Reverse Psychology

[Content warning: suicide]


It all started when I made that phone call.

I was really bad. All the tenure-track positions I’d applied to had politely declined, and I saw my future in academia gradually slipping away from me. Then the night before, my boyfriend had said he thought maybe we should start seeing other people. I didn’t even know if we were broken up or not, and at that point I couldn’t bring myself to care. I sat on my bed, thinking about things for a while, and finally I called the suicide hotline.

“Hello?” a woman’s voice answered on the other side. Somehow, just hearing someone else made me feel about five times better.

“Hello,” I said, a little more confidently. “I’ve been thinking of committing suicide. I need help.”

“Okay,” she said. “Is there a gun in your house?”


“All right. The first thing you need to do is get one. Overdosing on pills is common, but it almost never works. You can get a firearm at almost any large sporting goods store, but if there aren’t any near you, we can start talking about maybe jumping from a high…”

“What the HELL?” I interrupted, suddenly way more angry than depressed. “You’re supposed to @#!$ing tell me not to do it!”

“This is the suicide hotline,” the woman said, now sounding confused. Then, “Are you sure you weren’t thinking of the suicide prevention hotline?”

“Give me a break! I took a psychology class in undergrad, I know what a suicide hotline is!”

“I’m sorry you seem to be upset. But this is the suicide hotline. It’s like how there’s the Walk For Breast Cancer, but also the Walk Against Breast Cancer.”

“There’s the what? But…I was in the Walk For Breast Cancer! I thought…”

“It sounds like you have some issues,” said the woman, politely.

“Ugh,” I said. “Yeah.”

“Do you feel like you need professional help?”


“I do have a free clinic with an opening available tomorrow at three PM, would you like me to slot you in for an appointment?”

So you’re probably wondering why in the world I would take an appointment arranged by the suicide hotline that wasn’t a suicide prevention hotline. The answer is – were you even listening? A free clinic? With an appointment available the next day? Normally I was lucky if I found a place with an opening in less than two months and a co-pay that wasn’t completely ruinious. You bet I was taking that appointment before someone else snatched it up.

Dr. Trauer’s office looked gratifyingly normal. There was a houseplant, a diagram of the cranial nerves, some Abilify® merchandise, and on the wall one of those Magic Eye stereographic images that resolved into a 3D picture of the human brain. Dr. Trauer himself looked like your average doctor – a little past middle age, a little overweight, a short greying beard. He motioned me to sit down and took the paperwork I’d been filling out.

“Hmmmm,” he said, reading it over. “29 years old, postdoc in biochem, recent relationship trouble…mmmm…you did the right thing.”

“In coming here?”

“No, in considering suicide. After getting rejected from a tenure-track position, your life is pretty much over.”


“I mean, here you are, hundreds of thousands of dollars in debt, with only one area of expertise, and now you’ve been rejected from it. I can totally see why you might think it’s worth ending it all.”

“But…there are lots of other things I can do! I can get a job in industry! I can work in something else! Even if I can’t find a job right away, I have parents who can help support me.”

“Industry!” Dr. Trauer was having none of it. “A bunch of bloodsuckers. Do you realize how bad work in the private sector is these days? They’ll abuse you and then spit you out, and once you’ve been out of university too long nobody else will want you.”

“Lots of people want biochemists! If I work for a company for a few years, I’ll have more experience and maybe that will make me more attractive to employers! What…what kind of a psychiatrist are you, anyway?”

“Cindy didn’t tell you?”


“The woman on the phone.”

“She didn’t really tell me anything!”

“Well,” said Dr. Trauer. “To answer your question, we’re dark side psychiatrists. This is the state’s only dark side psychiatry clinic.”

“Dark side psychiatry? Really?

“We’re a…well, some people say sect, but I like to think of it as more of a guild…dedicated to improving negative mental health. Think of it this way. When you’re a hijacked murder-monkey hurtling toward your inevitable death, sanity is a completely ridiculous thing to have. And when the universe is fifteen billion light-years across and almost entirely freezing void, the idea that people should have ‘coping skills’ boggles the imagination. An emotionally healthy person is a person who isn’t paying attention, and our job is to cure them.”

“There’s more than one of you?”

“Oh, yes. There’s a thriving dark side psychiatric community. There are dark side psychopharmacologists – you’d be amazed what a few doses of datura can do to a person. There are dark side psychotherapists who analyze and break down people’s positive cognitions. There are dark side child psychiatrists who catch people when they’re young, before sanity has had a chance to take root and worsen. And there are dark side geriatric psychiatrists, who go from nursing home to nursing home, making sure that the elderly are not warehoused and neglected at exactly the time it is most important to ensure that stroke or dementia does not protect them from acute awareness of the nearness of death.”

“That’s awful!” I said.

“Is it? Look where sanity’s gotten you. You want to kill yourself, but you don’t have the courage. Work with me for ten sessions, and I promise you we can help you get that courage.”

“You’re a @#!$ing quack,” I said. “And if you think killing yourself is so great, how come you haven’t done it yourself yet?”

“Who says I haven’t?” asked Dr. Trauer.

His hand went to his face, and he plucked out his right eye, revealing an empty void surrounded by the bleached whiteness of bone. I screamed and ran out of the clinic and didn’t stop running until I was in my house and had locked the door beside me.


“…and that’s pretty much the whole story, doctor,” she told me. “And then I looked to see if there were any real psychiatrists in the area and someone referred me to you.”

“Well,” I said, my face unreadable. “I can certainly see why you’re complaining of, how did you put it, ‘depression and acute stress disorder’.”

“Not so acute anymore. It took me two months to get an appointment at your clinic.”

“Oh,” I said. Then, “Sorry, we’re sort of backed up.” Then, “Okay. We’ve got a lot we have to work on here. Let me tell you how we’re going to do it. We’re going to use a form of therapy that challenges your negative cognitions. We’re going to take the things that are bothering you, examine the evidence for them, and see if there are alternative explanations.”

“What do you mean?” she asked.

“Well,” I said. “It seems to be this Dr. Trauer incident that’s traumatized you a lot. I can see why you would be stressed out. The way you tell it, it sounds absolutely terrifying.”

