Related: 1/4, 2/4

[Content warning: psychiatry, suicide. Note that all stories involving patients are mixtures of several different people which have been obfuscated and changed around in order to protect confidentiality. The ethical standard I have heard in this situation is “must be so well disguised that the patient would not recognize himself if he read it” and I have tried to meet that standard – which means that these capture the spirit of situations only. The same is true of some of the other stories here, just in case. Please do not link.]


I’m back at Our Lady Of An Undisclosed Location hospital now as a final-year resident. You wouldn’t think a year would make so much difference, but it does.

Identifying residents by their year is easy. The first-years walk around, deer-in-the-headlights look to them, impossible to confuse with anybody except maybe a patient having a panic attack. The middle-year residents are a little more confident. And then the final year residents, leading teams, putting out fires, taking attendings’ abuse in stride.

(True story – last week an attending yelled at me for not knowing some minor detail about uraemic encephalopathy. Later I couldn’t find the detail he’d mentioned, so I asked for a reference, and he said it had been discovered by one of his friends at the big university hospital where he used to work, but the friend had died before he could publish his findings. I think the attending realized as he was talking that it might have been unreasonable to expect me to know a fact whose discoverer took it to the grave with him, but he didn’t apologize.)

It’s only sort of a facade. 99% of things that happen in a hospital are the same things that happened yesterday and the day before, so if you hang around long enough you can learn what to do, or at least which consultant you can call to make it not your problem anymore. On the other hand, Actual Pathology is still a gigantic mystery. I’m not sure this ever changes. One in every X patients with symptoms won’t have any of the things that could possibly be causing those symptoms, won’t respond to any of the treatments that are supposed to cure those symptoms, and you’ll still have family members and hospital administrators demanding that you fix it right now (and in psychiatry, X is probably a single digit number). All you can do is keep up the facade, put your skill at taking attendings’ abuse in stride to good use, and start learning necromancy so you can summon the one big university hospital researcher who studied it but never got a chance to publish their findings.


Two of the most important things I learned during my third year were “Tell me more” and “[awkward silence]”.

“Tell me more,” works for every situation. Part of the problem with psychotherapy is that you’re always expected to have something to say. As a last resort, that thing is “Tell me more”. It sounds like you’re interested. It sounds like you care. And if you’re very lucky, maybe the patient will actually tell you something more, as opposed to their usual plan to stonewall you and hide all possibly useful information.

I saw something on Tumblr the other day which, despite being about a 9-1-1 operator, perfectly sums up being a doctor too:

my bf has many interesting stories and observations from his new job as a 911 operator

my favorite is how meandering people are, even in the midst of a terrible emergency

they respond to “what is the emergency” with “well, the thing is, four weeks ago–”

and then he’s like “WHAT IS THE EMERGENCY RIGHT NOW”

and they’re like “so what happened this morning was, i said to my wife, i said–”


“oh i’m having a heart attack”


my second favorite is how specific he has to get sometimes

like, “what is your emergency?”

“i’m sitting in a pool of blood.”

“… is it… your blood?”

“yes i think so”

“do you know where it’s coming from?”

“probably the stab wound”

“have you been stabbed?”

“oh yah definitely”

Psychiatry is like this, except it’s all very vague, and your patients are really suggestable, and people are always afraid that if you just ask specific questions like “Are you depressed?” then they’ll say yes to make you happy and won’t talk about how the real problem is their anxiety or something. So instead, the patient says something like “I’m sitting in a pool of blood”, and I say “Tell me more…”. They say “Well, it’s my blood.” I say “Tell me more…”. After repeating this process a couple of times, we finally get to the stabbing, and the patient doesn’t feel like I railroaded over their chance to tell their story.

Or it helps you figure out what’s important to the patient. If someone said “I hate my husband so much,” my natural instinct might be to ask “Why?”. But maybe why isn’t the question the patient cares about. Maybe what she really wants to talk about is how guilty she feels about hating their husband, and if I asked her why then we’d get on a tangent about what the husband is doing that never addresses her real problem. Maybe she’s agonizing every moment about whether or not to divorce him, and losing sleep over it, and coming to me for a sleeping pill. Maybe she’s just hatched a plan to kill him and wants to check it over with me to see if I can find any flaws. In any case I should probably figure out why they hate him eventually, but if their real issue is whether or not I approve of their murder plot then we should probably get to that first.

So instead, it’s “I hate my husband so much.” “Tell me more.”

“I’m feeling depressed.” “Tell me more.”

“Sometimes I think life isn’t worth living.” “Tell me more.”

“Listen, if you don’t give me a prescription for Adderall right now I swear to God that I will stab you right here in this office!” “Tell me more.”

This has seeped into my personal life. I was on a date with a girl earlier this year, and whenever she started telling me about her life I would just say “Tell me more”, and it worked.

And then there’s [awkward silence]. I learned this one from the psychoanalysts. Nobody likes an awkward silence. If a patient tells you something, and you are awkwardly silent, then the patient will rush to fill the awkward silence with whatever they can think of, which will probably be whatever they were holding back the first time they started talking. You won’t believe how well this one works until you try it. Just stay silent long enough, and the other person will tell you everything. It’s better than waterboarding.

The only problem is when two psychiatrists meet. One of my attendings tried to [awkward silence] me at the same time I was trying to [awkward silence] him, and we ended up just staring at each other for five minutes until finally I broke down laughing.

“I see you find something funny,” he said. “Tell me more.”


If the patients are cryptic, the doctors are even worse. In a worst case scenario, I’ll be filling in for another doctor – this happens all the time at free clinics, but it happens at least a little wherever there are doctors who go on vacation. The documentation will be obscure or missing. The patient’s family is out of contact range. My only information will be the patient in front of me, whose information-transmitting ability is on par with that person from the Tumblr post who took four tries to mention that they’d been stabbed.

So imagine this – a guy from out of state moves in, comes to me without any documentation, and says in a monotone that his only problem is feeling “weird”. All my “tell me mores” and [awkward silences] fail to get him to explain further. I look at his medication list, and he is on a cocktail of supramaximal doses of really old-school antipsychotics that I could not imagine giving anybody unless they were an axe murderer who had killed their last three psychiatrists and I wanted to cool their metaphorical brain temperature to the level of winter on Pluto. Sure enough, the guy is stiff, displays no emotions, and his only hobby is staring at the wall – all exactly what you would expect of somebody who is super-drugged on all of the strongest chemicals known to mankind. I ask him if maybe he’s schizophrenic, or bipolar, or something. He says no, he just feels “weird”.

I know that if I don’t change the medication, he will probably be a zombie like this until such time as somebody else does change it, which may be never. But if I do change the medication…well, there must be some reason somebody put him on that, and the idea of somebody who needed that much medication not being on it is too horrible to imagine. Also, I’m only seeing him once, and then he gets transferred to someone else. What do I do?

The maxim is “do what lets you sleep at night”, so I punted. I kept him on his medications and turned him over to the next guy. I just hope the next guy gets my documentation instead of thinking “Dr. Alexander kept him on all this medication…I wonder what he knows that I don’t.”


“Instead of putting patients on these toxic medications, why don’t you just give them therapy?”

Sometimes I worry I might be the worst person in the world to do psychotherapy. My coping strategy is to not talk about or react to my emotions and wait for them to go away. This usually works. I know this is exactly the opposite of what psychotherapy is supposed to teach, and all I can say is that it works for me and I seem to be pretty psychologically healthy and maybe I am just a mutant.

My relationship strategy is the same. Date really low-conflict, low-drama, agreeable people. If we have a conflict anyway, then agree to disagree and wait for the problem to go away. Apparently this is terrible, and maybe this is why my only really serious relationship only lasted a year or two, but it leaves me with something of an understanding deficit for the people who want to replay every single argument they’ve ever had with their spouse and figure out exactly what it means about their mental state.

Heck, even polyamory is like this. I can’t tell you how many patients I’ve had come in because their partner is cheating on them, or they worry their partner is cheating on them, or they’re cheating on their partner, or their partner worries they’re cheating on them, or something, and my natural instinct is to just say “Have you considered not worrying about it?” and as usual my natural instinct is terrible. So instead I just say “Tell me more…” and listen to them describe how the possibility of their girlfriend cheating is rending their heart in two.

This is even worse in any form of therapy based around investigating childhood traumas. Look, I’m sorry you didn’t like your mother, but have you read The Nurture Assumption? But of course I can’t say that. I just have to play along. And then somebody expects me to come up with something to heal the maternal trauma that I’m not even sure people really have, and then if I do come up with something it feels like a clever fake.

Cognitive behavioral therapy is a little better, because it tends to be pretty common sense techniques that any reasonable person would agree with. The problem is, it’s pretty common sense techniques that any reasonable person would agree with. I think that I and most of my friends would respond to the average CBT session with a sort of anger at being condescended at, combined with annoyance at the therapist for wasting our time with obvious things. “My job sucks”. “Well, have you considered making a list of good and bad things about your job?” “Yes, that was the process by which I determined it sucks. How much am I paying you again?”

Most of the time I do therapy, I feel cringeworthy, unnatural. I feel like a fraud, even when (according to the supervisors watching me) I’m doing it exactly right. I feel like I’m responding to people in fake, silly ways, like they’re coming to me with problems from the depth of their being and I’m giving them facile non-answers. It doesn’t even help that most of them get better anyway. In a way, that just makes it worse. How dare you get better after me telling you stupid things I feel embarrassed to say? That’s just going to encourage people to make me keep doing that!


I nevertheless hold a special place of annoyance in my heart for psychoanalysis/psychodynamic therapy.

The attending who started my training in psychodynamic therapy (I got a new psychodynamic supervisor recently who I don’t know too well yet) was an elderly doctor in an office attached to the clinic, full of creepy modern art statues. He is convinced that patients’ lives revolve around their therapy and their therapists. I know that in moderation this is the idea of “transference”, a genuine and important tenet of the therapy style. My attending does not do it in moderation.

My patient will say something like “My best friend moved away and now I am sad”, I will think “That sounds straightforward, better bring it up to my attending and see how he wants me to deal with this.” My attending will invariably say “What your patient means is that he’s afraid of losing you, his therapist.”

I will say “No, I’m pretty sure he actually lost his best friend. He told me all about how they’d been together since middle school, but now he moved away to take a job in Texas, and then he broke down crying.”

Then my attending will get really angry and tell me that if I’m just going to take everything my patient tells me exactly literally, then I shouldn’t be in psychiatry, because a monkey could listen to a patient say he was sad about losing his best friend and conclude he was sad about losing his best friend, and my duty as a trained professional is to be able to see beneath that to the true thought which my patient is trying to express. Which is always, 100% of the time, about how much the patient cares about psychodynamic therapy and wants to continue doing it.

Even worse, he wants me to do this to the patient. When the patient says “I’m really upset about losing my best friend”, I’m supposed to answer “Are you sure this isn’t about how you’re worried I’m sort of like a friend to you and one day you’ll lose me?” If talking about relationships and cognitive therapy makes me cringe, this super quadruple makes me cringe.

Still, I have to do it, because my attending grades me and if I don’t pass psychodynamic therapy I don’t get to graduate. So I do it, and then my attending declares he was right all along based on extremely strained interpretations of whatever happens next. Like, if the patient misses their next appointment, he’ll say “I see your patient missed their next appointment. That means they’re having a defensive reaction to the fact that you called them out on their being afraid of you leaving them. And to think that you told me you weren’t sure that was true! This just shows how much you still have to learn about psychodynamics. I certainly hope that after this you won’t keep questioning me every time I try to help you.”

But when I leave for good, I’m getting him a present, and it’s going to be a copy of The Nurture Assumption. Heck, maybe I’ll give that to all the psychoanalysts I know.


It’s kind of morbid to feel smug about your patients not attempting suicide, but I guess I am a kind of morbid person.

The doctor down the hall from me had one of his patients attempt suicide in October. Then another doctor I knew had two of his patients attempt suicide in the same week in January. And I was really sympathetic and tried to comfort them, but I also had a part of my mind thinking “Hey, I haven’t had any of my patients attempt suicide yet, this is pretty good.”

March. April. May. My coworkers told me their stories, but I kept my secret morbid goal – I was going to go the entire year without any of my patients trying to kill themselves. I mean, on one hand this sounds like a pretty minimal standard. On the other, when you’re taking care of like a hundred mentally ill people, many of whom have really bad depression and a history of past suicide attempts, it’s not exactly trivial.

I got the call just a few weeks ago. The patient was a former heroin addict who had been clean for a long time. He slipped, took heroin, felt terrible, and stabbed himself in the heart.

Luckily the heart is a little to the right of where most people think it is. Stabbing yourself in the lung isn’t great either, but he was a young healthy man and he could take it. He went to the hospital, they patched it up a little, and he was fine. He said it was the best thing that had ever happened to him and now he knew how low he could get and he was going to stay clean forever and today was the first day of the rest of his life.

A lot of things in psychiatry are reverse lotteries. In the regular lottery, you pay a constant small cost for the possibility of a stupendous benefit. In the reverse lottery, you get a constant small benefit at the risk of a stupendous cost. Lots of things are like this. If you give someone a powerful medication, then they’ll definitely recover, but there’s a risk you’ll have a catastrophic side effect. If you let a severely ill patient leave your office when they promise they’re okay, then you definitely save them the trauma of an involuntary hospitalization, but there’s a risk they’ll do something disastrous. If you don’t check someone’s vitals every time you see them then it definitely makes the appointment quicker and smoother, but there’s a risk you’ll miss something really bad.

It’s really easy to fall into playing reverse lotteries. I think almost everybody does it to a degree. The usual pattern is to play some of them tentatively, do more and more of them as you reap the benefits and nothing goes wrong, then boom, close call, and you resolve never to do anything like that again and you’re going to do a full half-hour neurological examination on everybody who comes into your office including random passers-by who just want to use the bathroom.

After my patient stabbed himself I spent a week totally neurotic, looking over every aspect of his case – could I have checked up on his Narcotics Anonymous meeting attendance more frequently? Maybe if I’d given him a long lecture every appointment about how heroin was definitely still bad, that would have changed something? Maybe if I hadn’t forgotten to check his blood pressure that one time…? In the end, I decided I had done a pretty okay job on that case – which just made me more acutely aware of all of the reverse lotteries I was playing on everybody else. Now I’m a little bit paranoid. Maybe that’s temporary. Maybe it’s permanent. I don’t know. The DSM-V says you have to have it six months before you can give yourself a schizophrenia diagnosis, so there’s that.

I am getting good at dealing with annoying attendings, meandering patients, unreasonable requests, and silly bureaucracy. Actual Pathology remains scary, mysterious, and really hard to predict. Hopefully that’s what fourth year is for.

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596 Responses to 3/4

  1. MugaSofer says:

    I can’t imagine you haven’t thought of this, but: just as it’s irrational to play the Lottery, it’s rational to play the Reverse Lottery, and for the same reason. Expected utility, all that.

    Every time you cross the road there’s a small chance of being hit by a car, and so on.

    • DanielLC says:

      The lottery is specifically set up so that the odds are against you, which is what lets the people selling the tickets make a profit. Naturally occurring lotteries aren’t like that. Sometimes they’re worth it. Sometimes they’re not. The same is true of reverse lotteries.

    • Assume, to avoid DanielC’s (correct) point, that the reverse lottery is in cash with an expected return of zero. Ninety-nine times out of a hundred you gain a dollar, one time you lose ninety-nine dollars.

      Declining marginal utility implies that, just as with a normal lottery, the expected return in utility is negative.

    • B says:

      In finance this is sometimes referred to with the evocative metaphor of “picking up pennies in front of a steamroller.” In finance it is possibly rational because the worst that happens is you go bankrupt and possibly permanently destroy your reputation and many of your relationships. But when your life is on the line it is good to be extremely careful that the juice is worth the squeeze.

      Incidentally, that canonical example of this parable is the collapse of the hedge fund Long Term Capital Management, and the principals of that venture seem to be doing fine for themselves. Myron Scholes is now an executive at Janus, Robert Merton is at MIT Sloan and advises a large hedge fund called Dimensional Fund Advisors, and both still have their Nobel prizes. John Meriwether has had some spots on his reputation prior to LTCM, but ran a couple more hedge funds and is still insanely wealthy.

      • Chalid says:

        The “picking up pennies in front of a steamroller” strategies seem to usually have positive expected value. The “behavioral” explanation is that people overestimate the frequency of rare disasters and thus overpay for protection. The “rational” explanation is that in bad times, the utility of an extra dollar is higher.

        • Leit says:

          If you wait until the steamroller’s gone past then you have pieces of metal that are no longer legal tender, and so can be sold as scrap for more than a penny’s worth. Why would you try and pick them up in front?

