis “narcissism is an evolution of society”.

            Assume H is true.

            Then this “narcissism” is worth studying for precisely the same reason we yell about problems with today’s glaciers. If we understand the forces driving the change, and especially if those forces are the result of individual choices on a massive scale, we can do something to alter incentives and arrest—maybe even reverse—the change.

  36. caryatis says:

    > If his patients say they’re upset at losing their job, he’s so “superficial” that he just talks to them about their job and how they can support themselves financially! A janitor could do that!

    This is the whole secret. Talk therapy works (to the extent it does) because people feel better when they can get someone else to listen to their problems. Particularly someone they respect, who pretends to care, and who isn’t already entangled in the problem, allowing them to offer a different perspective. This is why people get as much benefit from talking to their priest or lawyer (!) as from talking to someone with psych credentials. But if we realized this, psychiatry would have to abandon its pretense of being just like any other medical science.

    Edit: of course, Scott gets to this by the end of the post.

  37. Richard Kennaway says:

    I feel like Arthur Dent asking Ford Prefect why the people vote for the lizards, but…why are you doing your job, when by your own account it is so like the world of these novels? What Shem is describing in them, and you describe every time you write about the places you work in, is Hell, and I don’t mean that word as an empty interjection, but a very live metaphor. Why? Why?

    Please read this as bafflement, not criticism. I’m sure that somehow, you manage to do valuable things there, but what can you do in the end, in a system like that?

  38. Winja says:

    “…at which point my supervisor switched the discussion to why it was so important to me to believe that his plane had been delayed that I would do an Internet search about it, and whether I was trying to defend against the unbearable notion that my patient might ever voluntarily miss one of our sessions.”

    HOLY FUCK.

    This is the most utterly fucking infuriating thing I think I’ve encountered in the last four months.

  39. trevormmurphy says:

    Yo, if you wrote a review of TLP’s posts on narcissism … well I would read it and share it all around. I feel like I’ve got a good personal handle on the concept, but I could easily be mistaken.

    As an offering of the one post that spoke to me more than any other: http://thelastpsychiatrist.com/2012/10/the_story_of_narcissus.html

    Specifically, the paragraphs at the end where TLP describes hypothetical bad parenting.

    No one knows what Liriope and Cephisus did, but whatever they did, it worked: he didn’t even recognize his own reflection. That’s a man who doesn’t know himself. That’s a man who never had to look at himself from the outside.

    How do you make a child know himself? You surround him with mirrors. “This is what everyone else sees when you do what you do. This is who everyone thinks you are.”

    You cause him to be tested: this is the kind of person you are, you are good at this but not that. This other person is better than you at this, but not better than you at that. These are the limits by which you are defined. Narcissus was never allowed to meet real danger, glory, struggle, honor, success, failure; only artificial versions manipulated by his parents. He was never allowed to ask, “am I a coward? Am I a fool?” To ensure his boring longevity his parents wouldn’t have wanted a definite answer in either direction.

    He was allowed to live in a world of speculation, of fantasy, of “someday” and “what if”. He never had to hear “too bad”, “too little” and “too late.”

    When you want a child to become something– you first teach him how to master his impulses, how to live with frustration. But when a temptation arose Narcissus’s parents either let him have it or hid it from him so he wouldn’t be tempted, so they wouldn’t have to tell him no. They didn’t teach him how to resist temptation, how to deal with lack. And they most certainly didn’t teach him how NOT to want what he couldn’t have. They didn’t teach him how to want.

    The result was that he stopped having desires and instead desired the feeling of desire.

  40. normativeforce says:

    Scott, you write: “Sometimes the imagery clicked; other times, it just seemed like caricatures.”

    Perhaps it’s just that people in the (at least decades distant) past actually were in fact as bafflingly stupid and crude caricatures it seems they must have been? Because, you know, everyone, through all the increasingly exponentially complex connections between people, their phones, their pets, suggesting a book, seeing this or that situation in terms of Lacanian theory about mirrors or whatever, every single interaction and causal happening of this because of that, and all that, interacting in all sorts of exponentially complex ways, has in fact made it so that what they had to struggle to see is now completely obvious to us?

    So what clicks is the essential insights they had, and what’s crude caricature stuff is, well, because, people actually were crude caricatures back in the day, because they hadn’t learned to see all that’s, thanks to their efforts, completely obvious to us.

  41. AcademicianZex says:

    “Rarely have we seen a person fail who has thoroughly followed our path. Those who do not recover are people who cannot or will not completely give themselves to this simple program, usually men and women who are constitutionally incapable of being honest with themselves. There are such unfortunates. They are not at fault; they seem to have been born that way. They are naturally incapable of grasping and developing a manner of living which demands rigorous honesty. Their chances are less than average. ”

    That is read out at the start of every AA and NA meeting. At the start of the hour – so probably five minutes ago or so – tens of thousands of vulnerable, suffering addicts are treated to that message, and what a perfect encapsulation of their attitude. First, there is the blatant disregard for anything like facts – this claim is empirically testable, has been tested, and found hilariously incorrect. AA is not a panacea, according to Scott’s own research, it gets maybe a few percentage points above control, if that. There are millions and millions of people who fail, following their path. Why is an organization that is supposedly based upon truth, on elevating us to a more honest state of being, starting every single meeting off with a lie?

    If that were the only thing they’d be like any other snake oil salesman, probably getting in the way of legitimate treatment but likely harmless. The cult is not content with that, of course. They not only need to inflate their own efficacy beyond any reasonable level, they insist on denigrating the character of those for whom it does not work. And I simply cannot believe that you can think this is anything like responsible medical practice, Scott. What would happen to you if you told a patient that they were “constitutionally incapable of honesty” if a certain medication or therapeutic technique didn’t work? AA is in a position of power over its members, sometimes in a literal legal sense, but always in a psychological sense.

    It’s difficult to overstate this – if you’re going to your first AA meeting, you’ve probably hit rock bottom, or been forced to by a court or family member that is willing to threaten anything to get you there. AA, by its own design and the indoctrination of its users, is seen as the only source of truth. If you question it in the slightest, you are accused – first by AA itself, then be the people you love – of being a dry drunk, not committed to recovery, a bad person because you’re still trying to find an excuse to drink. It’s quite similar to the description of psychiatry (and Staliism) above. It’s never considered that you might be angry with them because they’re telling you what a piece of shit you are and instilling foreign values in you. It’s always the disease talking.

    They have power over people when they are at their lowest and most fragile, when self-loathing is running rampant, and questions about whether they’re even capable of being a good person. To tell that audience that failure to get better with a cure that barely works better than chance is proof that they are fundamentally dishonest, broken people goes beyond mere professional irresponsibility. It’s abusive. AA isn’t a cult, of course. It’s just as abusive as one.

    Writing the smallest good thing about the organization, and thus encouraging more of society’s most vulnerable to submit to the psychological abuse of the self-loathing, is irresponsible.