“You don’t believe me,” she said, not accusatory, just stating a fact.

“I think it would be helpful to examine alternate explanations,” I said. “I’m willing to assume it happened exactly as you tell it. I can see why you would think Dr. Trauer wanted you to commit suicide. But are there any alternative explanations for the same event?”

“I don’t see how there can be,” she said. “He outright said that he thought I should kill myself.”

“Right. But from what you know of psychiatrists and therapy – and you did say you took some classes in undergrad – are there any other reasons he might have said something like that?”

She thought for a second. “Wait,” she told me. “There’s a technique in therapy called paradoxical intention. Where you take a patient’s irrational thought, and then defend and amplify it. And then when the patient hears it from someone else, she realizes how silly it sounds and starts arguing against it, and then it’s really hard to keep believing it after you’ve shot it down yourself.”

I nodded. “That’s definitely a therapeutic method, and sometimes a very effective one. Do you have any evidence that this is what Dr. Trauer was doing?”

“Yes! As soon as he said I should commit suicide, I started arguing against him. He told me that if I couldn’t get a tenure track position there would be no other jobs available, and I told him there would be! Then he told me that the jobs would be terrible and I’d never be able to make a happy life for myself with them, and I argued that I would! That must have been what he was going for!”

She suddenly looked really excited. Then, just as suddenly, the worry returned to her face.

“But then what happened with his eye? I swear I saw him take it right out of the socket.”

I nodded. “Can you think of any alternate explanations for that?”

Thinking about it that way, it only took her like five seconds. She slapped her head like she’d been an idiot. “A glass eye. He probably had some kind of injury, had to put in a glass eye, and could take it out any time he wanted. He must have thought it would be a funny gag and didn’t realize how traumatized I’d be. Or he wanted to scare me into realizing how much I wanted to live. Or something.”

I nodded. “That does sound like a reasonable explanation.”

“But…don’t people with glass eyes usually have like scar tissue and normal skin behind them? This guy, I swear it was just the bone and this empty socket, like you were seeing straight to his skull.”

“You’re asking the right questions,” I said. “Now think a little more.”

“Hmmmm,” she said. “I guess I was really, really stressed out at the time. And I only saw it for, like, a fraction of a second. Maybe my brain was playing tricks on me.”

“That can definitely happen,” I agreed.

She looked a lot better now. “I owe you a lot of thanks,” she said. “I’ve only been here for, like, fifteen minutes, and already I think a lot of my stress has gone away. All of this really makes sense. That paradoxical intention thing is actually kind of brilliant. And I can’t deny that it worked – I haven’t been suicidal since I talked to the guy. In fact…okay, this is going to sound really strange, but…maybe I should go back to Dr. Trauer.”

I wrinkled my forehead.

“It’s not that I don’t like you,” she said. “But he had this amazing free clinic, and what he did for me that day…now that I realize what was going on, that was actually pretty incredible.”

“Hold on a second,” I said.

I left the room, marched up to the front desk, took the directory of medical providers in the area off the shelf, marched back to the room. I started flipping through the pages. It was in alphabetical order…Tang…Thompson…Tophet…there we go. Trauer. My gaze lingered there maybe just a second too long, and she asked if I was okay.

“Um, yeah,” I said. “It’s just that he doesn’t – he doesn’t take your insurance. That’s the problem.”

“It’s okay,” she told me. “He said it was a free clinic. So that shouldn’t a problem.”

“Well, uh…the thing is…when you see out-of-network providers, your insurance actually charges, charges an extra fee. Even if the visit itself is free.”

She looked skeptical. “I’ve never heard of that.”

“It’s new. With Obamacare.”

“Really? How high a fee is it?”

“It’s…um…ten thousand dollars. Yeah, I know, right? Thanks, Obama.”

“Wow,” she said. “I definitely can’t afford that. I guess I’ll keep coming here. Not that there’s anything wrong with that. You’ve been very nice. It’s just that…with Dr. Trauer…well…sorry, I’ll stop talking now. Thanks a lot, doctor.” She stood up and shook my hand before heading for the door. “Seriously, I can’t believe how much you’ve helped me.”

No, I thought, as she departed you can’t. I told her she was asking the right questions, and she was, but not all of them.

For example, why would a man with only one working eye have a stereographic Magic Eye image in his office?

I picked up my provider directory again, stared a second time at the entry for Dr. Trauer. There was a neat line through it in red pen, and above, in my secretary’s careful handwriting, “DECEASED”.

Before returning the directory to the front desk, I took my own pen and added “DO NOT REFER” in big letters underneath.

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188 Responses to Reverse Psychology

  1. Tom Hunt says:

    I’m not actually sure if it’s meant to be funny, but I still can’t stop laughing.


  2. Tracy W says:

    Outpatient psychiatric care rotation is going well I see.
    (Great story.)

  3. E. Harding says:

    Good ghost story. Is there some kind of meaning behind it I’m not seeing?

    • Scott Alexander says:

      None at all.

      • phil says:

        Except the name I assume? (“Trau” = true / “Trauen” = to trust in German)

        • Creutzer says:

          The cognate of “true” is “treu”, not “trau”. But the verb “trauen” is connected. More importantly, though, “Trauer” also means “grief”.

          • phil says:

            Ah ok. Though grief seems like a less sinister option…

          • Someone from the other side says:

            “Trauer” only means grief in German and is mostly used if someone has died, so it’s quite suitable here. But it has no link to trust whatsoever. The verb is “trauern”. FWIW, there is the related “traurig” which means sad.

            Funnily enough, “Trauen” itself does have multiple meanings, however, it can mean to trust, to dare or the act of getting married.

            (native German speaker).

          • Creutzer says:

            Minor nitpick: It could theoretically be an agent noun of “trauen”, even if that is kind of absurd (slightly less absurd semantically with the “marry” meaning, which my brain completely failed to access). Hence my “also”.