          • If you wait until the steamroller’s gone past then you have pieces of metal that are no longer legal tender, and so can be sold as scrap for more than a penny’s worth.

            If coins were worth more (for the metal) than their face value, they wouldn’t remain in circulation for long, regardless of laws against melting them down.

            See: U.S. silver coins in 1964-65.

          • Glen Raphael says:

            A pre-1982 penny is worth about 40% more than a penny, which is why the US then switched from copper to zinc. (Post-1982 pennies are worth about a half cent.)

          • Chalid says:

            If you wait to pick them up, someone else will grab them first!

          • Steven says:

            Not any more.

            Back about eight years ago or so, when you had zinc at $2.10/lb, copper at $4.50/lb, and nickel at $22/lb, your basic 97.5% zinc/2.5% copper US penny and 75% copper/25% nickel US nickel were at melt-for-profit prices, yes.

            Now that zinc’s under a dollar/lb, copper is at about $2.25/lb, and nickel’s all the way back down to $4.60/lb, a current US nickel is about three cents of metal and a current US penny is about half a cent.

          • Ptoliporthos says:

            If it was worth it to pick up the pennies, someone else would’ve picked them up already!

      • Aran says:

        > worth the squeeze

        Metaphor choice…

      • Lumifer says:

        In finance this is sometimes referred to with the evocative metaphor of “picking up pennies in front of a steamroller.”

        Yep. Usually people who do this are aware of the steamroller but think that they are quick and the steamroller slow — they will be able to duck in time. Usually they are mistaken.

        canonical example of this parable is the collapse of the hedge fund Long Term Capital Management

        Nope. LTCM’s basic problem was the misunderstanding of the risk they were facing. They miscalculated their probability distribution (underestimating fat tails) and so when a tail event happened they didn’t have enough money on hand and were unable to meet margin calls. LTCM might be the poster boy for black swan events, but not for picking pennies in front of a steamroller.

        • CatCube says:

          No, the problem is that they usually are fast enough to pick up the pennies, until that one time where they slip or the roller is faster than it was previously, in combination with them getting (over)confident and letting the roller get closer.

          One of my favorite statistics came from a briefing given by a lady from the Army Substance Control Program on the installation I was stationed at at the time. The context was the standard briefing that us officers give every weekend before letting people go: “If you drive drunk, you’re going to get caught.” She pointed out that the average drunk driver drives under the influence 88 times before they get caught (whether by an accident or being pulled over). So it’s simultaneously true that you’re probably going to get caught (eventually) if you drive drunk, but the odds of it happening this particular time are still pretty remote.

          • Chalid says:

            I’m told that diversifying among a large number of uncorrelated penny-snatching strategies is a pretty good way to make money – they’re hopefully not going to all blow up at once, and so you reap the positive expected value without so much of the risk.

            Of course correlations have a nasty tendency to change at the most inconvenient times. And the very fact that people invest in this way itself increase the correlations of the strategies.

          • Lumifer says:

            @ Chalid

            diversifying among a large number of uncorrelated penny-snatching strategies is a pretty good way to make money

            It is. This idea was first popularized by Michael Milken who discovered that buying a lot of different junk bonds works well even if some of them default.

          • Anonymous says:

            It’s also the idea behind an MBS. Unfortunately those bad pennies turned out to be highly correlated.

          • Chalid says:

            @Lumifer That’s not really what I was thinking of. Junk bond prices are highly correlated with each other, for good fundamental reasons, and everyone knows it and (I think) has always known it.

          • Jason says:

            That they obscure the true odds of getting caught says something about how we process odds.

            I remember hearing something similar about HIV transmission. Telling the at-risk population there was actually only an 11% chance of transmission during intercourse was found to be extremely unhelpful to efforts to prevent HIV spreading.

          • Lumifer says:

            @ Chalid

            Junk bond prices are correlated, but their probabilities of default not so much. Basically the high yields of junk bonds are the compensation for the default risk, but Milken was the first to realize that the default risk is diversifiable.

          • Chalid says:

            @Lumifer But doesn’t default risk spike in a recession, for example?

          • Lumifer says:

            @ Chalid

            Yes, it does (2008 was not a good year for junk bonds). However there is still a large idiosyncratic component which is diversifiable.

            Basically, if you have a lot of drones gathering pennies in front of a lot of different steamrollers, some drones get smushed, but the pennies from the rest will more than pay for the replacement of the flattened drones.

        • alexp says:

          I’d always interpreted it as the steamroller is black swan events.

          • Lumifer says:

            Nope, steamroller is visible, you just think you can avoid it. Black swans are unpredictable.

        • lemmy caution says:

          One problem that hedge funds can face is liquidity risk:


          Hedge funds buy investments and short other investments in a way that historically provides a good return that is not that correlated to the stock market. If things start to go a little bit bad, they can face margin calls which can result in them buying shorted investments (or selling investments they are long on). This can cause the value of the shorted investments to go up (or the the investments that they are long on to go down) which will cause additional margin calls which will ….


    • Anonymous says:

      Hey! You’re cheating! Your gravatar isn’t symmetric! And why did you change the color? Aren’t you proud of purple?

  2. tcheasdfjkl says:

    I hate the awkward silence thing SO MUCH.

    It might just be that I had read about that strategy (maybe even on your Tumblr, Scott) before I went to my current therapist who uses it. But it gives me a really strong feeling of being manipulated – worse, of being manipulated through my guilt about other people’s feelings and need to smooth things over, which is ironically precisely one of the things I’m there to talk to a therapist about! Learning not to fix other people’s awkwardness is actually a great skill for me.

    So when my therapist awkward-silences at me, I recognize that she has violated normal conversational protocol and I sit there and wait for her to say something, and then I sort of feel like I won. (Except it’s awkward because she doesn’t know what to say either.) Which is not terribly constructive, but I hope she stops doing this at some point.

    “Tell me more” would be totally fine with me, though, because there the therapist is in fact being reasonable and straightforward in that they actually do want me to tell them more, and I can try to do so.

    • Bassicallyboss says:

      Next time, you could try politely expressing this feeling. Most therapists I’ve talked to have been pretty receptive to style requests like this.

      • tcheasdfjkl says:

        Yeah, but I’m not sure how to express it politely 😛

        • Jack V says:

          You could just say “should I go on?” if she goes quiet? Or if you’re not sure what would be useful, you could ask, “what do you think I should talk about?”

        • Umberia says:

          I feel like for a professional relationship the way you said it was plenty polite. But if you wanted to be extra careful you could use the sort of I feelings statements pop psychology loves. For instance “when you stay silent like that it makes me uncomfortable because it triggers my need to rush to fix social situations which is a big part of what we are trying to work on.” Then either ask for her to do something or ask can we talk about how I should handle those pauses. (I included the second since if you have a case study for what you want to address happening in the visit why not use it)

        • Luke the CIA stooge says:

          My experience is that rudely calling them (people who play mind games, not just psychoanalysts) on it is better than politely asking them not to.

          Politely asking is a sign of deference and perpetuates their dominance, rudely saying ” looky here, some who talks for a living has gone mute!” And then continuing to be rude until they engage you as a rival (ie. an equal) is far better if you want the dominance games to STOP.

          I’ve known many rivals who’ve become respected friends, I’ve never known a servile figure to rise to the ranks of equal through good service.

          • Jill says:

            This view assumes that the therapist is trying to play a game to put you down. That’s certainly not impossible. But it’s more likely they have some purpose for doing it, which you just don’t know.

            Why be rude or servile, either one? If you don’t understand, you don’t understand. Why jump to conclusions about what the therapist’s intentions are? Why not just ask what the purpose of their silence is. Maybe they are trying to be helpful in some way. Maybe they think you are needing more time to reflect on why you are there and what you want from the therapy, so they are making sure not to interrupt.

            Not every action or inaction that you don’t understand is a struggle for dominance. In fact, therapy works far better when there is cooperation rather than the therapist dominating the patient. So most therapists don’t want to do that. Most therapists want to be allies in healing for the patient.

          • @Jill:

            At a tangent …

            Do you think psychiatry is a real and useful body of knowledge? That’s a question about psychiatry, not psychiatrists. I can well believe that some psychiatrists provide a valuable service to their patients, just as other people with other labels, such as priests, sometimes did in the past. But is that because they have learned a body of scientific knowledge, like medicine or engineering, that makes them much better at it than they would otherwise be, or is it because they are perceptive people good at understanding the problems of others and helping them deal with those problems?

          • Lumifer says:

            @ David Friedman

            In the context of your question it might be useful to distinguish psychiatry (which generally operates by prescribing drugs and is focused on your brain) and psychotherapy (which generally operates by talking and is focused on your mind).

          • Evan Þ says:

            @David, given the existence of CBT, I’d say “yes.” The usefulness of any other psychotherapy, AFAIK, is questionable.

            (Note that virtually all my knowledge of psychotherapy, aside from pop-culture Freudianism, has been obtained from this blog.)

          • Nornagest says:

            I thought CBT was being looked at with a different set of standards, and when you apply the same standards to other forms of psychotherapy (even transparently superstitious bullshit like Freudianism), the difference evaporates?

            Don’t remember the details, though. Was probably a post lodged somewhere in this comment section’s cloaca, not that that narrows it down very much.

          • g says:

            Nornagest, you may be thinking of Scott’s post called Scientific Freud.

    • Pku says:

      I enjoy it because it gives me time to think things through. In most ordinary conversation, I worry that if I leave things open too long the other guy’ll assume I don’t want to talk about it and move the conversation away, but with my therapist I can really take my time thinking things through.

    • Liskantope says:

      I knew someone who at one point didn’t want to return to a particular therapist and cited awkward silences as a reason. As far as I know, she continued with that therapist for a while longer with good results, though…

    • Erythrogonys says:

      I once went to a therapist who used the awkward silence technique. He said nothing. I didn’t know what to say, so I said nothing. He continued to say nothing… After an hour had passed in silence, that was the end of the session.

      I expect Scott’s psychodynamicist colleague could explain why that was not a wasted hour for both of us, but I couldn’t, and so that was the only time I tried talking therapy.

      (It occurs to me now that this must happen all the time to therapists who use the “awkward silence” technique, so there must be a standard explanation for why it’s a good thing.)

      • Shieldfoss says:

        here must be a standard explanation for why it’s a good thing

        It works.

        I mean, yeah, not for you, in that situation, and I don’t know why your therapist didn’t change tack but in general.

        I didn’t learn it as therapy (Because lol@the idea of me being a therapist), I learned it as a negotiating technique. If somebody makes you an offer, just say nothing. Maybe look like you’re thinking about it. Worst case, they fill the silence with “what do you say” (which is no worse than if you just accepted the offer immediately) and best case, they fill the silence with a reason for you to agree, like a price reduction or similar.

        I mean, theoretically they could fill the silence with “I recognize that technique and fuck you, the price just rose by 40%” but that has never happened yet.

        • Matthias says:

          There’s only so many gimmicks you can use in negotiations. The one true technique is to make sure you have good BATNA before you even enter the room: ie you can afford to walk away without a deal.


          (The gimmicks can be useful, but someone might call your bluff. There’s no way to call your BATNA.)

          • Alex Z says:

            Understanding what you are willing and able to accept and improving that before walking in the room is definitely important, but a lot of the time you’re negotiating over true surplus. And in those situations, improving your position will sometimes be a lot harder than claiming a bigger share of the surplus.

        • Simon says:

          Well I presume your therapist was getting paid so although that’s not a good thing it’s not harming him as such.

      • Lambert says:

        The real trick is to stare blankly at the wall for so long that your cones start to desensitise and the texture of the wall goes a strange kind of purple.

      • tcheasdfjkl says:

        Your experience is hilarious and mystifying. My therapist at least does start talking when it becomes clear I don’t have anything to fill the awkward silence with. Maybe your therapist just wanted to see if you would eventually crack.

        (Needless to say your experience is not at all typical for therapy and thus probably not a good reason to not try it again if you otherwise feel some need for it?)

    • schall und rauch says:

      Wouldn’t be a simple solution to break awkward silence with a question back to the therapist? That signals clearly that you don’t want to say anything more and that it’s the therapist’s job to continue the session.

      “What do you think about the situation?”, “Do you understand how I felt?”, “What should I have done?”, “What do you recommened how I cope with such a situation?”, “So how do we proceed from here?”, etc.

      • tcheasdfjkl says:

        Sometimes. But sometimes I don’t really have a question – often the silence is after the therapist has said something, and I guess she expects me to come up with something relevant to say about my life, though she doesn’t offer any sort of question or explicit prompt.

        Anyway, despite little annoyances like this I (so far) find talking to her helpful, so it’s not a big deal.

    • Saint Fiasco says:

      If you know that the reason therapists do that is that they expect that you are not saying something important, couldn’t you just cooperate?

      When it feels like they are giving you the silent treatment, just pretend that the awkward silence already stretched for 10 minutes without actually spending 10 minutes. Then just say whatever important thing you were not saying or just say that you don’t have anything else to say.

    • Ghatanathoah says:

      I hereby precommit to talk about nothing but “Dragonball Z” if I am ever in an “awkward silence” situation with a therapist.

    • Jill says:

      The therapist must have some particular reason for the “awkward silences.” You might ask her. It sounds like you are jumping to the conclusion that she wants to make you feel awkward or otherwise do something where she feels power over you. And you are instead sitting there waiting for her to say something, so you can “win” and instead exercise power over her.

      You don’t know, in her case, why she is doing it. It’s okay to ask. Perhaps she is actually doing the opposite of what you have guessed she is doing. E.g. perhaps she is trying to empower you, by giving you enough time to reflect on exactly what you have come to her for, and to express that–rather than interjecting comments or questions of her own, which might not be helpful to you.

    • Diadem says:

      Perhaps I’ve been really lucky with the two therapists I’ve talked to in my life, but with both of them I could just talk about therapy, during therapy. We often had meta-level talks about why they asked certain questions, or about the effectiveness of different techniques. I always found that extremely useful. It’s amazing how much easier it is to trust a therapist, and confide in them, when they treat you as an adult and equal.

      In your case I’d just tell her: “I’ve read that a technique many therapists use is to let silences linger, because people don’t like silence and will start talking if you let a silenced stretch on. It feels like you are sometimes using this technique on me as well. I have to admit that this really bothers me, for . Could you please stop doing this?”.

      There’s nothing wrong with such a request, and a good therapist will pick up on it.

  3. Pku says:

    I think these are my favourite kind of posts – the ones that aren’t study summaries or ideological arguments, just life stories. I can understand why you do them less now that you have lots of (often hostile) strangers following you, but I like reading them when you do.

    • ReluctantEngineer says:


    • Virbie says:

      +1, the comment threads tend to be better too, IMO

    • LPSP says:

      What is it with those sorts of comments and the word “autism” these days? Is it just the insult treadmill in action, or is it a sign of a rise in the actual condition’s prevalency? It seems to be a byword for “this guy likes something more than I think is appropriate”.

      • Nornagest says:

        “Autistic” is the new “retarded”.

        Well, not exactly. It’s more like the new “nerd”, but more offensive.

        • LPSP says:

          I think it’s fascinating how retarded and nerd have become so bundled up in this one term.

          The basic thesis seems to me one of calling out a phony – the slanderer is saying you use hobbies and obsessive pursuits to cover up a deep stupidity, and without those predilections we could all see how dumb you really are. The literature on autistics seems to say (to most people at least) that autistics are both geniuses (Isaac Newton etc.) AND hand-flapping Chris Chans who won’t shut up about Sonic the Hedgehog and leave their parent’s house.

          Regardless, the fact that autistics can recieve money from the government of most 1st world countries must be some sort of catalyst for the griefing. Some people recieve benefits because they’re disabled and it would be unfair to expect them to compete on a job market otherwise, while others recieve grants because they’re talented and the government is happy to support them in the hopes that their own devices will prove productive. Autistics may seem then to have the best of both worlds. It’s not fair! the average internet slanderer is saying.

          • Nornagest says:

            The literature on autistics seems to say (to most people at least) that autistics are both geniuses (Isaac Newton etc.) AND hand-flapping Chris Chans who won’t shut up about Sonic the Hedgehog and leave their parent’s house.

            Is this some sort of outgroup homogeneity thing? It seems obvious that, while they might both have been high-functioning autistic or aspies or whatever we’re calling it now, Newton was a lot smarter than Chris-Chan.

            (Newton wandered down a lot of blind alleys himself, of course, although they tended at least to be fascinatingly weird.)

          • Lumifer says:

            The literature on autistics seems to say (to most people at least) that autistics are both geniuses (Isaac Newton etc.) AND hand-flapping Chris Chans

            Not both, but either or.