          • Scott Alexander says:

            (hint: “Freud” is German for “joy”)

          • Someone from the other side says:

            Relax, took me two edits to recognize the marry part, myself 😛

            (I am anti-marriage because the whole concept does not make the slightest amount of sense to me so maybe that’s part of the reason)

            As for Freud, technically it is “Freude” (think Ode an die Freude …) but dropping the e works in a number of dialects.

          • Anonymous says:

            Yeah I am anti things-I-don’t-understand too. And what do I get for it? Marginalised, vilified even. What the hell bro? What can we do?

            t. Homophobe

      • ryan says:

        This is awesome. Your fiction is great, very enjoyable.

  4. Ted Sanders says:

    FYI, the universe is closer to 50 billion lightyears across than it is to 15. Even though light has only travelled ~15 billion lightyears to its edge, those ~15 billion lightyears have expanded by about a factor of 3.

    • Decius says:

      It’s 15bly from the center to the edge, and 15bly in the opposite direction from the center to the other edge.

      It’s just that in 30by, the distance between where one edge is now and where the opposite edge is now will be 50bly.

      Plus talking about distance in relativistic postulates means that it is a derived value and not an inherent one; the length of an artifact is not constant or even well-defined.

    • Martin-2 says:

      And even by Dr. Trauer’s naive reasoning the observable universe would be 30 billion lightyears across, 15 billion in every direction.

  5. Varqa says:

    This is my new favorite urban legend.

  6. Michael Watts says:

    why would a man with only one working eye have a stereographic Magic Eye image in his office?

    …for the people who go through? Why would an adult pediatrician have Highlights for Children in his office?

    • DanielLC says:

      Or he could have put it up there before he lost his eye.

    • LHC says:

      That was just a hint. The [DECEASED] label was the real kicker.

      • Shenpen says:

        I must say I did not understand the ending. I get it so far that Trauer was using rev. psy. OK. But what is this stuff with deceased and do not refer?

        • Marc Whipple says:

          Trauer is dead. And has been for some time. “It is a ghost that is speaking to you now.”

          (The last line of that story is both hilarious and oddly sympathetic to me. 🙂 )

    • Miriam says:

      That was my favorite line! I took it to actually be a shot at the type of kids mystery stories that I loved when I was younger. Of course there are tons of other reasonable explanations…but it’s always some innocent clue that’s a dead giveaway allowing the young hero to solve the mystery.

  7. pterrorgrine says:

    I like how you fiction. Please, continue.

  8. I love it.

    I would buy an anthology of your stories.

    • Vivaldi says:

      I would buy the copyright of his stories. Seriously.

    • Mary says:

      Hmmm. . . . self-pub them would not be too difficult. . . though it would take a number of steps.

      At the barest of bare minimums, there is collect ’em all in a single document and slap a cover on it. A cover with no rights issues.

      • Marc Whipple says:

        Easy-peasy. Royalty-free cover images are cheap and widely available. The beaker on the cover of my short story book was a royalty-free illo. Cost a buck and a half for unlimited single-property use rights.

        • Mary says:

          Or less if you use a public domain one. Or muck up your own. (I use public domain for my fantasy works — and am planning on using imaginary stellar scenes of my own creation for

          I observe, however, that first off you have to find a good image, meaning not only attractive but indicative of genre and suitable for a cover, which is to say the right shape, looking good at a small size and a large one, and having a space for a title and byline.

          Or capable of being made suitable. There’s the gentle art of photoshopping in enough neutral space to put a title on, for instance.

          I muse on complications of this at length:

        • Mary says:

          Oh, yes, I also must note you want a rights-issues-free font, too.

          This is easier than images but not something to take for granted.

          • Marc Whipple says:

            (I am an attorney, but I may or may not be licensed in any jurisdiction where a person reading this is located. Nothing in this message should be taken as legal advice.)

            Type, aside from artistic wingdings and even that’s iffy, cannot be copyrighted. Digital font software can, but not the bitmapped output it is used to create. Many people believe that the bitmaps are derivative works of the font software, but this is not the case.

            If you had the right to install the font software on your computer, you can use the typefaces it contains for the cover of a book. Most ebooks don’t embed font files, so that’s not an issue in most cases either. (A PDF or similar document may include embedded font files, which changes the equation.)

        • The best cover I’ve ever had for any of my books was produced by a contest on my blog. Scott has more blog reader/fans than I do.

      • Deiseach says:

        Having seen some of the self-published/republishing out of copyright works on Amazon, I second that the cover art is no problem.

        Some of it is so obviously “I went online and found some free stock photos and slapped them together in MS Paint” that anything Scott might procure could not be worse and might well be better.

  9. Who wouldn't want to be anonymous says:

    This is the best thing ever.

  10. Excellent story; but the sudden change of viewpoint character halfway through is really confusing for a while. Maybe mark it with a line of asterisks or something?

  11. discorded says:

    Nice, although a little less satisfying than your other recent stories. I think it would help to tighten up some things (e.g., shorten the description of the dark side psychiatric community, which feels like info dump as dialogue), or maybe expand in places to give more of an emotional arc to the story. It feels aloof to me.
    (Disclaimer: you’re a better fiction writer than I am; this was just my layman’s reaction.)

  12. Toggle says:

    Bravo! The more you wrestle with the moral complexities of your chosen profession, the more fun I have.

  13. Lambert says:

    v.good. I do enjoy the highly surreal.

    Dark Side Psyciatry is the kind of thing that sounds like it would be common in the Greater Nightvale medical community.

  14. Glenn Willen says:

    This reminds me of Charles Stross’ “Laundry Files” series.

  15. Jack V says:

    That was awesome.

    And wow, you really, really, really REALLY heavily obfuscate your patient stories! 🙂

  16. danfiction says:

    I enjoyed it—watching one therapist use their technique to examine somebody else’s was a great structure for a story.

    Dr. Trauer reminds me of Walker Percy’s “Thought Experiment: A New Cure for Depression” (and, for that matter, Lost in the Cosmos in general.)

  17. Seladore says:

    Cosmologist here!

    It’s actually a common misconception that the Universe is 15 billion light years in diameter. The actual figure is 93.2 billion light years in diameter.