            The autistic spectrum is very very wide. On the one end you have socially awkward geniuses. On the other end you have people do nothing but sit facing a wall, rocking and occasionally smashing their head into that wall. They are not the same people, though they are both called “autistic”.

            As to the insult, I think the underlying meaning is just “socially incompetent, so you’ll never get girls and I can stomp all over you to reaffirm my non-omega status”. I bet the “average internet slanderer” doesn’t even know about the existence of low-IQ mute self-harming autistics.

          • Cord Shirt says:

            As to the insult, I think the underlying meaning is just “socially incompetent, so you’ll never get girls and I can stomp all over you to reaffirm my non-omega status”.

            No, it’s more complex than that.

            John Michael Greer of the Archdruid Report has Asperger’s. His latest post has a concise summary of the problem that the insult “autistic” is accusing the target of having:

            The savant so saturated in abstractions that he’s hopelessly inept at the business of everyday life has been a figure of fun in literature for many centuries now, not least because examples of the type are so easy to find in every age.

            Sometimes this is a fair accusation.

            Other times it’s the accuser who has misunderstood the target, often due to a genuine g gap.

            And this confusion goes both ways. As I commented on another blog (OP was arguing that smarts isn’t unattractive, it’s attractive, and gave the example of “If a risk-taker is still alive, it means they’re smart”):

            Smarts lets you see more downsides and risks, which means all else being equal, the smarter person will be less smiley and take fewer risks. That’s what causes the problem people are noticing [MOTAS apparently not being attracted to smarts].

            BTW–from the average person’s POV, this is a problem in both directions. It’s not just that “oh it’s only that s/he’s smart” gets mistaken for unpleasant/boring. It’s also that sometimes “actually unpleasant/boring” gets mistaken for smart! I watched this happen to an average-IQ relative who was looking for smart. She found an average-IQ [disagnosed] autist instead.

            Sorry all, I wouldn’t normally be that implicitly insulting to diagnosed autists here, but that just means I’d give up on ever expressing the point here–it doesn’t mean I’m capable of expressong the point without the example or describing the example in a politer way. 🙁 (IOW I believe this is an example of a comment that would fit the old policy due to being “unkind, but true and necessary.”) It is a fact that she was looking for a high-IQ man, and it is a fact that the man she picked out had an average IQ and an autism diagnosis instead. (From the time before they did away with the Asperger’s dx, too–he fit the *autism* criteria, and more clearly than most who got the Asperger’s dx at the time, too.)

            The point I’m trying to make here is that:

            1. to someone who is not smart enough to see the relevance of your point, your relevant comment is indistinguishable from an actually irrelevant one such as is a diagnostic criterion for autism;

            2. to someone who is not smart enough to follow what you are saying, your real-world-valuable and/or relevant-to-their-interests comment is indistinguishable from the “droning on about unimportant/uninteresting things” that is a diagnostic criterion for autism;

            3. I have seen this play out in the real world in both directions; oh and to pull it all together

            4. if most people you ever encounter are not smart enough to see the relevance of or even to follow your explanations of *the only points you consider non-obvious enough to be worth making*…then *most people* will be sincerely unable to tell you apart from an average-IQ person who fits diagnostic criteria for “high-functioning autism.” (Well…except by resorting to IQ scores. One reason they’re valuable.)

            This is understandably something most high-IQ people don’t want to realize: That by behaving what to them is “appropriately”–only making non-obvious points; not assuming anyone else is any less smart than they are–they *truly are* making an impression on most people as “unpleasant and boring” (IOW as “droning on about irrelevant and hopelessly complicated things”).

            (It’s also tough for those who have typical social instincts to fix, too. If you have the social instinct that most people do, of typical-minding, then you *instinctively* use yourself as the basis for deciding whether some point is non-obvious enough to be valuable–and this usually happens at a level below conscious awareness. If you *have* that instinct, it operates so automatically that it’s hard to disengage. Those who lack it can often exhibit more adaptive behavior more consistently.)

            So back to the first point, there *is* such a thing as getting rigidly wedded to abstractions to the point that you lose contact with reality, and that is what “autistic” as an insult is referencing…and there *is* a reason the term became associated in the popular mind with that tendency.

            But also this phenomenon *is* easy to confuse with “person who’s making a valid point I can’t follow.”

            Like I said: A complex insult. And one that’s easy to misapply.

          • LPSP says:

            Nornagest: You would be surprised how often the concept of variable intellect seems to fly out the window once conditions are brought up. I’ve told people for example that maybe Chris-chan is a mess because he has an IQ less than 90, and recieved a mixture of blank looks, people acting like their minds were blown and snorting derision. “The autism” just seems to outweigh all other factors.

            Lumifer: That’s literally just the basic premise of the conversation that you’re underlining. The fact that the term autism means all of these things may be a factor in why it pisses people off, and lends itself to use as a slander, so much. (and lel, what, the kinds of people who throw terms like that around are drawn to worst-case-scenarios like flies. They probably know very little BESIDES the head-banging shriekers or the case studies in cringemancy)

          • Edward Scizorhands says:

            “Autistic” is mostly separate from IQ.

            If you have high IQ and are autistic, you will be able to super-focus on hard problems in your field, which tends to be successful.

            If you have low IQ and are autistic, you will super-focus on Sonic the Hedgehog, to the exclusion of everything else.

          • LPSP says:

            That is a fantastically complex analysis Cord Shirt, and one I pretty much cannot disagree on any point of substance. It is a bit of a waterfull of text, very stream of thought, but with a little organisation for easier parsing it’d be all-round great.

            The point you raise about how the average person would struggle to tell the difference between any high-IQ individual and any non-low-IQ autistic – it taps into the core issue I sought to explore, which is not only that the term autism is used wildly in everyday speech, but whether autism itself is even a useful diagnostic. I’d lean towards “yes, it is useful, but we all know it’s very easy to cock up”, precisely because the combination of specificity, adherence to only pointing out the non-obvious, high adaptability and superficial unpleasantness signature to autism really are indistinguishable from the condition of having a 140 IQ on the day-to-day level.

            When autism is used to describe particular oddities of behaviour in low-IQ or disabled people, such as highly limited verbality, hand-flapping or rocking and so on, the term’s usefulness as a tool becomes extremely evident. No-one can knock it because nothing else really describes that cluster of repetetive behaviour. nevermind so accurately and succinctly. I think our generation – which is to say our generation of shitposters and flamers, because they’re just normal people who would be perfectly polite over facebook or whatever – has picked up on this, and uses it as an exploit against “mid-functioning diagnoses” that are (/seen as) trying to claim special status but are really “retarded” (all by the crowd’s perception). As IQs climb higher, autism as a tool quickly turns vague and becomes ever more arbitrary in use. It makes me wonder if we should stop using it for high-IQ cases altogether.

            Alternatively, we could start using autism/asperger’s syndrome as episodic terms – an individual could be going through a patch of asperger’s for instance, with limited social interaction and an obsessive pursuit of some weird complexity. It would be no different to going through a hyperactive patch, or a phase of depression, or any other neurodifferential state which happens to have an associated chronic form (ADHD, depressive disorders).

          • wubbles says:

            Some of us have both high IQ, and exhibit rocking and flapping, poor theory of mind, and sensory sensitivities. I’m good at managing, and probably could stop some of the more obvious symptoms, but they are there.

            High IQ correlates with popularity, thus poking a hole in your theory of the insult. It’s an insult because it’s a difference, and we’ve decided that children should be allowed to be mean to those who are different.

          • Anonymous says:

            Am I going to have to be the asshole that makes the obviously true, but equally obviously unkind point?

            Online where we can’t see hand flapping or poor facial recognition ability we can still do better than a coin flip at identifying people with autism. It isn’t just an empty insult. When you are on a message board and you see the same old patterns as you see when dealing with autistic people in real life it isn’t hard to figure out what’s going on. The guy who can’t shut up about his pet topic even if it has no connection at all to the discussion? Come on now.

            Maybe it’s terribly mean to use autistic as a slur and people ought to especially not do that where they suspect it is true. But no matter how much we might wish it otherwise autistic people are often annoying to the rest of us. When people get annoyed sometimes they lash out. That’s just the way things go.

          • John Schilling says:

            Online where we can’t see hand flapping or poor facial recognition ability we can still do better than a coin flip at identifying people with autism.

            How do you know?

  4. Richard says:

    I find it amazing how much psychotherapy seems to have in common with consulting.

    In fact, I think it might be worth reading The secrets of consulting. it’s a quick and amusing read and you might pick up a few tips that can be applied to your line of work.

    • Scott Alexander says:

      Tell me more.

      • Nelshoy says:

        I think he [awkward silence]’d you.

      • Richard says:

        In my consulting gig, the client is usually aware that he has a problem, but has either a fundamentally wrong understanding of what it is, or at best no idea what the problem is.

        The trick is to:
        a) make the client come to a decent understanding of what his problems are, (it’s never just one)
        b) come up with a sensible strategy for prioritising said problems,
        c) then find a way of solving the most important ones,
        d) while all the time making the client believe he is the one coming up with the insights.

        you do this mostly by asking the client to tell you more, waiting him out and nudging him towards ideas.

        Sounds familiar?

        If you’re asking about the book, it’s just a very amusing introduction in how to do the above, speckled with fun anecdotes and examples. Worth the read just for amusement really.

        • So consulting is psychiatry for organizations?

          • Joeleee says:

            Interestingly, I often describe consulting as being a doctor for businesses to friends and acquaintances who ask what the hell I actually do. Seems to fit the bill pretty well.

          • Richard says:


          • Lumifer says:

            More like psychotherapy. Good drugs for organizations are hard to find, the usual radical measures involve things like amputations…

        • Anonymous says:

          I do software consulting, and I can absolutely confirm that this happens all the time. The client comes to you with some strange out-of-context technical question like “How do you raise the maximum number of file descriptors?” or “What’s the throughput of /dev/null?” and pretty soon you find out that their whole system is on fire and they’re desperately shooting in the dark trying to stop it (yes, shooting at a fire), instead of just telling you the problem outright and letting you fix it.

          (I apologize: these examples are somewhat contrived. I’m trying to change my clients’ stories for privacy, as Scott described. But you get the idea.)

          • Funny, these examples don’t seem contrived to me at all.

          • Murphy says:

            Contrived? the only question is whether the client is literally shooting bullets at a literally flaming server. And I can’t utterly rule that out.

            Clients do strange things.

            I get similar ones where someone will ask me about some tools for writing parallel code that i know damn well are going to be a nightmare for them because in their head they’ve got stuck on one possible way of deal with their problem and it turns out they can deal with it better with a few shell commands or switching a few things around in their code.

          • Leit says:

            Let’s not joke about shooting their servers. Was told a story by a guy who worked with banking software. Apparently their mainframes have a lot of redundancy, and this has always been the case. Some time back they relied on machines that had basically complete physical redundancy, with an actual metal plate separating the redundant components just in case. Think it was called a tandem mainframe.

            At one stage he was called in to help fix a minor data issue that had resulted from the client becoming frustrated and opening fire on the server. The damn thing was *still running*.

          • Sol says:

            Hurm, this is remarkably relevant to the (software development related) e-mail I’ve been working on writing in a different window. I wonder if I should add Secrets of Consulting to my reading list…

          • Lumifer says:

            help fix a minor data issue that had resulted from the client becoming frustrated and opening fire on the server

            Oh, so that’s what a “minor data issue” means… 8 -/

        • Before I coded for a living, I was briefly a BSA, or business systems analyst. Getting the business people with a problem and the IT people with a (potential) solution to talk to and understand each other was my full-time job. (And generally speaking, it was a failure of communication, not of capacity, that lead to the need for consultants to put out the resultant bullet-ridden server fires.)

          I bring this up because I was also trained in the Awkward Silence Kata, but my manager at the time strictly forbade me to use it on people from the IT side of the fence, because so many of them would either take it as a challenge or just be genuinely comfortable with silence.

          Of course, these days, if someone tries to lead with awkward silence, you can always go “So, how does this work? Do I talk first? Do you talk first?”

        • Gbdub says:

          Given that you presumably want repeat business, shouldn’t step d) be “all the time making the client believe your presence is absolutely essential for these insights to spontaneously emerge from the ether”?

          • Richard says:

            You’d think that, but in reality, you get more repeat business if they think they don’t need you. No idea why it works like that, but it sure does.

          • Anon says:

            It’s true. Clients like it when you tell them, “Oh, you don’t need to do that expensive thing; it’s a non-issue/you can do this cheaper thing instead.” It’s a signal that you’re honest.

          • gbdub says:

            I’m not saying be dishonest per se, or recommend expensive when cheaper will do. Just that a fishmonger who offers fishing lessons might find the clientele for his main business drying up.

            In seriousness, how do you, on the one hand, maintain your status as an “expert” worth paying for if you make the client think you were unnecessary? Don’t you need to make them see value in their investment?

          • Well, a big part of consulting is also being the fall guy that the client can point to if anything goes wrong with a solution. So, even if you convince them they came up with the ideas, they still want you around to backstop the idea to their bosses as “look at what this consultant we paid for said (who has insurance, btw)”.

            Most of my clients also like having some backup they can call on for dealing with contractors actually implementing the changes. They get to avoid being the bad guy or souring relations with contractors by saying, “look if it was up to us it wouldn’t matter, but this is what the consultant said and its their insurance we’re banking on if this breaks so we have to follow their instructions”.

        • naath says:

          This reminds me of the teddy bear left on the helpdesk when no-one was there “tell the bear your problem, he might fix it”… turns out lots of problems can be solved by a bear.

          • gwern says:

            (Better known as ‘rubber duck debugging’. Possibly also known as ‘the dodo bird verdict’…)

          • Outis says:

            See also: you don’t really understand something until you are able to explain it. In fact, you can often understand it better *by* explaining it.

          • Mary says:

            Which is why basic programmer courtesy is that the correct response to “Nevermind” in the middle of an explanation is “Glad I could be of assistance.”

        • Ghatanathoah says:

          That reminds me of a common piece of advice given to writers:

          “If a reader tells you your writing has a problem, they are probably right. If they tell you they know exactly how to fix that problem, they are probably wrong.”

          • onyomi says:

            That is such good advice, as applies to academic writing also. Rarely do peer reviewers actually tell you exactly what you really need to do, yet if they aren’t happy, chances are there is something you need to do, even if it’s just “cite them more.”

          • Mary says:

            Even if they tell you what the problem is, let alone how to fix it, they are probably wrong.

            The problem is when some readers single out the place for praise.

        • Kaj Sotala says:

          I’ve been reading about coaching recently, and this sounds just like it.

      • Vaniver says:

        I have that book. It’s excellent. The author was a software consultant who fixed business problems / established good systems, and much of the book is tips for how to get set up in consulting yourself. (Some of that will transfer to any other businesses you might want to run.)

      • Nornagest says:

        If this comment section was just a hundred people saying “Tell me more”, I would not have been disappointed.

        • LHN says:

          Though this suggests that programs like Eliza were actually too complex in their interactions, and might have been more effective if their responses were pared down.

          • jimmy says:


            I wrote a chat bot that hypnotized people on omegle. One of the main approaches I had it take was what is called an “expectancy induction”. Basically, “when I say X, you will feel Y. All you have to do is let me know when you feel it. Are you ready?” “yes” “X”

            I’d normally say other things if they didn’t respond in 30 seconds or so, but for the first runs of the bot I hadn’t gotten around to programming those in – figuring “oh well, a rigid approach like this isn’t going to get everyone, and if some people get bored and disconnect when it isn’t working, that’s okay”. However, looking through the logs I found that there were actually quite a few people responding that they felt it after several minutes of silence.

            Also, I originally had it parse responses into “yes” “no” and “neither”, each having their own response on the flow chart. Later I realized that it worked better to just ignore anything that doesn’t parse into “yes” or “no” and wait until they clarify/respond to the question asked.

            So basically, yes, silence works well for chat bots 🙂

    • Matthias says:

      Ha, the similarities between PUA tricks, and stuff that works in negotiations is eery, too. (And the failure modes are similar as well.)

      • Mary says:

        It’s almost as if they all had to do with people!

      • Edward Scizorhands says:

        Even if you hate hate hate PUA people, you should read what they do, because I’ve realized I had people pull the same things on me, and been able to deal with it in the future.

        I’ve been negged in professional situations. Once you realize what it is, you can just toss it out instead of proving how awesome you are.

  5. Tracy W says:

    On the awkward silence, I did a negotiating course once and the instructor told the story of the manager of the Beatles, as they were just starting to become famous. The manager got a call from America, which went something like:
    “Yo! We want the Beatles to tour the USA. We’ll pay $1 million.”