    The misconception stems from assuming that the Universe can only expand at the speed of light. Thinking this, a 15 billion year old Universe can only be 15 billion light years wide.

    But, this isn’t the case. The speed of light only limits the velocity of objects *inside* the Universe. The expansion of space itself can go at any speed. Measuring the actual expansion speed, we get a diameter of 93.2 billion light years.

  18. ChosenOneMore says:

    I wish to enthusiastically second the idea that you should publish an anthology of your stories.

    (However, that was super, super scary to someone who might soon become a postdoc in biochem.)

    • Tracy W says:

      Why? It’s not like you can escape dark psychiatry just by not doing a biochem post-doc.

  19. Chris Cooper says:

    The story is brilliant.

    I’d like to add my own clumping, prosaic, literal-minded, missing-the-point-yet-strangely-intriguing factual query: as a Brit, I know next to nothing about US medical insurance. What’s the grain of truth, if any, behind:

    > … when you see out-of-network providers, your insurance actually charges, charges an extra fee. Even if the visit itself is free.



    • It’s a totally false statement, where the grain of truth is that US insurance is complicated enough that people can’t easily tell the difference between true and false statements.

    • Loquat says:

      What we’ve managed to do over here is create a system where most people have no idea what the “true” price of a medical service is or how their insurance company determines what the patient pays, and the massive amount of political whargarbling surrounding Obama’s health care reform has only added to the confusion. The truth is that if an American sees a doctor who’s not in their network, their insurance company will make them pay either (a) the entire bill, or (b) a larger percentage of the bill than they’d pay for an in-network doctor, but I have to admit I really only know that because I’ve worked for health insurance companies.

      • Mary says:


        It’s always been described in my insurance plan. And the website for my insurance always lists “in-plan” and “out-of-plan” separately in my out-of-pocket totals. Plus the letters I have sometimes gotten from providers or insurance companies or both telling me that negotiations were breaking down and the provider might go out of plan. . . .

        • Loquat says:

          Well yeah, if you read your policy and pay attention you know what to expect. But I can tell you from experience, a substantial number of people do not read their policies, and of those that do there are still some who will readily fall for all sorts of false claims about what Obamacare has forced or will force their insurance company to do.

        • ADifferentAnonymous says:

          I thought it was that simple, too. Then I learned (fortunately not first-hand) about “maximum allowable amount”, “balance billing” and “drive-by doctors”. Google those if you don’t know what they are, and then reevaluate how stupid a patient would be to believe there’s an inexplicable fee for a free clinic.

      • Joshua Hanley says:

        Don’t forget the part where neither the insurance company’s employees, their website, the doctor, nor the hospital/practice which employs the doctor can definitively tell you whether a particular doctor is in-network for your plan.

        • BBA says:

          And sometimes a doctor you don’t choose and never interact with can bill you. Sure the hospital where you’re getting surgery is in network, but what about the anesthesiologist?

          • Mary says:

            It astounded me how many different bills I got after my operation. . . .

          • Loquat says:

            Oh man, the out-of-network anesthesiologist who works at the in-network hospital… my husband just found out about that phenomenon, and now he’s pre-emptively planning to act as gatekeeper at the theoretical birth of our child. I’m not even pregnant yet and he’s already rehearsing his “prove you’re in our network or GTFO” routine.

            I laugh, but considering that thousands of dollars’ worth of medical bills could be on the line, I’m not about to stop him.

          • Deiseach says:

            Yes, what is it with anaesthesiologists? The one time I had (a) a private health insurance policy (b) needed a small surgical procedure which had to be done under anaesthesia, the same damn thing cropped up with getting reimbursed: paying the consultant, fine. Paying the clinic, fine. Paying the anaesthesiologist – um, hang on, we have a dispute going on here.

            Also re: allergies, my late father was allergic to penicillin and of course, anytime he had to be admitted to hospital, the usual “Does he have any allergies?” “Yes, he’s allergic to penicillin” exchange took place. But we found we couldn’t assume that doctors read the notes, because there were a couple of times one or another went “Well, we’ll give him a course of antibiotics” and we had to ask “Is that penicillin?” and the amount of times – it got to the stage anytime a nurse, doctor or anyone who looked vaguely medical, said something like “Hello, and how are you this morning?”, we all automatically recited “He is allergic to PENICILLIN, are you going to give him PENICILLIN, please don’t give him PENICILIIN because he is allergic to PENICILLIN”.

          • Loquat says:

            re: anesthesiologists, in the US system it’s common for doctors who work at hospitals to be independent contractors rather than employees of the hospital, and as independent contractors they don’t have to accept all the same insurance plans the hospital accepts. It happens with a number of different specialties; anesthesiologists just happen to be the most visible.

            You’d think it would be logical to pass a law requiring everyone who normally works at a hospital to accept all the plans the hospital itself accepts, but apparently hospitals fear that would make it more difficult to recruit doctors.

          • Marc Whipple says:

            It would be a good idea to have some sort of regulation that said, “If a procedure takes place in a hospital that accepts Insurance X, EVERYBODY INVOLVED has to accept Insurance X.”

            The problem with it is that there are specialists who are sometimes called in to assist with procedures – anesthesiologists are the best example – who don’t take Insurance X, don’t want to take Insurance X, and who are the best qualified to participate in this particular procedure. As a specific example, there is an anesthesiologist in the south suburbs of Chicago who essentially specializes in pediatric dental anesthesia for children with communications issues (like my daughter.) If your kid is autistic or whatever and needs a general during dental surgery, he’s the guy you want. So if he doesn’t take your insurance, and the rule above were in effect, you’d either pay him cash or do without. And people do not LIKE doing without.

          • If I had an allergy like that one to latex or penicillin, I would get a warning label tattooed on both forearms.

        • Careless says:

          My psychiatrist is out of network 3 blocks from me, but in network 5 miles from me

          • Marc Whipple says:

            Has zero to do with distance, except that the doctor has to be in a jurisdiction where the insurance company can pay for medical services. Has 100% to do with whether the provider will accept the rates and payment terms the insurer offers.

          • Mary says:

            However, because of those restrictions, distance does have that effect.

            Could be the other way round in other situations, but that would be less — ironic.

          • Setsize says:

            Similarly, no ophthalmologists are in network for me inside the boundaries of the city where I live. Have to drive out to the bedroom exurbs before the office rent is low enough that any will take my plan’s rates.

      • Marc Whipple says:

        It helps if you realize that the development of health-care insurance provider networks is a never-ending battle between the forces of cost reduction and the forces of service expansion.

        For instance, take HMO’s. HMO’s were originally intended to be strictly-enforced provider-network plans which negotiated deep discounts with preferred providers and encouraged patients to use those providers by paying vastly reduced out-of-network contributions for use of other providers. In addition, they would have fairly large co-pays that would encourage people to use medical services responsibly. For example, one HMO I belonged to in the 1990’s had a 90/60 payout with a $50 copay for OON and a $10 copay for IN doctor visits. That is, they’d pay 90% of the total bill after the first $10 for providers that were in-network, and 60% of the total bill after the first $50 for providers that weren’t. Now that’s a pretty serious incentive.

        This worked very well in that it reduced costs considerably. However, people soon learned that it meant you couldn’t use the “good” doctor or the “good” hospital because they were in higher demand and therefore had less incentive to accept the HMO’s discounted payments. So they complained to their legislators and insurance regulators and employers and HMO were gradually loosened until the cost-savings had largely evaporated. Then people wondered why HMO didn’t save them any money and/or keep their premiums low like they had promised.

        With the ascendancy of Obamacare the service-enlargement side has won a critical victory. I would almost say “decisive,” but I really believe this battle is endless, because we really can’t afford Obamacare in the long term, so the forces of cost reduction will, with the help of math, eventually regain some tactical advantage.

        • CJB says:

          As a conservative working with the regulation of medical devices, my schaudenfreude glands are preparing for when all the people who worshiped at the shrine of European healthcare encounter European style healthcare.

          The most startling difference, for an American, is this-

          In the US, efficacy is the main focus- does a device work, does it work better than the competition. Particularly when it comes to the all important insurance coverage- the US is (was) incredibly focused on having the best things available, but passing the costs on.

          In Europe “efficacy” and “Cost” are equally balanced- if you’ve got a device that’s a lot better but more expensive than the alternative? Too bad- hope people can pay for it out of pocket…..if you can even get it registered in the first place.

          I’m looking forward to people discovering that actually, no, you aren’t getting the Brand New Top Of The Line Treatment- you’re getting the 20 year old tech because it’s cost effective.

          • Shenpen says:

            As a Euro how could I even demand my government to provide the latest tech if I have no idea even what it is? When my dad got cancer, it looked modern enough – CT, MR scans, surgery, chemo.

            Then it got worse, and nobody really knew why, it looked just like infections, but he could not eat, got about 1000 kcal in his bloodstream a day which should be enough when bedridden but got thinner and weaker every day, the made him swallow an ultrasound probe which they claimed is modern tech, found nothing, then he suddenly died, official reason was pneumonia but autopsy found metastasis in the stomach which the ultrasound did not find. RIP at 63, cigar smoker, moderate drinker, exercised, was fit, and had a really lot of stress, so a halfway unhealthy life which I expected to last about 70.

            I sensed there is some incompetence going on here – this kind of a cancer patient should be able to saved.

            But as we here have no idea what is the latest tech, if the doc says swallowing an ultrasound probe is, and does not find shit with it, how can we argue or demand better?

            It doesn’t help that the latest tech is also usually invented in the US, or China, or Japan, or anywhere that is not so fucking decadent as the EU so this reduces the chance of EU citizens demanding it.

            Shortly before he died I talked with the boss doc. He said he already spent several times the allowed budget on him but will try some new things. I asked how this budget is calculated. He said it is at every stage of the prognosis they recalculate the expect number of quality years left in ones life and have a budget per that.

    • Marc Whipple says:

      None at all. Insurance companies do not charge overhead fees to their insureds. A clever fiction to support a clever premise.

    • Chris Cooper says:

      You’ve worked hard on these answers! What have I learned?

      … EvolutionistX and Marc Whipple tell me there’s no truth in it.
      … Mary says she’s seen it in her plan. And Loquat seems to agree.
      … And I can ‘t understand what anybody else said.

      The UK National Health Service made a brilliant PR move when it decreed all treatment would be free at the point of use (and pretty much all of it free to the patient, period). It makes us very stupid consumers, and the whole shebang is collapsing, but we love our NHS, ‘cos we don’t have to worry about all this insurance stuff you’ve talked about above.

      I’d love to have a free-market health-care system in the UK. I bet you’d like to have one too.

      • Mary says:

        They also timed it with the introduction of mass-produced antibiotics, which would make any system look better.

      • BBA says:

        There hasn’t been free-market medical care since physicians lobbied Parliament to pass a law banning the practice of medicine without a license in 1511.

        • keranih says:


          (Not a simple issue. But, yeah – the license is (on top of everything else it is) a gatekeeper for a money-printing business.)

      • Loquat says:

        Clarification – there is no extra fee the insurance company charges on top of the out-of-network doctor’s own bill. Worst case scenario, the patient pays the doctor’s entire bill as if they had no insurance.

        My assertion was that the system is sufficiently opaque that a lot of people don’t understand how their out-of-pocket costs are determined, and I believe Mary was saying this should not be the case because her own insurance plan’s cost structure was clearly described in the plan materials.

        ETA – I would be very interested to see a true free-market system with actual price transparency. Sooooo many of the complaints we have over here stem from the utter lack of knowledge among both patients and doctors of how much a given treatment will cost.

        • no one special says:

          I would be very interested to see a true free-market system with actual price transparency.

          A friend of mine’s wife is from Jordan, and he told me that they try to get a decent amount of their work done when they’re visiting there. Two things leap to mind; One: They could buy common prescription drugs over the counter, so they would buy in bulk and then just fill their own prescriptions from their stores. Two: that when they went to the dentist, the dentist gave them their own X-Rays, the easier to move them to another provider, if needed.