    “Oh you’re a tough man. $2 million!”

    • Walter says:

      I like the idea of America calling bands, and having a voice kind of like a gregarious frat bro.

    • Vaniver says:

      This is mostly how I did my salary negotiation the last time around; disinterest / mild disappointment whenever they mentioned a figure. (Then a few days later they’d call with a higher number.)

  6. Thecommexokid says:

    This post once again reaffirms that if you graduate and start practicing in a fashion that involves some variety of talk therapy and not just drug-prescribing, I will be very tempted to move to that place so you could be my shrink.

  7. AnonymousCoward says:

    Sometimes I worry I might be the worst person in the world to do psychotherapy. My coping strategy is to not talk about or react to my emotions and wait for them to go away. This usually works. I know this is exactly the opposite of what psychotherapy is supposed to teach, and all I can say is that it works for me and I seem to be pretty psychologically healthy and maybe I am just a mutant.

    My relationship strategy is the same. Date really low-conflict, low-drama, agreeable people. If we have a conflict anyway, then agree to disagree and wait for the problem to go away. Apparently this is terrible, and maybe this is why my only really serious relationship only lasted a year or two, but it leaves me with something of an understanding deficit for the people who want to replay every single argument they’ve ever had with their spouse and figure out exactly what it means about their mental state.

    Heck, even polyamory is like this. I can’t tell you how many patients I’ve had come in because their partner is cheating on them, or they worry their partner is cheating on them, or they’re cheating on their partner, or their partner worries they’re cheating on them, or something, and my natural instinct is to just say “Have you considered not worrying about it?”

    This hit so close to home, I thought I was the only one! Biggest downside for me has been when a partner has interpreted my lack of visibly being upset about or lack of initiative to “work through” a disagreement as evidence that I don’t care about them.

    I don’t completely ignore things when I feel bad, rather I treat the symptoms by going for a run, lifting weights, getting enough sleep and eating well. These things tend to make me feel happier regardless of the cause. If that’s ignoring my emotions then ignoring emotions is great!

  8. Anonymous says:

    Re: para 2. I once heard someone claim that in every educational institution the first years and final years are obvious. And in 2-year programs, the difference is stark.

  9. “and maybe I am just a mutant.”

    Maybe? How many other people do you know with forty hour days?

    “Most of the time I do therapy, I feel cringeworthy, unnatural. I feel like a fraud, even when (according to the supervisors watching me) I’m doing it exactly right.”

    Have you considered the possibility that therapy, done right, is a fraud? Does your account of your psychodynamic attending provide any relevant evidence?

    • Jugemu Chousuke says:

      >Have you considered the possibility that therapy, done right, is a fraud?

      I’m pretty sure Scott is in fact implying that psychodynamic therapy is nonsense. Less so CBT and other techniques.

    • Saint Fiasco says:

      From a consequentialist point of view, does it really matter? If fraud makes the patient feel better, and if the psychological issue was about feelings, then nobody is really harmed by the “fraud”.

      The only exception would be if the patient needs medication and is doing therapy instead of that.

      • Evan Þ says:

        Wouldn’t another exception be if some other form of therapy (whether formalized or informal such as talking with friends) would help better?

        • Saint Fiasco says:

          If you know about some other form of therapy that can work better, just do that form of therapy instead of the bullshit one.

      • Titanium Dragon says:

        Except for the fact that we’re paying people a very large amount of money to do something that we could pay literally anyone to do with minimal training, instead of twelve years of higher education.

        That would suggest that a great deal of the enterprise is ultimately a scam on some level.

  10. Rosemary says:

    I am an NP hospitalist and I do admissions from the ED and floor call over 12-hour night and evening shifts.

    I have never commented on your blog before; I am here only to tell you how EXACTLY EXACTLY that hilarious tumblr post (and your commentary on it) sums up my experience taking a history and physical.

    (This account also fictionalized.)

    “So, what brings you to the hospital today?”
    “Well, last time I was here — I think it was ’76? I broke my leg and everyone was real nice.”
    “No, I’m sorry, I meant, why did you call the ambulance this evening?”
    “I’ve been nauseous. Oh, and also I noticed I was yellow.”
    “OK. How long has this jaundice and nausea been going on?”
    “Oh, for six months at least, but my daughter says more like a year.”
    “………and what was it that made you call the ambulance tonight?”
    “Well, I’m YELLOW!”
    “Yes, I see that….was there something that changed in your condition? Sudden onset of abdominal pain, maybe? Intractable bloody vomiting? No? Nothing? It was just……it was one in the morning, and you thought, ‘I’ve been yellow for six months, now’s the time to come in?’ ”
    “Oh, no, that was the chest pain.”


    Keep fighting the good fight.

    • Richard says:

      To be fair to ER-patients and 911-callers, they have gone through something traumatic to get there. I know that the first time I was stabbed, the adrenaline and panic made certain I was not even remotely coherent.

      When you get to the point where you routinely patch the skin together with superglue and drive calmly to your regular GP for stitches and a checkup, you can give an accurate and concise description of the problem, but at this point, you’re not calling 911.

      • eyeballfrog says:

        “I know that the first time I was stabbed”

        This is something that happens to you on a regular basis?

        • Leit says:

          Doesn’t have to be stabbing.

          First time I was in a motorcycle accident, after rolling across the freeway, I got up, dragged off my scratched and cracked helmet, realised I couldn’t hear anything the very animated person next to me was saying, immediately lost interest in them and wandered into the (mercifully slowed down, thanks rubberneckers) traffic in order to retrieve my missing shoe. Spent the rest of the evening at the hospital in a similar unfocussed stupor.

          By the third time, I was calming down the panicked lady who’d hit me and explaining the process of filing an accident report, despite being in excruciating pain and having just been smacked across a road by two tons of tasteless metal and plastic.

          • Tracy W says:

            This reminds me of being a nurse’s aide at a secure unit for people with behavioural difficulties.

            Though no matter my experience, I kept getting the shakes after each incident. It got a bit weird, thinking, “okay shakes should be kicking in any moment now, oh, yes, there they are….”

          • It sounds like motorcycle riding might be bad for your health.

        • Richard says:

          I’ve had a few violent exes, so yes.

          • Outis says:

            Did they feel bad after the fact and patch you up, making them experts at first aid, which becomes plot-relevant when a major character shows up wounded at their door?

          • Finger says:

            Any tips on recognizing these people in advance?

          • Richard says:

            I have an absolutely perfect way of spotting such people: If I’m massively attracted to someone after knowing her less than 5 minutes, she’ll have a history of violent rages. This system has not failed yet 🙂

            Sadly, it’s not very transferrable and I have no good ideas for the general populace. On the other hand, since I obviously pick up on something subconsciously, there has to be something that can be observed.

      • Ghatanathoah says:

        I’ve frequently encountered people who have the exact same problem for much lower-stakes scenarios. I know people who are asked to explain the premise of a book and begin with a detailed biography of the author. I know people who go into detailed explanations of why they need something they want you to pick up from the store for them before even mentioning what it is. I know people who try to get you to watch five different Youtube videos so you will understand the context behind the one video they actually want to show you.

        • Schmendrick says:

          Can confirm. My mother (who otherwise is wonderful and who I love very much) is one of these people. I find this intensely annoying.

        • onyomi says:

          The psychology of this is really interesting to me. On the one hand, I feel like I am better at getting to the point than most people I meet. On the other, I very frequently have the experience of, after ten rewrites, finally figuring out what the main point of something I’m writing was all along.

          Pinpointing the main idea without “talking/writing a barn around it” as a friend might say is surprisingly difficult.

          Part of it is probably just that clarity and simplicity are harder than they seem because once something’s clear it’s hard to remember why it was once so confusing. But I think part of it may also be an innate tendency to focus on what is easy, even if it’s tangential. This happens in politics all the time, of course, where everyone focuses on feel-good symbolic stuff while ignoring elephants in rooms because addressing the elephant requires real, practical high-effort, slow-reward work, as opposed to grandstanding, which temptingly offers quick accolades for little work.

          • Amanda says:

            It is extremely difficult to be clear and direct, as I’ve noticed through consciously trying to be better at it. One is, as you say, I don’t always know what my main point is up front, even if I think I do. I learn things as I’m talking or writing. Two, is that I don’t do the thinking in advance, as I probably should. I know people who do, and they are more concise, but there are long pauses before everything they say. I know almost nobody who is quick-to-respond and focused on their point—not about a topic with any complexity anyway.

            On the other hand, I often intentionally give a doctor more information than they seem to want. If I’m taking my kid in for a non-emergency sickness or injury, I want them to know all the possibly-relevant information, even if I have to pay with the social awkwardness of watching them wish I would stop. I don’t push it as far as it might sound like I do, but I’m not stopping at, “sore throat for two days, fever of 102 since this morning.”

          • Virbie says:

            > The psychology of this is really interesting to me.

            I catch myself doing this occasionally, and for me it’s just when I’m distracted and my brain slips into a different conversational context (one in which having a tight summary of all the background is more likely to be useful than not).

            At work, when I tell someone about something, I’m usually pretty good at giving the relatively concise big-picture, just so the other person has all the information we need and we don’t need to go back and forth over it (this is particularly useful for email threads to avoid the potentially high roundtrip time).

            When I’m telling my roommate why the maintenance guy is coming at noon, he probably doesn’t need to know the history of why our CO detector needs to be moved, no matter how concisely I manage to communicate said history.

          • Nornagest says:

            On the other hand, I often intentionally give a doctor more information than they seem to want.

            I’ve found that I usually get better results from doctors if I’m intentionally vague about the problems I’m having. Giving too much context, or showing too much specific knowledge of the problem, leads at best to “oh, do you have a medical background?”, and at worst to a fifteen-minute kabuki dance where I restate everything in vague terms anyway just to prove that I’m not a hypochondriac or a medication-seeker.

          • onyomi says:

            I do sometimes feel like I’m in a struggle when I see a doctor because I believe I’m a special snowflake zebra and he’s looking really hard for a horse. I believe if he only knows all the details, he too, will see the zebra. He wants me to shut up so he can diagnose horse as soon as possible and move on to the next person.

            While I am often wrong about the extent of my zebrahood, I think my doctor is also often wrong about the extent of my horsiness. A big part of it comes down to my conviction that any problems I have are probably interrelated, whereas doctors don’t want to treat things that way. Again, they are sometimes right that the back pain and stomach pain are unrelated, but also sometime wrong.

          • Anonymous says:

            I recommend meditation and intermittent fasting.

          • Amanda says:

            While I am often wrong about the extent of my zebrahood, I think my doctor is also often wrong about the extent of my horsiness.

            Very true. In the imaginary scenario above, where I give the doctor the whole week’s worth of possibly health-related issues, the doctor listens with vaguely-suppressed signs of impatience, and at least 95% of the time, he’s right:

            sore throat + fever + stomach-ache-three-days-ago = strep throat + totally-unrelated-stomach-ache-three-days-ago.

            My brain just spends a lot of time focused on that 5%, (especially in different hypotheticals with confusing ambiguous symptoms).

        • alaska3636 says:

          I call this over-prefacing.

          As Schmendrick says below, my mother does this constantly.

          I see this happening a lot when people are insecure about requesting something and start trying to convince you before you have a chance to decline the first request.

          • Shieldfoss says:

            As with all my other problems in life, I blame overexplanations on my father.

            No really.

            Our relationship was (it has gotten much better now) not a good one, and a way to get what you want instead of a denial is to say why you want it so your request cannot be dismissed as trivially unimportant.

        • Anonymous says:

          I get this at work sometimes, when people need me to query a database for government records. The requests come in from the public as a standard form, filled out and signed. All my co-workers need to do is drop them on my desk and I’ll get back to them in five minutes, but surprisingly often they’ll show up, form in hand, and proceed to explain to me what the person called about, what a database is, what this database is for, and could I please check to see if we have these records in it?

          It’s amusing and annoying at the same time.

    • TomA says:

      Sometimes the reverse happens.

      Two years ago I suddenly started sweating sheets off my forehead into my breakfast and felt a tightness in my chest. I then picked my wallet and keys, drove the local ER, and walked up to the receiving nurse at the counter expecting to get a clipboard with forms to fill out. She looked up at me and simply said “go sit on that gurney back there” (pointing behind her). I said, “don’t you want my insurance card?” She said (in a forceful voice) “NO, GO SIT!” Fifteen minutes later I was in surgery and now have three stents in my LAD artery.

    • Garrett says:

      I volunteer in EMS. One of my first interactions to patient unreliability. Pt. is sitting in the ambulance with his shirt off.
      Me: “Do you have an history of heart problems?”
      Pt.: “No.”
      Me: “What’s that scar on your chest from?”
      Pt.: “My triple-bypass surgery.”
      Me: Facepalm.

      • Mary says:

        OTOH, there are other reasons, too:

        “Have you ever had any serious injuries?” I asked.
        “No,” he replied.
        “And have you ever been in the hospital for anything?” I continued.
        “Yes, four times.”
        “What for?”
        “Broken skull.”

        I should explain in parenthesis that the tattooed classes of England do not consider fractures of the skull to be serious injuries, even when they result in operations, steel plates inserted into the remainder of the skull, and prolonged sojourns in the hospital. It is difficult for them to conceive of everyday occurrences as being serious

        Context (not on this topic, actually 0:) here:

      • Berna says:

        “But that’s not a history! That was just the one time! “

    • HeelBearCub says:

      “I am at the intersection of $STREET and $AVENUE in $CITY and there is an (assault|fire) in front of me right now.”

      It’s usually better to adapt the user interface to the user.

      In this case, you are presenting the 911 operator with an unfamiliar interface that is step-inversed from their usual mode of interface.

      Far better to say “I need help. I see someone being being severely beaten [pause for the question] I am at the intersection of X an Y”

      The advantage here is that the first sentence is a response to the query they most likely asked “911. What is your emergency?” By responding with your location, you, are to some extent, providing a non-sequitur.

      • Diadem says:

        I remember from my first aid course that it is recommended when calling 911 (or actually 112, since I’m in Europe) to start with your full name. I don’t remember why this was important, but they were quite insistent on it. I think it had something to do with establishing yourself as serious / not a prank call.

      • tgb says:

        See I’ve read exactly the opposite advice in the past (thanks reddit) and did the script exactly as Mark did, which was how it had been recommended. I also had to repeat every step of the conversation. The rational for location first is that if that’s all they get before your phone dies unexpectedly, they’ll just send this your way which is a pretty good failure mode. This is just to make a meta comment on taking advice.

        But I wonder if this example is more another instance of the thing where I ask someone how to spell a name but then am somehow totally unprepared for the answer when they rattle off letters. Maybe it doesn’t really matter what the first sentence is, it just won’t be fully processed since our brains aren’t ready yet, apparently even for experienced operators. Perhaps precisely because they expect the first sentence to be side track, as it is much of the time. Maybe that’s why starting with your name works.

    • LPSP says:

      You know, I genuinely thought only my mother did this with explanations. I’m beginning to get the feeling that actually, not only am I not alone, but frankly I have it good compared to servicepeople who endure it from multiple strangers a day.

      How do you find the strength to perservere?

  11. Anonanon says:

    Thank you for confirming every bias I had about psychodynamic therapy.

  12. ------- says:

    Oddly as a patient I find this perspective quite comforting. I’ve always gotten along best with psychiatrists who tool the attitude that this was a complicated problem we were solving together by trial and error, not that they were the sole sources of enlightenment and wisdom

  13. Thursday says:

    I can’t tell you how many patients I’ve had come in because their partner is cheating on them, or they worry their partner is cheating on them, or they’re cheating on their partner, or their partner worries they’re cheating on them, or something, and my natural instinct is to just say “Have you considered not worrying about it?” and as usual my natural instinct is terrible.

    I don’t fault anyone for not being jealous themselves (being neurologically atypical is not a crime), but shouldn’t a little knowledge of Darwinian evolution be enough to know that the overwhelming majority of people are going to react just horribly to even the possibility of being cheated on.

    • I don’t think pure evolution exactly gets you there, because there are plenty of species that don’t pair bond or where female mate with multiple males, etc. But it may be an evolved thing for humans, or some humans.

    • Tedd says:

      a.) Evopsych is a much, much less reliable guide than people think, as you will find if you try to apply it to form predictions rather than explain known things, and,

      b.) obviously Scott knows that most people react poorly to the possibility of being cheated on, so I’m not sure what the evopsych analysis is supposed to do for him here.

    • Psmith says:

      I liked this piece a lot overall–Scott’s memoirist voice is pretty great–but that paragraph, well.

      I guess this underscores the importance of being willing to shop around for a suitable therapist.