          (And everything was a whole lot cheaper, of course.)

  20. Ptoliporthos says:

    You lost me at the beginning.

    Why would a biology postdoc be hundreds of thousands in debt? Biology grad school is not like med school where everyone attends on borrowed money. If you don’t qualify for a fellowship covering your tuition and a stipend, then you don’t get admitted. Similarly for a post-doc, you either apply for a fellowship or are listed as key personnel on and paid out of your mentor’s grants. People who are that highly achieving tend to have done well with scholarships for undergrad as well.

    The only biology post docs I know with hundreds of thousands in debt usually also have an asset worth hundreds of thousands of dollars — i.e. they have a mortgage on a house.


    Oops, forgot to say that otherwise I enjoyed the story.

    • CAE_Jones says:

      Meh, I’m a French BA with ~100,000 in debt just from undergrad. (Akrasia will mug and shoot your scholarships in an alleyway. And force you to switch majors to French, because Akrasia also hates lab reports.)

      So, yeah. If they didn’t get a free ride and went to an expensive Ivy league college (or one of the colleges that are approaching Ivy League prices because this somehow makes them more popular), and went all the way to Postdoc… I am not the least bit surprised at the amount of debt.

      • Setsize says:

        This varies wildly by field. Here’s some relevant graphs:

        US Ph.D. students in STEM fields typically accumulate no debt in the process (and existing loans are deferred, without accumulating interest, while the student is enrolled.) Typically they are employed as research/teaching assistants (i.e. the grease for the gears of the research machine) for a subsistence wage.

        Postdoc is a job that pays a living wage, not a further level of being a student.

        • Nicholas says:

          Postdocs in the state of New York qualify for food assistance.

          • Ptoliporthos says:

            That seems unlikely. The average biochemistry postdoc salary in New York State is close to the national average of biochemistry postdoc salaries $45,000 (mostly because these salaries are set by federal grants and fellowship programs). The income threshold for food assistance in New York State, even with 4 dependents, is around $31,000. Your postdoc on food assistance is either unusually fecund or not in biochemistry.

      • Ptoliporthos says:

        Ivy League schools are only expensive to wealthy students, but its a little complicated.

    • Horror story possibly involving the undead….. D-: ….. disturbed by accounting innaccuracies.

      • Ptoliporthos says:

        I assumed that the horror story would be improved by more accurate accounting, and not by removing the undead. Although maybe not.

  21. See also Provocative Therapy. As I recall, it started with telling patients inconvenient truths and drifted (apparently without the author’s knowledge) to teasing patients. I’m not sure which category telling someone suicidal that no one will be sad at their funeral falls into.

  22. Alsadius says:

    For people like me who were wondering what datura is:

    • Leo says:

      Nasty stuff. Lost some relatives to it. Stay away.

      • Anonymous says:

        If you don’t mind: what sort of situation are you living in where more than one person related to you has died from datura?

        • leshiggydonatello says:

          Maybe they did datura together? Random guess.

        • John Schilling says:

          In this context, “lost” does not necessarily mean “died”.

          • Leo says:

            Good guess. They’re alive. Just not exactly able to hold a conversation about something other than “buy me booze”. Even if you’re the staunchest anti-ableist in the world and think that they don’t lose anything by being unable to live alone or restrain violent impulses, I personally have lost [ability to communicate with] them.

    • Deiseach says:

      It constantly amazes me the things people will do to get high. Maybe Golden Age detective fiction is not commonly read nowadays, but I had enough exposure to “datura poisoning” as a murder method from those novels to at least get the idea that it was dangerous.

      I really don’t understand someone thinking “Well, I never heard of this stuff before, and looking it up I find it has a bad reputation – great, I’ll try getting off my face on it!

      • Leo says:

        Can you understand someone thinking “I haven’t heard of datura from old detective fiction or from psychiatry blogs because I read neither, but my druggie friends tell me it’s a great high, and since they also tell me it’s dangerous I can look brave by accepting the risk”?

        • Deiseach says:

          It’s the risk-running to get high I don’t get. That to me simply blares addiction, if you’ve never heard of something, looked it up, got a long list of “Noooo don’t this is bad juju” and still thought “Okay, there’s a very good chance bad things will happen, but still – I might get a temporary buzz!”

          I fully acknowledge the irony of somebody who’s admitted to suicidal ideation saying about someone else “This could possibly kill you, are you crazy?”

        • Setsize says:

          Approximately 0% of my druggie friends claim datura is a great high. It’s a thing you can get weird off of, and that’s enough for some to seek it out. Looking through a few Erowid reports, none of them really seemed to have started out fully aware of the risks.

        • Nornagest says:

          My druggie friends’ comments on datura generally fall into two categories: “I’ve never tried it, but from what I’ve heard it’s scary as hell” and “Jesus Fuck, no”. This seems to be a common theme for unscheduled hallucinogens; Salvia divinorum gets similar but less extreme comments, more along the lines of “thoroughly unpleasant” than “dangerous and terrifying”.

          I think I’d be more concerned about uninformed speculation, like what tends to get produced by the high-school rumor mill.

      • Anonymous says:

        Popular drugs (stimulants, opioids, GABAergics, cannabis) aside, most drug use it more about inducing novel states of mind than good feels.

        • Shenpen says:

          It seems you only observed it in highly intelligent people. I saw both. Highly intelligent people did acid and talk days on about philosophical insights. Lower IQ people went to some rave, did acid and when I asked them what it was like “LOL we so wasted duuuude like total wasted LOL it was fun we had no idea who we are lol just wasted”.

      • Tracy W says:

        We had a datura plant growing in the front garden of a flat I was in as a student. The police stopped by and my flatmate mentioned it (yes I know). The officer said datura was a self-limiting problem.

        • Deiseach says:

          Swerving aside to pick something out of that blog post about taking datura, the guy said the source he found was in asthmatic cigarettes and he couldn’t understand why smoking had been considered a treatment for asthma.

          Well, here’s where reading Edwardian crime stories comes in educational! 🙂 Yes, there were various brands of cigarettes for asthma, but they weren’t tobacco (or at least, not wholly) as in ordinary cigarettes.