    • Anonymous says:

      Just so!

      • Outis says:

        The “just so” thing is pretty much an isolated demand for rigor, though. It is a valid criticism of evo-psych from practitioners of scientific fields whose domain does not overlap with evo-psych. But when it comes to the actual conclusions of evo-psych, all other fields that offer competing answers are even more steeped in “just so” stories. Thus, pretty much everyone who has an actual object-level disagreement with evo-psych is not in a position to use the “just so” criticism.

        • Anonymous says:

          The default position is “we don’t know”. You don’t need a just so story to make that work and everyone is in a position to make that critique. Furthermore, Thursday’s comment doesn’t reflect any actual literature. It isn’t evo-psych. It’s a made up on the spot just so story, or even more accurately, hand waiving in the direction of a just so story that isn’t even made explicit.

          It was a terrible comment and he should feel bad about himself.

    • suntzuanime says:

      The reason we acquire a little knowledge of [X] is so that we can override our natural instincts when they are inappropriate/incorrect.

      • Outis says:

        It’s really just a way of promoting some instincts over others. Rationality has no value content.

    • Bugmaster says:

      You don’t even need evolution. Statistically speaking, most people react extremely negatively to being cheated on. Also, statistically speaking, this reaction is practically instinctual and nearly completely undeniable. You may argue that such reactions are illogical, or that our society would be better if people didn’t have them, etc.; but all of that is irrelevant.

      Our society would (probably) be better if everyone could fly by will alone; but when a guy comes to you with a broken leg due to a fall, and you tell him, “well, have you tried flying ?”, you are the irrational one in the conversation. Regardless of whether or not you happen to be Superman.

    • Julie K says:

      Interesting how people choose to have non-marital relationships, and then re-create the norms of marriage. (Not wanting partner to cheat; celebrating anniversaries.)
      According Judith Martin (“Miss Manners”), in the old days there were three categories of relationships: married, engaged and “just friends”, and if you weren’t in the first two categories there was no expectation of exclusivity.

      • HeelBearCub says:

        I don’t think this can be right.

        Dating rises after courtship ends, correct? I think there was, if not a strict prohibition, a sense that being courted by two men at the same time was likely to lead to high feelings, or that courting two women at once was caddish behavior.

        • Julie K says:

          a sense that being courted by two men at the same time was likely to lead to high feelings,

          So if a man was courting someone, he unilaterally rendered the object of his courtship off-limits to his potential rivals? Doesn’t seem right.

          or that courting two women at once was caddish behavior.

          In your favor: In _Persuasion_ (Jane Austen) the narrator says that Captain Wentworth was not to blame for causing his rival pain, because he didn’t know about said rival’s relationship with the lady he was courting, but “he was only wrong in accepting the attentions (for accepting must be the word) of two young women at once.”

        • HeelBearCub says:

          My understanding that one asked permission to court (usually of the parents of the woman in question). It involved all sorts of (relatively) formal interactions, usually with more people present than just the couple.

          I mean, that was only for those who had some social status though. I don’t know what the “commoners” did.

          Basically, I think that a) humans are sexual creatures, and b) there are pretty strong indications that rivalry for exclusive mating rights is pretty damn normal for our species.

          I highly doubt you will see many examples that differ from this basic behavior, no matter how many weird, formal steps they go through.

      • Tyrant Overlord Killidia says:

        Maybe marriage was invented to give authority to courtship norms that were prevalent before marriage.

      • How far back is she going? Fifty years ago there was an institution referred to as “going steady.”

        • Julie K says:

          She prides herself on being more old-fashioned than that.

          ” …it is perfectly proper and respectable for single people to date as many other single people as they wish.”
          _Miss Manners’ guide for the turn-of-the-millennium_ (1989)

          • Lumifer says:

            Note that the meaning of the verb “to date” changed considerably in the last 30 years.

          • Mark Z. says:

            Yes, it changed all the way from “not admitting that you sleep together” to “admitting that you sleep together”.

            In some sense this is a complete reversal of its meaning.

          • LPSP says:

            Which begs the question – what term replaced the old meaning? It seems we’re stuck with many awkward wannabe-portmanteaus like “I-like-him/her-but” or “I-maybe-fancy-X”, or unhelpful vaguery like “Just friends, 😉 😉 ;)”.

          • Leo says:

            Er, if I have feelings but no involvement with someone I “have a crush on” them, if we have some form of involvement but are not bound by any duties we are “going on dates” or “courting” or maybe “flirting”, if we are bound by a relationship we want social recognition for and that requires explicit breaking off we are “dating” (different for previous meaning) or “in a relationship” or “together”. What point sex enters the picture at is not public information and therefore doesn’t come with a label, if you need to know I’ll use the words “we’re not having sex yet” or “yeah, we’re totally banging”.

          • LPSP says:

            Ah, but that’s precisely the bit of information your parents want to know! You’re not marrying some harlot that will put out before marriage, after all.

            (I think this might perhaps underline an issue in the talk about cheating – even if you’re not having sex with a partner, you’d still be upset if they were seeing someone else. Or would you?)

          • Lumifer says:

            @ LPSP

            even if you’re not having sex with a partner, you’d still be upset if they were seeing someone else. Or would you?

            I think whether you’d be upset is a function of your “contract” with your partner — whether it includes exclusivity or not. Such “contracts” (which are, basically, a set of recognized expectations on both sides) are, of course, implied and usually not explicit.

            If the parties have not synced their understanding of the expectations, drama and fireworks follow.

          • LPSP says:

            That’s very literal and not wrong, but orthogonal to the point I was angling at – do you even have a contract at all, or will you just be upset no matter the circumstances? Perhaps anything that smells of an infidelity, no matter its actual content, is the trigger.

          • “even if you’re not having sex with a partner, you’d still be upset if they were seeing someone else. Or would you?”

            Assuming “partner” means someone you are hoping for a long term relationship with, possibly marriage, then yes.

            I think two different issues are getting confused in this discussion. If the woman I’m interested in has agreed to an exclusive relationship (which might mean not sleeping with anyone else, might mean not dating anyone else, depending on context) and is violating that agreement, that’s a reason to feel betrayed.

            But even with no such agreement, if I want to end up with her it’s perfectly reasonable for me to be unhappy at the existence of competition.

          • Lumifer says:

            @ LPSP

            I don’t think it’s orthogonal. The set of mutual expectations (“contract”) is what actually determines whether you’d be upset or not. In any kind of relationship, even casual, you always have such a set.

            Beyond that, expectations vary. For some people having sex automatically inserts the exclusivity clause into the “contract”, for some it doesn’t.

            Generally speaking, the concepts of “loyalty” and “betrayal” are relevant here. Basically, if you think you’ve been promised exclusivity (=”loyalty”) and that promise was broken (=”betrayal”), you will be upset. At which point and how do you come to the conclusion that you’ve promised exclusivity (rarely verbally, of course) is subject to much variation. And, as I mentioned, people make mistakes in interpretation.

            It is also the case that if you really want exclusivity and it hasn’t been promised to you, you will still be upset if it turns out you’re not getting it. But I think the degree of upset at “betrayal” tends to be much greater than at “S/he is not accepting what I want”.

        • Leo says:

          Yep, the contract that turns a “person I’ve been on a few dates with” to a “person I’m dating” is what makes it my business who else they’re involved in any way with. Whether the terms are “inform me when you’re bringing a one-night-stand home” or “do not flirt with anyone else” is orthogonal.

          I will tell my parents what they want to hear about whether we’re having sex, because one should lie to tyrants.

          • “I will tell my parents what they want to hear about whether we’re having sex, because one should lie to tyrants.”

            Does your parents’ power over you come from the fact that they are providing you with food and housing? If so, your “lying to tyrants” looks to me more like obtaining goods and services by fraud.

            If you are young enough so that if you leave they can have the police bring you back and they would in fact do so, on the other hand, your position makes more sense.

          • Leo says:

            I think you gotta extend that a bit further than 18, because on the day you turn 18, you can run without the police catching you, but on the other hand you have exactly the possessions and the job skills they let you get, they’re holding all of your paperwork, if you’ve been unlucky you don’t have any friends who aren’t completely allied with them. And I suppose as a card-carrying libertarian you won’t accept that all of society (from the employer that demands education you can’t afford without at least a letter from them saying they don’t support you so you can get loans, to the landlord who won’t rent to you) will punish you for doing so, but I do accept it. I also have no idea what you make of the possibility that through their actions you have contracted a disorder that makes it hard for you to do things in general such as depression, or difficulty evaluating your own self-interest such as crippling fear of ever going against them.

            I am not a fan of parenthood, as an institution.

          • Mark Z. says:

            “If so, your “lying to tyrants” looks to me more like obtaining goods and services by fraud.”

            One should also steal from tyrants.

          • Lumifer says:

            @ Mark Z.

            That makes declaring someone to be a tyrant to be very convenient, doesn’t it?

          • caethan says:

            How exactly do you think children should be taken care of then?

          • Leo says:

            If I knew that, would I still be here?

            A stopgap measure is to dramatically lower the age to make various decisions (medical decisions, where to live, how to manage money). Another could be to give “you’ll thank me later” teeth, allowing adult children to sue their parents for damage.

            What we need most is some escape from abuse, but I can’t think of what. All we have now is even more abusive than parents.

          • I think the obvious change is to permit children to leave their parents much younger than eighteen if they choose to do so, whether to support themselves or be supported by voluntary substitute parents.

            Your view seems to put all of the blame for how you turned out on other people and conclude that if you aren’t satisfied with your present state it’s their fault, so you are entitled to defraud them in response.

            Are you doing whatever you can to make yourself self-sufficient at present, thus eliminating the problem?

          • Leo says:

            No, I think this won’t help at all without some mechanism that helps kids be self-sufficient (in this economy?!) or that produces remotely decent willing caretakers.

            I’m extremely confused by that last part. This can’t possibly apply to a generic “you”, so what are you asking? Are you seriously telling me I am obligated to either refuse to ever visit my mum, or inform her of every detail of my private life so that I’m not defrauding her of some juice and crackers when I do?

          • “Are you seriously telling me I am obligated to either refuse to ever visit my mum, or inform her of every detail of my private life so that I’m not defrauding her of some juice and crackers when I do?”

            No. What I wrote was:

            “Does your parents’ power over you come from the fact that they are providing you with food and housing? ”

            Visiting your mother and not telling her things you don’t want her to know isn’t fraud. Living with your parents as an adult and deliberately deceiving them about things that you know matter to them because otherwise they won’t provide you with food and housing is. That’s why I put my comment as I did.

            Your “I will tell my parents what they want to hear … because one should lie to tyrants” pretty clearly implied that their treatment of you made you free to deliberately deceive them.

    • Alexp says:

      He obviously knows that people feel jealous. He just has trouble empathizing.

      And I’m not sure you it’s necessarily a good thing for your therapist to empathize.

  14. Thursday says:

    This is even worse in any form of therapy based around investigating childhood traumas. Look, I’m sorry you didn’t like your mother, but have you read The Nurture Assumption? But of course I can’t say that. I just have to play along. And then somebody expects me to come up with something to heal the maternal trauma that I’m not even sure people really have, and then if I do come up with something it feels like a clever fake.

    I wouldn’t be surprised if there are mental health issues that require some sort of trauma to trigger, but then life is filled with trauma, but you need to have an underlying genetic vulnerability, and it doesn’t necessarily matter whether it is your parents or someone else that delivers it. And, even if true, all of that really says nothing about what treatment should be.

    • Paul Torek says:

      Right. But one thing about treatment that seems pretty clear is that if you deny or belittle or just evade a patient’s concerns, there won’t be much of a therapeutic relationship.

  15. I spent a few seconds trying to figure out why you hadn’t reduced 2/4 to 1/2. 🙂

    You know, while you might tend a little too far toward the ignoring them end of the ways to deal with relationship problems spectrum, I think re-hashing them in endless detail is actually much worse.
    Technically, it’s not the hashing itself that’s so bad, though this does stress people out, so much as the basic underlying personality that leads people to keep replaying events over and over, to focus endlessly on potential slights or things that might have gone wrong or to keep being angry even years or decades after something bad happened, instead of moving on and continuing with life.

    CBT may be trying to address this; you probably can’t fix the fact that the person’s job sucks, but maybe you can help them cope a bit by not endlessly focusing on it.

    The only (grown) people I know who haven’t worked out their parental issues are the same people who endlessly re-hash everything. I think their problem is less that they had exceptionally bad childhoods and more that they’re just still talking about the bad shit that happened to them. (There are, of course, some people who really have had horrible childhoods.)

  16. TomA says:

    It’s natural to try your best. It’s unnatural to obsess on whether it’s good enough. That’s an evolutionary legacy in most species.

  17. anon says:

    Did anyone else read this post imagining it being narrated by Ellen Pompeo?

  18. Pseudoperson Randomian says:

    Ah, the “art” of history taking.

    In which you realize that cynically deconstructing how normal people work in normal situations and then using those insights to your advantage, at least on a subconscious level, is the best way to get the information (and the cooperation) you need.

    I once knew a Pediatrician who used intimidation from authority (in a third world setting), including yelling and threats, to get parents to cooperate, provide information and to follow instructions, even when those instructions went against tradition and taboo. It worked. Really well. Higher compliance and better outcomes, compared to his milder colleagues. Out of the hospital, though, he was one of the most jovial, happy-go-lucky, non-confrontational people I’d ever met.

    Psychiatrists just happen to be better at this sort of thing.

    Personally, I think most good doctors are fundamentally broken on some level, sort of like how most good soldiers are. We encourage this because the statistics keep coming back in our favor. And numbers always win. The universe doesn’t care about about your puny feelings.

    Somehow this reminded me of your post where you listed some of the more…uh, interesting feedback you’d gotten. I wonder why the folks calling you a “beta orbiter” get so upset and told you were “missing the forest” and that your posts are “just a bunch of bloviation with no purpose”, considering the whole “red pill” business, and the “SJW” business, are essentially cynically deconstructing normal people in normal situations to get/do what they want, and then writing really long meandering posts about their insights…your blog just has more numbers.

    • MawBTS says:

      I once knew a Pediatrician who used intimidation from authority (in a third world setting), including yelling and threats, to get parents to cooperate, provide information and to follow instructions, even when those instructions went against tradition and taboo. It worked. Really well. Higher compliance and better outcomes, compared to his milder colleagues. Out of the hospital, though, he was one of the most jovial, happy-go-lucky, non-confrontational people I’d ever met.

      Yeah, we all know at least one person who can bully their way to good outcomes.

      Steve Jobs was one. Gordon Ramsay is one. Perhaps Donald Trump, to an extent.

      Charming bullies – how do they do it? It’s a totally mysterious talent that seems impossible to emulate unless you’re one of them. Obviously 95% of the Silicon Valley wannabes who think that swearing at board meetings makes them the next Steve Jobs are going to crash and burn. And whenever I’ve tried to be a charming jerk, I just look like an asshole.

      • Pseudoperson Randomian says:

        I said “Intimidation from authority”, not bullying. Also in a third world setting.

        Two different things.

        “Out of the hospital, though, he was one of the most jovial, happy-go-lucky, non-confrontational people I’d ever met.”

        This last line was meant to signify that he used intimidation as a tool. Most people, by default, tend to comply with directions from an authority. Yelling is just a tool in the toolbox – one that needs to be used carefully, even. That’s all there is to it. Being a jerk and mindlessly yelling randomly isn’t going to get you anywhere. It requires some skill.

        Here’s another example from one of Scott’s older posts
        “With very few exceptions, there is nobody so mentally ill that calmness + authority + the implied threat of burly security guards won’t get them to grumble under their breath but generally comply with your requests, reasonable or otherwise.”

        My point is that this is not normal behavior, but is something that is learnt. Flexing the authority muscles (because people tend to respect and comply with it) is just one example.

      • Anatoly says:

        Survivorship bias, at least to some extent (I’m not claiming it explains everything, but important to keep it in mind).

  19. Zombielicious says:

    Perhaps the psychodynamics guy is playing n+1 levels deeper and giving poor psychotherapy advice in order that Scott questions and analyzes it as thoroughly as possible, thereby optimizing for more effective psychotherapy skills in the long run. He knows this is the most effective way to train Scott due to his expert psychoanalytical powers. Such psychodynamical genius allows him to affect the cues Scott conveys to patients, so that both the patient and Scott end up in the proper intended psychological state, thereby explaining any positive results in spite of having given intentionally ridiculous instructions.

    (100% joking, of course.)

    • Typhon says:

      « Such psychodynamical genius allows him to affect the cues Scott conveys to patients, »

      You don’t even need to go that far, you could argue that he’s playing some sort of utilitarian long game, trading off Scott’s current patients’ wellbeing in order to give him more effective psychotherapy skills towards his future patients.

      • Jiro says:

        That’s why we have ethics rules about the doctor acting in the best interests of the patient. You aren’t permitted to deliberately give a patient poor care to help future patients any more than you are to help the cause of scientific research.

        • Mark Z. says:

          More broadly, that’s why utilitarianism doesn’t work.

        • Tracy W says:

          Thus explaining why no junior doctors ever get trained.

          Actually apparently this is a reason why c-section rates are rising. With a c-section, compared to a forceps, training is easier as the experienced surgeon can see what the newbie is doing, and it’s basically the same technique regardless so it’s much faster to train.

          • Who wouldn't want to be anonymous says:

            You know, I thought the rise in c sections was changes in consumer demand.

    • FullMeta_Rationalist says:

      Hypothesis #2

      Psychodynamics (a subdiscipline of Placebomancy) derives its power from the Placebo Effect.

      If the Psychodynamics guy admits that Psychodynamics is fraud, then Scott will feel more comfortable since the secret is then Common Knowledge (between the two of them). Comfortable enough that one day, the secret might slip out in front of the patients. Then word spreads among patients that Psychodynamics is fraud. And suddenly, Psychodynamics has lost its power.

      The Psychodynamics guy’s goal then is to make Scott realize the truth of Placebomancy without admitting it outright. And the optimal method to achieve this is to dispense maximally absurd advice, much like how a Zen master will dispense contradictory koans in order to instill Satori.

      Placebomancy koans

      — The first rule of Placebomancy: never discuss Placebomancy.

      — If you meet the father of Psychoanalysis on the road, kill him.

  20. Leo says:

    My coping strategy is to not talk about or react to my emotions and wait for them to go away. This usually works. I know this is exactly the opposite of what psychotherapy is supposed to teach, and all I can say is that it works for me and I seem to be pretty psychologically healthy and maybe I am just a mutant.

    I think this is a reverse lottery. It almost always works, and it’s nice because it takes very little effort and hasn’t created any new problems by the time the old problem goes away. But occasionally it won’t go away, and festers, and you find yourself ruminating about a tiny problem and unable to focus on anything else, and therefore less able to function, which then creates bigger problems.

    If your go-to strategy is to ignore the problem harder, this spirals out of control. You need an interrupt signal to go and actually solve the problem. When it’s a practical problem that’s easy. When the facts are perfectly fine and the problem is obsession, it’s even easier: just complain to a friend, and then it’s not your problem any more and you can relax. I think a part of therapy is to provide this impulse to confront the problem, as well as a black hole you can complain into without consequences other than getting it off your chest.

    My relationship strategy is the same. Date really low-conflict, low-drama, agreeable people. If we have a conflict anyway, then agree to disagree and wait for the problem to go away. Apparently this is terrible, and maybe this is why my only really serious relationship only lasted a year or two, but it leaves me with something of an understanding deficit for the people who want to replay every single argument they’ve ever had with their spouse and figure out exactly what it means about their mental state.

    Yeah, I’ve tried this strategy and it is terrible, although bringing up every little thing is worse, and the Nonviolent Communication method of tying every little thing to your innermost feelings is worst of all.

    First, there’s a risk that you won’t succeed in ignoring the conflict. You’ll resent your partner. You’ll bottle it up until you blow up and have a major fight, or never blow up and just quietly grow to hate them. (Or you’ll go and complain about the problem but only to people other than your partner.)

    Second, if you never ask for anything and let your partner walk all over you, they will lose striking amounts of respect for you, strikingly fast.

    Third, if there’s a problem you’re ignoring and your partner isn’t, it’s quite likely that it’s because you’re getting what you want while screwing over your partner, and your partner is asking for a fairer compromise. If you won’t talk about it, your partner’s options are to let you have your way entirely (which is generosity or tolerant rejection of drama the first few times, and humiliation afterwards), escalate the drama until you can’t ignore it, or leave you.

    Fourth, if you only have arguments over things so bad you can’t possibly ignore them, you will have no idea how to stay reasonable and productive when you do end up needing to have one.

    Fifth, if you don’t exchange honest information about the nature and strength of your preferences, you will make wrong guesses. You will go six years without having sex because one of you doesn’t want to make a fuss, or you will give up all your hobbies because they look like they kinda bother your partner, or you will do the opposite of what your partner wants in an attempt to do them a favour.

  21. chaosmage says:

    So now there’s an internet commmunity of paranoid psychotics confirming each other’s delusions of persecution and mind control. They call themselves “targeted individuals” and they produce some fascinating and deeply disturbing web sites.

    No question, I just thought there’d be someone here who would be interested in that.

    • Outis says:

      Is paranoia connected to narcissism? The delusion assumes that you are especially important and worthy of attention.

      • Mary says:

        It’s a delusion of grandeur, and you have to monitor a paranoid patient after treatment to see if he needs treatment for depression.

      • LPSP says:

        That’s a good thought. I always felt that a lot of such states reveal egoism on some level. People who don’t have “the confidence” to do things, when questioned very simply about their ability or competence, often react with explosive pride and offense; victim complexes often revolve around the idea that “I COULD defend myself but that would be dishonest/unnice/[codeword for being like THEM], and seeing as how I am better than THEM I simply won’t”. Depressives often say they don’t recognise themselves in the mirror any more, which suggests that their reflection isn’t up to their internal standard – it’s too high, I must be better than this – leading to a cognitive dissonance between their cognition and their ego.

  22. MawBTS says:

    Interesting as usual.

    my attending declares he was right all along based on extremely strained interpretations of whatever happens next.

    They talk about how your beliefs should pay rent: that you’re more likely to come up with correct ideas when there are consequences for coming up with the wrong ones. It’s easy to believe in some weird model of physics when you’re sitting in your armchair. Not so easy when you’re trying to land a spacecraft.

    But it seems that for a certain type of people, this hunger for confirmation leads to a reality distortion field – facts being stacked and aligned so that their wrong idea gets confirmed, no matter what. ANY belief can pay rent if you give it infinite credit and a 0% APR. Misreading reality like this seems even worse than merely having a wrong idea.

    He said it was the best thing that had ever happened to him and now he knew how low he could get and he was going to stay clean forever and today was the first day of the rest of his life.

    Please keep us posted on this guy, at least insofar as patient confidentiality allows.

    I’m curious as to how often these “bouncing off the bottom” stories have happy endings.

  23. Lysenko says:

    Out of curiousity: My father was always on about “The House Of God” and its relevance to residency. Is that book still a cultural touch stone or is it pretty much out of fashion at this point?

    • roystgnr says:

      It was popular enough to inspire a runaway success medical sitcom in 2001. And it still has
      Amazon Best Sellers Rank: #4,290 in Books (See Top 100 in Books)
      #3 in Books > Humor & Entertainment > Humor > Doctors & Medicine
      #7 in Books > Literature & Fiction > Humor & Satire > Dark Humor
      #23 in Books > Literature & Fiction > Genre Fiction > Medical

      On the other hand, this just suggests that the general public hasn’t forgotten about the book. I’d also be curious to know whether today’s medical residents are particularly aware/dismissive/appreciative/whatever.

    • Lysenko says:

      Given that no one else has responded, I’m guessing either completely forgotten, or one of those “you have to read this!” recommendations that is pushed so often that it’s become tedious and is generally brushed off.

      I was especially curious as to how the last tenet “The Delivery Of Good Medical Care Is To Do As Much Nothing As Possible” maybe intersects with the experiences in this series of blog posts. I see some correlations, even if the practice of profit-driven unnecessary admissions has gone away.

      • Jill says:

        A lot of excellent books are old ones, that are so completely correct and informative that they have never been improved upon. Some ideas are just timeless, or at least correct for many generations in a row.

    • Anonymous says:

      I read it at the tentative suggestion of my physician mother, who knows that I like medical stories, and found it basically dreadful. Most of the jokes I recognized as having since found their way into general medical humor were treated in context as evidence of the protagonist’s depression and/or the general misery of clinical medicine, which was a surprise that didn’t work for me (black humor is funny, damn it).

      Psychology, especially pop psychology, has moved on; the increasingly overwhelmingly Freudian framing, and particularly the protagonist’s eventual recovery by way of Freudian insight, were totally bizarre to me—and a little revolting, rather like listening to someone obsessed with astrology or religion. I’m currently reading (unrelatedly) another popular book on psychology from the ’70s, and the extent to which psychoanalysis has just disappeared from cultural awareness (in comparison to other artifacts of the time) is pretty striking.

      I should specify that this was a while ago and my memories are now rather vague. I think my mother’s reservations were unrelated—she also knows that I dislike explicit sex scenes. I think that I found the book rather less explicit than she remembered, although I don’t recall whether she claimed that the orgies in the on-call room were totally true or totally false. I should ask her.

  24. Liskantope says:

    It occurred to me leaving his ritzy office that pretty much every philosophical idea I have – rationalism, belief in science, libertarianism, atheism, anti-SJ – originate in this feeling of revulsion at other people ordering me to believe things that I think are wrong and me not being allowed to argue with them.

    I am surprised that “libertarianism” is included here. My impression has always been that you have libertarian sympathies on many or most object issues, but that you reject it as a philosophical stance (hence the non-libertarian FAQ), but quite possibly I haven’t been reading the relevant posts carefully enough. I wouldn’t mind some expansion on how libertarianism fits in with the other views listed in terms of being ordered to believe things and not being allowed to argue. I guess I can see how it fits this description if we replace “not having the moral right to believe what seems right” with “not having the legal power to act on what seems right”. The similarity seems a little weak and never really occurred to me, whereas I always found the parallels between science, rationality, atheism, and SJ-skepticism to be obvious.

    • Murphy says:

      I think his positions tend towards libertarian by default but accepting most cases where people can actually justify government intervention reasonably.

      The libertarian community attracts a lot of quite independent minded people with a quite pleasant tendency towards not wanting to be told what to do/think/say.

      • James says:

        I also have a vague sense that Scott has slowly grown somewhat more libertarian in the years since writing that piece. Not sure how accurate that is.

        • Squirrel of Doom says:

          I think he just confirmed it.

        • Pku says:

          There was a post a while ago where he commented that when people tell him they like the FAQ he wants to respond “glad to hear it, have already started changing my mind.”

          I’m curious if that means he changed his mind in the bravery-debate sense of still believing the same principles but thinking reality is farther away from them to the nonlibertarian side than he thought, or because his principles got more libertarian.

  25. Rachael says:

    I really enjoy these kinds of posts.

    With your skepticism of CBT, you’re probably overestimating the average person’s rationality. I doubt they have made a list of the pros and cons, and that might come as a good insight. (And even normally rational people have their reason clouded when they’re upset about something.)

    • SolipsisticUtilitarian says:

      Well, I guess even to the average person it just sounds like trivial advice, something they could have thought of themselves, and having had to pay non trivial amounts of money for this advice they feel cheated. As with visiting a normal doctor, I expect some insight from the doctor, some proof to soothe my sceptical brain that I’m in safe hands rather than just waisting my time. The flaw in that reasoning is that even obvious advice still needs to be carried out in your life and a psychotherapist is probably best thought of as a facilitator.

      To combat the patient’s reaction, clouding this trivial advice in buzz words might be a strategy worth pursuing. “Make a list of good and bad things” becomes “Activiate your neocortex by conducting a positive-negative salience analysis”, “Downregulation of the evolutionary self- judgement system” for “Don’t be too hard on yourself”. If done right, Scott could become the placebo wizard he was talking about in an earlier post. I’m only half-joking, btw.

    • Murphy says:

      I’ve had to adjust my expectations on this score quite a few times in the past.

      I’d tend to assume that people with problem X of course would have tried [blindingly obvious simple, quick and cheap way of dealing with it] or at least [30 second obvious approach to trying to find a way of dealing with it] but it turns out that a very large fraction of the population lock up in the face of even minor problems, decide there’s no point trying and tear themselves apart inside until someone comes to walk them through a simple version of this sheet only for everyday life situations:


      • Squirrel of Doom says:

        I think most people do try the obvious things, but they’re not the ones who end up with the problems.

        Also, there are hundreds of potential problems, and if someone has successfully avoided all but one, it’s a little unfair to declare them fools for a 0.2% failure rate.

        I think I’m making a Selection Bias argument.

      • LPSP says:

        The thing about that comic is “icon or image that looks related to what you want to do” – nothing but sheer familiarity with computers will teach that to a person. It’s practically a sub-language of hieroglyphics that we all learn. Not surprisingly, older people without familiarity will struggle, for reasons entirely independent of their ability to think logically or grasp a computing process. How is grandpa supposed to know the difference between the piece of paper that brings up the fancy word processor, the piece of paper that brings up the sparse word processor, the piece of paper that opens up a random internet page and a piece of paper that does nothing but generate an error image? You could point out that 1 has a big M on it, 2 has lines across it, 3 had the logo for Chrome/Firefox/IE on it and 4 looked broken, but the problem is simply shuffled along one – how should I know what all these internet symbols mean, why the M means this one is fancier, what’s the difference between this and all the other M ones that open up the wall of boxes or the slideshows, and so on. It’s a baffling array of arbitrary facts that we computer-literates all take massively for granted.

        • FacelessCraven says:

          concur. Here’s the basic interface for a program I use frequently. I have a friend who ylearned to use it by hitting buttons randomly and seeing what they did; I’ve had little success with that method, as an awful lot of the buttons are state-dependent or -sensitive.

          bonus: Zbrush interface

          • LPSP says:

            Perfect examples. I just cannot get into image editors more complex than Paint for this exact reason. And for all that I sneered about Apple products as a teen (I’m still not a fan but I don’t judge people as heretics for buying them), at the end of the day what Apple offered was a legible interface with NO competition on the market. People like me were being the snobs purely because we lucked into being able to interpret Window’s brand of gibberish, and the same for Linux users.

          • John Schilling says:

            I was recently introduced to a very capable piece of image-analysis software, to not merely detect but quantify the extent to which images had been photoshopped, etc(*), where the user interface used deliberately obscure labeling with no user manual available. The software costs $30K, DRM can’t stand up to a grad student who wants a $30K package his professor can’t afford, but good luck ever using this without having the vendor send out one of his people for the three-day training session.

            * And the extent to which everything you see in the media and on the internet has been photoshopped is both surprising and disturbing.

          • Nornagest says:

            I’d love to play with that, but not $30,000 worth of love.

            …I wonder if you could do it by comparing the entropy in image regions. That wouldn’t even be that hard, you could just run a good compression algorithm over the region and see how big the output is.

          • CatCube says:

            Ah, yes. Getting anything done in a program from Bentley or Autodesk often requires learning the exact form of insanity the UI designer had.

          • Edward Scizorhands says:

            The software costs $30K, DRM can’t stand up to a grad student who wants a $30K package his professor can’t afford, but good luck ever using this without having the vendor send out one of his people for the three-day training session.

            A situation like this is always what I think of when people want all software to be open source because developers can support themselves by selling support.

          • Murphy says:

            @John Schilling

            30K. Wow, the sad thing is I have a pretty solid idea of how simplistic many of the metrics are. And yes. Pretty much everything is edited in some way.

            I wrote a set of tools for trying to do exactly this and the hard part isn’t figuring out if an image has been edited in some way, unless you’re dealing with someone who knows exactly how you’re going to analyze it it’s trivial, the hard part is spotting malicious editing.

            Pretty much everything has been lightened, darkened, rotated, cropped, re-saved at different quality levels etc etc etc.

            Most of these kinds of edits are “allowed”.

            My initial hope was to write my tools and then run the images from a few news sites through them. Unfortunately almost no images on public news sites are pure.

            The tools are however useful for newsrooms who are getting what are claimed to be raw/virgin images direct from the camera. Better again if they know the make and model of the camera or have a dataset of clean images from the same camera.

            I ended up with something which could generate a pretty decent report on an image and highlight areas of an image likely to have something odd going on.

            Still. 30K, fuck. I remember my brother telling me about when he discovered a product on the market roughly equivalent to his final year project wrapped in a slick interface for 250K. I think I now know how he felt.

          • Nornagest says:

            I remember my brother telling me about when he discovered a product on the market roughly equivalent to his final year project wrapped in a slick interface for 250K. I think I now know how he felt.

            If that was me, I think I’d be feeling like I should hire a couple of UI developers.

        • Lumifer says:

          I don’t think it’s a “sub-language of hieroglyphics” problem. I think it’s a problem of having a good grasp of the appropriate conceptual framework.

          If a grannie gets confused by icons on the screen, the real problem is that she doesn’t understand how the whole thing works. The icons being unfamiliar is just a relatively minor additional factor. But give a geek a new avant-garde desktop that decided to play games with icons and such, and he’ll figure out how to make it do what he wants fairly quickly.