          They did indeed contain datura (under the name of stramomium):

          The asthmatic had bitten off either end of the stramonium cigarette, and was soon choking himself with the crude fumes, which he inhaled in desperate gulps, to exhale in furious fits of coughing.  Never was more heroic remedy; it seemed a form of lingering suicide; but by degrees some slight improvement became apparent, and at length the sufferer was able to sit upright, and to drain his glass with a sigh of rare relief.

          If you think about it, before the invention of inhalers, how else to get an active ingredient into the lungs other than in the form of inhaled smoke?

          • houseboatonstyx says:


          • Deiseach says:

            Steam, certainly, but for an asthma attack waiting for a kettle to boil and then sticking your head over a bowl with a towel covering it is a long delay (not to mention if it happens when you’re in the street or the office or on an omnibus you can’t really use steam).

  23. vV_Vv says:

    I took my own pen and added “DO NOT REFER” in big letters underneath.

    Why not? It actually worked. Oh wait, the twist: the second psychiatrist is actually a dark side psychiatrist! (or he’s just trying to damage a competitor).

  24. Dan T. says:

    That “Suicide Hotline” sounds like something out of a Monty Python skit.

  25. notes says:


  26. Zach says:

    Brought to mind ‘the Suicide Shop’, which is a fun book translated from French about a store that sells death.é/dp/1906040095

  27. Deiseach says:

    I should trust you more, Scott. I thought when I started reading this that you were going to set up something along the lines of the Violinist thought experiment, but you did something much better.

    Though – paradoxical intention is a real therapy? When I read Chesterton’s “Manalive”, I thought Innocent Smith’s method of dealing with the suicidal (or more properly, those preaching/promoting a philosophy of suicide as the only sane and rational response to the universe) by shooting off a gun at them and carefully just missing them was nonsense (sorry, G.K., I didn’t think it would work like he said) but now it seems I was wrong and Chesterton was right 🙂

    • Scott Alexander says:

      The violinist thought experiment people use as a defense of abortion? I’m missing the connection.

      • Deiseach says:

        Probably it was because of the most recent flap about Planned Parenthood and selling/we’re not selling, we merely charge a shipping fee, foetal tissue.

        I’ve seen a bit of pro-choice outrage about crisis pregnancy centres (last time was a post on my Tumblr dash) and ‘how dare they’ about these fake clinics (wording as per Planned Parenthood) that cruelly and deliberately trick and manipulate vulnerable pregnant women by pretending to be real clinics but once they get the women into their clutches, they keep them there until it’s too late for them to have their abortion at their real appointment with a real clinic or they badger and brainwash them into not having abortions (see fearless undercover reporting on the horrors of these places).

        So I suppose I was primed and twitchy about seeing a defence of Planned Parenthood and/or pro-choice, particularly as I do think the Violinist experiment is set up as a “gotcha!” and does not really tackle the question it thinks it is tackling.

        “Suicide hotline that’s actually pro-suicide but fools person who thinks it’s real anti-suicide hotline” looked like it was the set-up to “crisis pregnancy clinic is fake clinic that forces women not to have abortions by tricking and manipulating them the way the pro-suicide hotline set the caller up for the free psychiatric clinic to talk them into suicide”.

        That’s why I said I should trust you more, Scott. Just because I’m gun-shy does not mean I should forget you don’t indulge in these kind of culture wars tactics. (Forgive me, I was expecting this to be “If you don’t agree that a suicide hotline should play on such semantic hair-splitting as ‘for’ versus ‘against’ and you don’t think they should use such tactics of deceit and misdirection, why do you think it is acceptable for crisis pregnancy clinics/anti-abortion activists to do the same?”)

        • Nathan says:

          Personally I read the violinist thing and can’t comprehend how on earth some figure it’s okay to let the poor bloke die. It’s not like he asked to be handcuffed to you.

          • Deiseach says:

            That’s why it’s a “gotcha!”, Nathan. It’s set up so as to steer you towards one (and only one) possible answer as the correct one, and you’re not meant to consider the other party involved.

            If you say “But what about the violinist?”, that’s missing the point. It’s all about you, the innocent party kidnapped and hooked up to this guy without your knowledge or consent and your life taken over for nine months while he uses you as a dialysis machine. If someone answers the thought experiment with “Okay, I’ll put my healthy kidneys at this person’s service since they’re a talented successful person who is achieving things I am not and cannot achieve in my ordinary common-place life”, then that is saying that you want women to be raped and forced to bear their rapists’ children, you monster!

            That’s why I think the proposer got it wrong; as it stands, it’s about “extraordinary measures” (or maybe even the right to die), but not about abortion.

            So even from a religious view of the matter, it is permissible to refuse extraordinary measures and answer that you’d refuse to help the violinist, and have that be consistent with opposition to abortion, as part of your religious/ethical philosophy.

          • Mary says:

            What I remember most clearly was the claim that it presumed nothing about whether abortion is permissible except to maintain that the question could be raised — when was it really presumed was that there was no question, the only matter at hand was who was the lucky duck with the right to decide.

          • In the violinist case, you didn’t arrange to have him be dependent on you.

            The problem with using it as an argument for permitting abortion is that, in most cases, the fetus is dependent on the mother due to choices the mother made, hence for which she is arguably responsible.

  28. R Flaum says:

    It took me a while to parse the sentence about the geriatric psychiatrists.

  29. Addict says:

    Highly entertaining! Almost as good as Anglophysics, better than God’s Response to Job!

  30. Ada says:

    So you need to post stories of yours lots more. Please.

  31. StataTheLeft says:

    Anybody know if there’s any evidence on when/whether paradoxical intention or provocative therapy is useful?

  32. Alraune says:

    “I’m sorry you seem to be upset. But this is the suicide hotline. It’s like how there’s the Walk For Breast Cancer, but also the Walk Against Breast Cancer.”

    I’ve always wondered how Suicide Assistance Dogs work.

  33. Pku says:

    Somewhat nitpicky, but if he was actually a darkside psychologist, wouldn’t Dr. Trauer be aware of reverse psychology and pick something that would actually work?