          This is so because in the second case all you have to do is generate a mapping from unfamiliar icons to familiar concepts. But in the first case you don’t have familiar concepts, so you don’t have anything to map to. Instead you have a series of black-box relationships (press the blue button and a banana pops out; press the green button and music plays) so if the colors of the buttons change you become confused to no end.

        • I think the other thing which makes learning difficult is believing that one ought to be good at it, so that failure seems like proof of innate incompetence. This isn’t just a problem with computer interfaces, of course.

          I’m not sure how older people get to the point of understanding that while there is a sort of computer style of thought, a lot of what you need is learning one fact at a time.

          I did get there, and sometimes inspiration strikes about what I need to try, but damned if I can explain how I did it.

          • LPSP says:

            >I think the other thing which makes learning difficult is believing that one ought to be good at it, so that failure seems like proof of innate incompetence. This isn’t just a problem with computer interfaces, of course.
            This is an absolute pearl of wisdom. It’s the fountainhead of stubborness in students, of all ages. I tutor privately, and most of my charges are excellent and keen to learn. I have the good fortune to be selective, and sometimes I will turn one sibling down to teach another because I can detect this exact “I BETTER be already competent” attitude a mile off.

            The worst thing is its prevalence among family members, who want my assistance in math/computer (not even a tech geek) /political things for free but interrupt any explanation to snort at words that sound implausible, like they’re completely above this nonsense excercise. Inevitably, the truth comes crashing down that actually, no, you haven’t a clue what do to and by dismissing everything the teacher has said you have learnt nothing. First time, they blame the teacher. Second and third times, they’ll blame circumstances. After that they just say “it’s unlearnable”, or “we have different types of brains, I can learn X and you can learn Y”. Usually most anyone that knows Y also knows X.

            I talked somewhere else in the comments about how egoism often lies underneath other conditions, sometimes unexpectedly. This ties in nicely with that. What may seem to be an irrational put-down at a glance is actually defending a notion of superiority.

    • Lumifer says:

      you’re probably overestimating the average person’s rationality

      Scott was quite clear that he isn’t talking about average people: “I think that I and most of my friends would respond to the average CBT session with a sort of anger at being condescended at” (emphasis mine).

      I wonder if CBT boils down to smart people telling stupid people how to fix their shit.

      • The Crunge says:

        I went to CBT for anxiety, and it helped me immensely. In fact, it helped so much that I was able to drop Zoloft without anxiety returning.

        I wasn’t stupid, I was stuck in poor thought habits and patterns. I knew that these patterns were stupid and that analyzing them would break their hold, but reading and thinking about it was not enough to spur me to actually do it. Thanks to my therapist’s grandmotherly kindness and shamanic powers, I was able to overcome my inertia, listen to & implement her suggestions, and see for myself just how ridiculous, disproportionate, unjust, and unfair my thought patterns were. Once I did, their hold snapped, and now I am closer to tasting for myself whether the water is hot or cold.

        All glory to the white magicians.

      • Lysenko says:

        As others have noted, I think it’s more inside view/outside view than stupid/smart. The gap I’ve always found in CBT is that it seems like for a lot of people (myself included), the patterns of thought and behavior we’re trying to combat with the exercises of CBT are more powerful, adaptive, and simply have more persuasive power.

        In a lot of cases, wielding mindfulness and decentering and so on against emotional death spirals feels like bringing a cheese grater to Omaha beach as your personal weapon.

        • Jill says:

          CBT doesn’t work for everyone. But since CBT is so popular, many people don’t realize that there are tons of other types of psychotherapy one could try.

          • Evan Þ says:

            Such as? The impression I’ve gotten from Scott’s posts (which might be wrong) is that CBT is the only psychotherapy that has measurably-better-than-chance results.

          • Jill says:

            He’s talking about research on groups of people. Actually he noted that short term psychodynamic does just as well, according to research. But if you are an eclectic psychotherapist and CBT is clearly not helping your patient, then you are going to offer them other options. It doesn’t matter if the therapeutic option they choose doesn’t help as many people as CBT does. If it helps them, that’s good.

            Also there are issues with research on groups of therapist-patient pairs. One therapist thinks they do CBT but they are gentle and empathic. Another thinks they do CBT but they are blunt and very open about their impressions of what they see going on with the patient. But according to the research report they are both doing “CBT.” I suppose you could have a robot do the therapy, but the lack of warmth and flexibility there could create its own problems.

          • Mark Z. says:

            The next best thing to having a robot do CBT is having a textbook do it, and there are eleventy billion CBT workbooks and other self-guided tools out there. I don’t know how the results on those compare to working with a therapist, but they’re definitely cheaper.

      • LPSP says:

        >I wonder if CBT boils down to smart people telling stupid people how to fix their shit.
        It really wouldn’t surprise me. Sometimes the solution to complex social problems seems to be simply creating a protocol for people of very differing natures to follow when interacting with each other. Teachers at elementary/primary school have a protocl for dealing with children, candidates of the political left and right wing have a format for dealing with each other. I’m pretty sure every not-chav/ghetto type who has had to live nearby these sorts has developed a simplified and overtly friendly manner just for dealing with these people, which causes interactions to go smoothly and go away.

        CBT then is just a formalised way for smart people to talk to stupid people. It’s a protocol to reassure the stupid person they are not being demeaned or decieved, and the smart person that the stupid person is listening and focussed. Once the ritual is performed, the symbols of speech that follow are no longer open to dangerous misinterpretation on both halves – stupid people start taking the smart person’s words at face value rather than assuming they’re just saying THAT to be nasty, and smart people in turn can safely talk at face value knowing the stupid person isn’t just saying “yes” reflexively and will act upon agreements.

    • Pku says:

      Irrationality aside, there’s value in having an authority figure telling you which cliches are worth chasing. Sure, making a pros and cons list or such is cliche, but so is blaming childhood trauma or consulting a horoscope. There are a lot of basic cliche approaches, and unless you have some extra evidence that they’re likely to be helpful it’s generally not worth spending the effort to do them. For example, I never tried CBT because I didn’t think it was worth the effort until I heard there was actual evidence backing it up, and then I found it (in some cases) shockingly helpful to actually go through with doing it properly.

  26. FullMeta_Rationalist says:

    “Universal love” said the cactus person.

  27. Besserwisser says:

    If it helps you anything, I think psychologists are pretty stupid from my experiences as a patient. Once I got old enough to decide that kind of thing for myself, I stopped seeking any professional psychological help. And look at me now, zero suicide attempts! Not even suicidal thoughts, if anybody was worried after that statement.

    I still firmly hold the belief there’s nothing really wrong with me. There was definitely something wrong with the assholes bullying me in school, I’m fine. And even if there was something wrong with me, there really wasn’t any appreciable change during the years I spend with one psychologists or the other. They’re all a bunch of quacks.

    • herbert herbertson says:

      The possibility that you had perfectly rational/external reasons for your distress doesn’t prove that other people can’t have internal or less-than-rational reasons for distress that could be helped professionally

      • Besserwisser says:

        True, but that still makes me question their ability to discern whether or not I had a problem they could be helping me with. Me being bullied at some point wasn’t exactly a secret to them but what they wished to accomplish was a mystery to me.

        • Jill says:

          Too bad they weren’t able to help you. Glad you solved the problems yourself eventually. Not every therapist is able to help every patient who might walk in the door. Sometimes the type of therapy, or the therapist personality, is a poor match for the patient.

          And sometimes the patient doesn’t want to be there e.g. because they are a child or adolescent sent there by parents. So they never actually consent to treatment. If someone doesn’t want to be there, they probably can’t be helped.

          • Back when I was a graduate student, my roommate for a while was a high school friend who was doing graduate work in psychology. He asked one of his professors what the evidence was that psychoanalysis worked. The professor pointed him at a bunch of articles and he read them. His conclusion was that about half the articles found that psychoanalysis had an observable positive effect, about half that it didn’t.

            That was about fifty years ago. Has the literature on that subject changed since?

          • Jill says:

            Scott has done posts on this, or rather on psychodynamic therapy, which is a modern and briefer and somewhat different cousin of psychoanalysis. But only a tiny percentage of therapists do actual psychoanalysis today. I don’t, and I don’t know anyone who does. So I would be surprised if there were much research on it at all.

          • Besserwisser says:

            I just thought I read something familiar from the perspective of someone from the other side, so to speak. It always seemed like my therapists were working off a script that was supposed to do something but bugger me if I ever knew what that was. And hearing what Scott had to say didn’t make me more confident in psychology as a discipline either.

          • anonymous says:

            oh my god stop with the shilling.

    • The Nybbler says:

      It’s not stupidity, it’s just that the only thing the psychotherapist can affect is you. So the only useful assumption is that affecting you will change things. (The analogy of the drunk looking for his keys under the lamppost is relevant.)

      If you figure out that what they want is to change you, but you remain convinced that the problem is external and beyond your control, therapy isn’t going to help at all. If they do succeed in changing you when the problem is bullying but this doesn’t stop the bullying so much as making you accepting of it, they’ve done you harm. But really, if the problem is external they can do nothing useful. So they must assume it is not.

      • anonymous says:

        “so they must assume it is not”

        This only holds if we round all harm to 0. (which is, by the way, insane)

  28. A tangential comment. In business interviews (for recruitment or promotion) there is an interview technique called SOARA (Situation, Objective, Action, Results, Aftermath). It’s tough on the interviewer(s) because they have to be very disciplined and tougher still on the interviewee – because the interviewee keeps being asked ‘…and why did you do that?’ followed by a pause, over and over until ‘the fundamental’ reason for the objective or action is revealed.

    Just another variation of “Tell me more” and “[awkward silence]”.

  29. Jack V says:

    Thank you, that was hilarious and interesting.

    “taking attendings’ abuse in stride”

    I’ve slowly come to realise it’s not that I respond badly to overly loud/overly diffident communication per se. If I know someone means “please fix this one thing, then it’s all fine”, I respond reasonably well, whether they said “HOW COULD YOU FORGET THAT YOU SHOULD BE SHOT [spittle]” or “err… err… err… what about the err thing?” But I find it hard to adjust — if I don’t already know someone well and they scream at me and tell me I’m useless, it feels fundamentally disrespectful to just ignore them out of hand, it feels like I SHOULD believe them unless I later establish otherwise.

    Come to think of it, I do try to take overly-diffident people seriously though, so maybe I should try to take loud people equally seriously, not more seriously.

  30. Murphy says:

    And forever more whenever people are attacking you they’ll say “and he declared himself to be ‘anti-SJ’!!!!!1!1! More proof that he’s evil! ”

    Absolutely no chance of them including any context.

    better add this to the “things I will regret writing” tag.

    • Outis says:

      Steve Jobs is much admired, but there are plenty of outspoken critics too. He’ll be fine.

  31. FullMeta_Rationalist says:

    “Tell me more” said Tom patiently.

  32. asxd says:

    III sounds like the start of an SCP case..

  33. eponymous says:

    Most of the time I do therapy, I feel cringeworthy, unnatural. I feel like a fraud, even when (according to the supervisors watching me) I’m doing it exactly right. I feel like I’m responding to people in fake, silly ways, like they’re coming to me with problems from the depth of their being and I’m giving them facile non-answers.

    Have you tried ignoring these feelings until they go away?

  34. maznak says:

    The Awkward Silence – my former boss was using this, and also other manipulative techniques. It worked – I had this strange feeling that I must tell him more and more details what I have done, why, what the benefits and risks might be, sort of explain and even excuse my activities or lack of those, etc. But it was also very annoying and I always felt that it puts him into some kind of social advantage that was beyond what I felt he was entitled to as my boss.
    So eventually I started saying: “this is about all I believe is relevant that happened since we spoke last time. If you want to know more, tell me what exactly you want to know”. When he stayed silent after this, I stayed silent too and did not feel awkward any more.

    Btw delightful reading Scott, as most of the times. It is a subject you deeply care about and one can see that immediately.

    • Michael Terry says:

      > that it puts him into some kind of social advantage that was beyond what I felt he was entitled to as my boss

      I like this description. It reminds me of a peeve I have on a totally different subject, which is how it used to be popular to respond to internet comments with “this”. I hated it because I felt the response delivered more than it deserved. Brevity is so powerful, and there’s no brief way to undermine it in a satisfying way.

  35. HeelBearCub says:

    Scott, not sure if that is appropriate for me to post, feel free to delete, etc.

    So, these postings are either just therapy for Scott, his way of telling us what is bothering him, telling us more, or when he finally finishes residency he is going to have some sort of existential crisis. Because every single time Scott posts about psychiatry or psychiatric studies, etc. my distinct impression is that Scott feels like the guy in seminary who, 3 months in, discovers he is an atheist, but hasn’t admitted it to himself yet.

    Either there is more positive to the story, or there is a reckoning to come.

    • Anonymous says:

      I don’t see a dislike for psychiatry as a whole. Particular branches, like the teachings of ritzy office guy, sure; but not all of it.

      For example: If he was the atheist he wouldn’t have tried to compete with his colleagues on patient suicide numbers. But he did, so he must believe he’s doing something positive.

      • Enkidum says:

        “If he was the atheist he wouldn’t have tried to compete with his colleagues on patient suicide numbers. But he did, so he must believe he’s doing something positive.”

        Sorry, what? Atheists aren’t allowed to value life?

        • Nornagest says:

          “Atheist” in HBC’s seminary metaphor, not a literal atheist. (He is, but that’s not the point.) Brown anon is saying that if Scott’s lost faith in the efficacy of psychology, he’d presumably see patient suicides as random chance that he couldn’t possibly affect.

          People feel guilty over the products of random chance all the time, but still.

        • Randy M says:

          Follow the metaphor. If he was to psychology as atheists are to theology, he wouldn’t have any reason to think patient suicides would reflect on him as a psychologists as, in that viewpoint, the entire field is nonsense.

          (hadn’t read Nornagest’s similar point when I posted this as I didn’t refresh comments recently.)

    • moridinamael says:

      More like an apprentice wizard who realizes that all the senior wizards are using a very unscientific, traditionalist approach to their wizardry, and the apprentice suspects that he could dispense with 90% of the handwaving and incantations if he understood how everything fit together, but because he doesn’t yet understand that, he’s forced to learn the traditionalist style before he can begin to deconstruct it.

      • Pku says:

        If ritzy office guy ends up getting hit by a giant pendulum, I will salute you.

      • Paul C says:

        This is my new favorite perspective on psychology. Now I’m disappointed that I’ve not known any therapists to wear wizard robes and fancy hats.

  36. moridinamael says:

    Your post on Unlearning Your Pain prompted me to read a couple of psychodynamics books. It is confusing to me that there seems to be a lot of value in the conceptual framework of psychodynamics, but somehow it never quite seems like psychotherapists are actually using or referencing this framework in a logical way.

    Like, do humans experience intense Id-based rages that are deemed unacceptable by the Superego and thus expressed in unhealthy ways? Sure, maybe! I mean, even if you can’t pin down the neural structures giving rise to this event, it makes sense, and it is largely borne out by my own experiences and my observations of other humans. Just this one concept by itself seems super-useful, even if you strip off the “Id” and “Superego” nomenclature and just say “I fundamentally disapprove of my own feelings and thus trick myself into not being aware of them even though they are influencing my behavior.” Phrased this way, it’s basically just a version of other more fundamental Rationalist Skills, and you even see echoes of this line of thought in literature on meditation.

    But it seems/sounds like therapists never want to just use the toolkit they have, and instead perform their own cleverness by constructing excessively elaborate applications. I almost wonder if a chatbot couldn’t do better.

    Or maybe I’m only demonstrating my own ignorance with this post. Probably.

    • Paul C says:

      Ignorant we may be, but there would need to be some spectacular secrets in the field hidden from effective observation. As it is, psychodynamics seems easily and constantly prone to suffer from confirmation bias in practice.

      How would one rule out a psychodynamic hypothesis about a particular patient with actual clinical evidence?

      • Jill says:

        In any form of therapy, the therapist can state their hypothesis, and then invite the patient to correct them if they are mistaken. It’s a good process in many ways, not the least of which is that it is good role modeling to the patient that one should accept the fact that one can be mistaken, and can just correct it and move on.

        I don’t use standard psychodynamic therapy, like Scott’s supervisor does. But I do use therapies that make use of some pscychodynamic concepts.

        In any form of therapy, I think it’s a good idea to empower the patient to speak up about what’s important to them, what they are experiencing etc. And to let them know that their active cooperation is needed, if they are to make progress– that they shouldn’t submissively wait for the authority figure therapist to figure things out without the patient’s help.