  34. fubarobfusco says:

    For some reason I am reminded of Hagbard Celine from Illuminatus!, the Discordian cult leader who, among other tricks up his sleeve, would sometimes give a new initiate a card that says:


    And, sometimes, instead, this one:


  35. John Sidles says:

    The Marriage Counselor From Hell
    (a true story)

    Alice and Bob  We’re here because we’re having trouble in our marriage.

    MCFH  No kids? No pets? No mortgage? Simple. It’s divorce-time.

    Alice (driving home)  MCFH is the worst marriage counselor ever.

    Bob  Definitely.

    Epilogue  Thirty-five years later, Alice and Bob aren’t so sure.

    • Scudamour says:

      It’s funny because it’s true, I sobbed.

      My rainbow facebook profile pic signifies that there’s now a new one born this way every minute. Welcome to the joy that is modern married life….

  36. LHC says:

    Ugh, you really need to write more fiction. You’re so good at it, especially seeing as it’s generally treated as a minor diversion compared to the rest of your content (which is also good, don’t get me wrong).

    • Scott’s fiction is sometimes good, but it isn’t as much better than the competition as his nonfiction is.

      • jaimeastorga2000 says:

        Seconded. Dr. Alexander’s fiction is okay, perhaps even publishable, but his nonfiction is world-class.

      • Dhaoxy says:

        Disagree. Point me to some “competition” that publishes short fiction of the weird and/or magical realism type as good as Scott’s.

  37. Joe says:

    Great post! This kind of writing is really awesome! I must be a glutton for punishment but this kind of therapy really appeals to me. If someone is being a jerk to you they must really love you. Who else would go out of their way to be an asshole? Then again they could just be evil. Life can be insane sometimes.

  38. Was there a date on the DECEASED line?

    Maybe the Magic Eye was there for verisimilitude.

    In any case, I thought zombies were overdone.

    • Marc Whipple says:

      He’s not a zombie. Classically, he’s a lich or a revenant. 🙂 He could be a Pratchett-zombie, but the same argument applies: Pratchett-zombies aren’t zombies.

      He could also be a ghost, for that matter. Psychiatrist-ghosts treating living patients isn’t even a novel fictional premise. 😛

      • Marc Whipple says:

        I thought it was a pretty good movie.

      • SFG says:

        Do liches exist as a separate species of undead outside of genre fantasy fiction? I thought it was just an old word for ‘corpse’, and Gary Gygax turned it into a new monster.

        To be exact, he displays no supernatural powers to make us think he’s an undead wizard of great power. 😉

        • Alraune says:

          The Chronicles of Prydain features a very identifiable lich. I don’t know where Lloyd Alexander’s idea came from, but that’s where Gygax got it.

          • Mary says:

            I think the question is whether the term was used. . . .

            Fantasy writers used it to mean “corpse (that happens to be walking around)” but the specific meaning appears to be D&D.

          • SFG says:

            According to Wiki, he got it from the short story ‘The Sword of the Sorcerer’ by Gardner Fox.

          • Mary says:

            I stand with C.S. Lewis’s Studies in Words in hand and ponder whether Fox’s usage was the word’s meaning or the speaker’s.

            After all, the modern day liche is, in fact, an instance of the older liche, it is a corpse.

          • no one special says:

            No, he wasn’t dead. I’d call him a Koschei the Deathless ripoff, but as Prydain is based on Welsh mythology, it’s probably got a local analogue.

        • Marc Whipple says:

          I think the use predates him, but no, it didn’t exist in that usage before modern fantasy IIRC.

        • Nornagest says:

          The term is a Gygaxism in this context, but there are distinctly lich-like creatures in real mythology. My favorite might be Koschei the Deathless, the villain of Igor Stravinsky’s Firebird and the Slavic folktales that it was based on.

  39. Jon Cantwell says:

    Yesssssss. Be weirder. Always be weirder. (And, seconding the Stross – Laundry vibe. Honestly, I’d love to see Scott roll up Iain M. Banks and Charles Stross and smoke the results; I’m also on the record as wishing he’d do nothing in the world other than write fiction as it is, though, so…)

    • Jon Cantwell says:

      Also, my mom has always said that the best way to get someone to stop wanting to commit suicide is to point a gun to their head; if it -doesn’t- work you can switch gears to “well, I won’t fire today, you have to wait for tomorrow” and work from there.

  40. Kevin S. Van Horn says:

    I enjoyed this story immensely! I especially got a kick out of the paragraph that ends, “An emotionally healthy person is a person who isn’t paying attention, and our job is to cure them.”

    • no one special says:

      This seems like a Lovecraftian/Cthulhu conclusion; Sanity is ignorance about the true nature of reality. Someone should do a writeup of Dark Side Psychologists for your favorite RPG.

  41. NZ says:

    I enjoyed this a lot, but thought it could have been about twice as long and gotten twice as weird. It ended just as it seemed to be warming up.

    People are saying you should publish an anthology, but that’s a tall order. I just want a sequel.

    • Mary says:

      A sequel could help fill up a collection. (Pedant’s note: an anthology is a bunch of stuff by different authors; a single-author’s stuff is a collection.)

      But be wary of being certain that an author can extend something. The Muse can be finicky about that.

  42. SFG says:

    Oh, and now that I’m done nitpicking: the story is very, very good.

  43. Loki says:

    Your fiction is amazing and I want to buy several books of it please.

  44. Noumenon72 says:

    I thought the twist was going to be that the second psychologist was also a reverse reverse psychologist, since he kept getting the patient to do things he said not to.

  45. dont-really-have-1 says:

    It’s official. You have too much time on your hands. WAY too much

  46. I’m late to the party, but I wanted to express my appreciation not only for the story (which had me laugh enough that I got some traces of tears in the corners of my eyes, congratulations) but also for the name of the ghost. Perhaps an understatement, but I still thought it was brilliant! 🙂

    (For those who don’t know, Trauer is the German word for sadness.)

  47. Jules.LT says:

    Loved it.
    I only hope that nobody will take the Obamacare thing seriously.