        • “In any form of therapy, the therapist can state their hypothesis, and then invite the patient to correct them if they are mistaken.”

          Sounds like a good idea, but it only works to test the therapist’s hypothesis if we assume both that the patient knows the truth and that he tells it. Do most therapists make those assumptions?

          To put it differently, are there likely to be objectively verifiable facts that contradict the hypothesis, as opposed to the patient simply saying he believes it isn’t true?

  37. John Schilling says:

    The whole of Section V is somewhere on the intersection of annoying and terrifying even from the outside. It doesn’t seem like there is any good strategy other than keeping quiet and hoping you can last the year. So I’ll join you in hoping you can last the year.

  38. Mason says:

    This makes me wonder – what if all of these elaborate psychological theories are bunk, and most of the real benefit of any such therapy is just being able to talk to somebody that you don’t have a lot of complex baggage and network of relationships with?

    • Salem says:

      This is a mainstream idea in the medical profession. “Talking” therapies are frequently compared to a “placebo” of unstructured chatting (sometimes with a medical professional, sometimes not). My understanding, perhaps out of date, is that CBT outperforms placebo, but psychodynamics/psychoanalysis does not. This, combined with psychoanalysts’ historical disinterest in statistical validation of their work, has indeed led many to conclude that the elaborate psychoanalytical theories of yesteryear are so much claptrap.

      CBT is popular because it’s cheap, it’s seemingly effective, and it doesn’t rely on complicated theories. On the other hand, it’s kinda dumb… it’s easy to understand why Scott feels embarrassed to be doing it.

      • gbdub says:

        Consider physical therapy after surgery. Most of the exercises you do would be hilariously simple for an able bodied person. They look kind of dumb, and you’d feel dumb walking a healthy person through them. Even as an injured person, you feel kind of dumb – you were lifting 10 times this weight a week ago. But they work! And they work because something got broken, and now you need to go step-by-step to rebuild (or build for the first time) the right way to do things. CBT seems like similar stuff for your brain – easy, obvious, but sometimes the best way to fix something is to work methodically through the instructions.

      • Saint Fiasco says:

        Scott wrote about that sometime ago. Turns out CBT doesn’t outperform placebo either.

        • jhgdzxhjkjjbv says:

          Are you talking about this? That is the opposite of what it says.

          • Saint Fiasco says:

            You are right, I got it mixed up. What I remembered from that post was that CBT and psychoanalysis had similar results, then Salem said psychoanalysis does not outperform placebo and just figured “then CBT doesn’t either”.

            Turns out they both outperform placebo.

      • Mason says:

        That’s pretty interesting. As somebody with no involvement in the psychological or medical profession at all, I can guess/theorize that people who are mentally in a place to apply simple, dumb logic to their life situation don’t tend to end up in therapists’ offices. Maybe people who have issues of various sorts hindering them from doing that benefit from having somebody else logic their way through the situation and tell them the results. But then I suppose that would be the idea behind it in the first place.

      • TrivialGravitas says:

        This is really the wrong way to handle non drug interventions. Instead of trying to create a sham treatment compare different treatment options, see if CBT is better than psychoanalysis or vice versa. If you consistently find no difference well…

      • Shieldfoss says:

        CBT also doesn’t work for everything. Sometimes you are depressed because your life is terrible, so “stop having inaccurate thoughts about your life” will not make you stop having depressed thoughts about your life.

        No amount of CBT or mindfulness helped with my depression, which was not cured until I read a book on procrastination that accurately described my lack of motivation, with a description of the cause that matched my lived experience almost 100%.

        Very soon after I told my father that I experienced his behavior as abusive, which he took very hard, but ever since our relationship has been much better and I have not suffered from depression.

        • Jill says:

          Good for you, Shieldfoss, for being persistent in your search. As long as a person and/or their therapist keep searching for those answers, it’s likely that the answers are likely tol turn up somehow– whether in therapy, in reading a book, or whatever.

          So you mind saying what the explanation for procrastination was that you read, and that fit your experience? Someone else here may have the same issue, or may be the therapist of a patient with the same issue.

    • Richard says:

      Why do you have to believe it is? I talk most of my problems out with my dogs and it seems to work very well. Dogs are great listeners, but I don’t expect there to be much wisdom there. If I didn’t have dogs, I frankly believe a rock would do just as well, but the dogs are better at following me around while I talk.

  39. Dr Dealgood says:

    I had some experience on the patient side of CBT, and it really helped me a lot, so here’s my take on your dilemma:

    CBT is the psychiatric equivalent of “have you tried turning it off and on again?”

    Yes, it’s perfectly obvious common sense advice. Which is exactly why you need to make sure that patients have already tried it before you take the top off of their head and start rooting around in there. Because you’ll both feel like putzes if all they had to do was some journaling to sort out a problem and neither of you thought of it.

    It made me feel like a moron when I used some CBT trick and it worked, because I really ought to have thought of something like that myself. But that’s the whole point isn’t it? I didn’t think of it, and my failure to do so had left me miserable. So rather than complaining I decided to be glad that my problems had such straightforward solutions: after all, I could have had mysterious difficult to solve problems instead.

    • Jason says:

      This whole thread is full of smart people that think they don’t need professionals to help them make logical solutions.

      These same people would think nothing of googling up a Youtube to get a professional to show them how to fix a bike chain or hammer together two bits of wood.

      Even smart people need a bit of help to see obvious solutions to problems they haven’t solved yet. I guess the big problem is the price psychs charge…

      • Jill says:

        Good points. Yes, there are a number of issues there. Another one is that you don’t have to have as much trust to let someone teach you how to fix a bike chain. And there aren’t as many ways to fix a bike chain, as there are types of therapies, and types of therapist personalities, that one could choose from.

        Another problem is that people who need the help the most, may have “learned” from peers, parents, relatives, teachers etc. that one can not trust other people. So somehow they need to trust another human, in order to get over the trauma of having had their trust violated by other humans. Or they need to somehow learn to communicate effectively in order to get over their habits they learned from their family or peers of communicating awfully and getting into unnecessary misunderstandings.

        So sometimes the problems that brought the person into therapy, can keep the person from making progress in therapy, or even getting into therapy in the first place. To whatever extent a person is aware of these issues, if they do go to therapy, they should openly talk about them so that the therapist can understand where they’re coming from and what they need help with.

        • Evan Þ says:


        • LPSP says:

          Very good analogy on the bike chain

        • Stezinech says:


          Just another thought: therapy exists in the fuzzy emotional realm. Fixing a bike chain or building with wood are very concrete and physical problems. Answers are more clearly right or wrong to those types of problems, than to emotional ones.

          Trying to find “logical” solutions to emotional problems is likely to be barking up the wrong tree. This actually support’s Jason’s original point, that smart people can make this mistake, rather than seeking outside guidance (emotional guidance for emotional problems).

  40. onyomi says:

    I was listening to a man argue with his mother in public while waiting for an airport tram the other day and it struck me how incredibly pointless the argument was, boiling down to “that one time you treated me with disrespect…” and “you totally mischaracterize that one time!” The thing was, I knew I had had similar arguments myself at various times, but listening to two total strangers have this argument it struck me how, from an outside, objective perspective, this argument was accomplishing exactly nothing and these people would be better off to just forget it and be pleasant to each other.

    I agree that a lot of arguments and negative emotions are like this: feed them and they grow, ignore them and they wither and die. This insight has been especially useful for me as someone with obsessive tendencies and morbid curiosity. Now, when someone says “don’t you wanna see [something like two girls, one cup],” I just say “nope,” even though my native impulse is to watch and think about and obsess over everything and how gross/disturbing it is. Petty grievances, too, I think, work like this.

    That said, there are probably some old emotional traumas and serious issues which do need to be worked through; I guess the problem is knowing what they are. For me, meditation works better than psychotherapy, because it brings unconscious things into the conscious mind in a way that chatting about my problems doesn’t seem to for me. Other physical things like taking a walk also help me more than talking.

    This is complicated by a phenomenon I have definitely observed occasionally in myself and rather frequently in my fiancee (I will indulge in stereotyping and say women, for whatever reason, seem much more likely in my experience to do this; men probably just do something else, like quietly hate themselves): the “I’m yelling at you about forgetting to take out the garbage because secretly I’m anxious about our future and can’t understand why you would love someone like me but I also don’t know that’s what I’m doing until I stop and discuss it for a while.”

    In this case the petty argument really is a substitute for the problem which maybe shouldn’t be ignored, but it’s hard to figure that out without discussing. In my experience, the tipoff is disproportionality: if the person is getting madder at you for not taking out the garbage than not taking out the garbage would seem to warrant, then go meta on them and ask why they are *so* mad about this.

    • gbdub says:

      “go meta on them and ask why they are *so* mad about this.”

      Before doing so, I’d recommend at least taking out the garbage first. At a minimum, this leaves them with less rotting food handy to huck at you when you “go meta”.

    • Zombielicious says:

      This reminded me of one of the better things I’ve read about ignoring problems and how relationships can deteriorate over time: scar tissue makes relationships wear out.

      tl;dr: Little issues that are easier ignored at the time often accumulate into unresolved resentment and negativity, eventually snowballing into the kind of ongoing, unresolvable situations like the one on the airport tram. Aside from going meta and trying to backtrack to the root(s) of the problem, the other solution is preventative maintenance in keeping those small wounds from accumulating by ensuring neither side leaves even minor disagreements with insignificant (at the time) underlying resentments.

      That’s probably why “ignore it and wait for it to go away” isn’t a great strategy for large swathes of the population. Even if ignoring does work for one person, there’s no telling if it’s actually working for the other side, since the marginal damage to the relationship is small with each incident. The more “baggage” a person retains from each conflict, and the longer the half-life of the resentment is, the faster the ignoring strategy causes the relationship to deteriorate on that side.

      • onyomi says:

        Yeah, I could see an argument that the type of seemingly pointless argument like I observed at the airport wouldn’t happen in the first place without deeper, unresolved issues.

        That said, there are times when you genuinely are just irritated about something stupid and it’s better to let it drop than take it out on your family.

        Related, it may also be that the petty thing is hiding anger about a deeper issue, but the deeper issue is not currently resolvable. If I yell at my fiancee about making a mess in the kitchen when what’s really bothering me is our precarious financial situation then there is a real problem, but maybe not one talking can resolve. Maybe I just need to change my spending habits or find a new job, and, in the meantime, not let my irritation about that situation find cover as a petty complaint directed at those closest (and therefore more convenient targets).

      • onyomi says:

        Re. “scar tissue,” I do think there is some truth to the rather bland sort of statistics I’ve seen to the effect of “people will continue to like you so long as 8 out of 10 of their interactions with you are pleasant.” I do think long-term relationships are made up primarily of many small interactions, and if a high proportion of your interactions with a certain person are unpleasant, whether it be because they have a serious mental health problem or are just really nitpicky, you will eventually tend to distance yourself.

        In other words, pick your battles: every time you get mad at someone, regardless of the reason, you are depleting a little bit of their reservoir of good will, which may be deep if they are, say, your mother or spouse of 20 years, but which is almost never infinite. Therefore, decide whether or not it’s really worth being unpleasant on this particular occasion.

      • Murphy says:

        Any strategy followed religiously and without exception is going to be a disaster.

        Not worrying about something for a little while to see if you even remember it in a few hours or days can be extremely healthy.

        Leaping on every little thing that even slightly annoys you and turning it into a conflict can destroy things extremely fast.

        As long as you don’t turn a single approach into your only approach like someone marching around with a hammer treating everything like a nail then it’s not a problem.

        If I emoted like my Fiancee we’d have broken up years ago. She amplifies reflected emotions, I dull them. If I was like her we’d be in constant screaming matches every 2nd day. If she was like me we’d probably be quite a bit more dull. As it is we very rarely fight and the very idea of standing screaming matches that some couples treat as the norm freaks me out.

        • onyomi says:

          I’d agree that any one rigid strategy used over and over will likely be inadequate. I’d also say, however, that this shouldn’t be used as an excuse to have no strategy and just do whatever feels right at the moment, which is what almost everyone does, with the result of 50+% divorce rate.

    • alaska3636 says:

      “I’m yelling at you about forgetting to take out the garbage because secretly I’m anxious about our future and can’t understand why you would love someone like me but I also don’t know that’s what I’m doing until I stop and discuss it for a while.”

      I have similar experiences with my fiancee. And they were very hard to pinpoint when they first started happening, but the quote above is a pretty regular argument when we do have them. I still don’t know what the answer is, but I no longer say “the answer is that life is uncertain so just stop thinking about it” even though that is what I am certain the answer is.

  41. Lumifer says:

    My coping strategy is to not talk about or react to my emotions and wait for them to go away.

    That strikes me as a prototypically male thing to do. In fact, I’d probably say that this is one of the classical male/female differences: women display and discuss their emotions, men do not (insert the usual caveats about “typically, but not always; individual differences; etc.”)

    • Zombielicious says:

      I kind of wonder if this tendency is a hangover from a time when non-lethal violence was less taboo. I’ve known guys who would get into straight up fist fights shortly after meeting, then end up becoming best friends not long afterwards. The authenticity of the friendships make it seem less like a way of determining some kind of hierarchical pecking order so much as a way of expressing emotions “by other means” (to borrow from Clausewitz).

      Not that I’m advocating a return to those days, just questioning the stereotype that men don’t “display or discuss their emotions,” so much as that one of the common mechanisms for their doing so has been removed.

    • Leo says:

      It is, but probably not as much as it looks. When a man or a woman successfully implements the strategy, nobody notices there was a problem in the first place (which is the point).

      When a man tries that strategy and fails, he finds a female (relative, friend, or partner) and looks vaguely dissatisfied near her until she does the woman’s work of giving him free therapy. She notices the attempt to be stoic, and his male peers notice nothing. Girls can’t do that, so they never look actively stoic, only passively.

      • Lumifer says:

        Girls can’t do that

        Of course they can, that’s what (girl)friends are for.

        • Leo says:

          Does that work? I’ve seen girls go “Oh well, Plan Stoicism is a failure, time to call up a friend and tell her all about my fickle emotions in so many words”, but I’ve never seen a girl get a friend to make her feel better without either openly acknowledging that someone is experiencing a feeling.

          • Lumifer says:

            Girls can means that girls can get “free therapy”, just not (usually) from guys. Can they get emotional support just by being mopey without explicitly discussing their problem? I guess it depends on the particulars of the relationship with their friends, but it’s not common precisely because girls have less hang-ups about discussing emotions with others and so they don’t need to be supported while they stand there saying nothing.

          • Leo says:

            To clarify, my whine about “free therapy” isn’t that friends help each other (I am not a Care Bears villain – yet, growth mindset). It’s that some people give a vague, unreliable hint they want help (sadface looks a lot like thinking-about-nothing face); are reluctant to give the information needed to help them, as described in the post; take that help for granted in that they’re upset and surprised when it’s not forthcoming; and feel no need to reciprocate in any way.

          • Lumifer says:

            @ Leo

            It’s that some people give a vague, unreliable hint they want help

            Do you know about Ask and Guess cultures? I think they are very relevant to this discussion.

      • Outis says:

        When a man tries that strategy and fails, he finds a female (relative, friend, or partner) and looks vaguely dissatisfied near her until she does the woman’s work of giving him free therapy.

        You know, I’ve never understood this notion of “unpaid emotional work” that feminists have. In a traditional marriage where the man is the breadwinner, the woman gets all her expenses paid. In modern marriage, she gets that and half of everything the man ever had. In dating, she gets attention, entertainment, food, etc. I guess it doesn’t count if they don’t have to pay income taxes on it and file monthly reports to their boss?

        • Leo says:

          I don’t have any experience of traditional marriage.

          In modern marriage, from experience observing many of them, both the man and the woman work 40-50h/week. (He probably works a little longer but not much.) They share household expenses in proportion to their wages, which means he pays slightly more in absolute terms.

          She handles the bulk of the chores (cleaning, cooking, grocery shopping, most things to do with the children), for three reasons: she has more stringent standards so it’s fair that she should do more of the work; she has more stringent standards so that by the time something is dirty enough that he’d want to clean it she already has; it doesn’t occur to him that he should pull his weight in women’s work.

          Some chores, like driving, are his, mostly because it doesn’t occur to her she should pull her weight in men’s work. Overall she still does more.

          She spends a lot of time noticing that he looks down because his boss is a dick, or that he tends to get cigarette burns on a lot of furniture, and thinking up ways of bringing that up to him, or better yet of fixing the problem without ever bringing it to his attention.

          If the marriage is happy, they both take initiatives to please each other. He’s slightly more likely to buy presents and organise outings, she’s slightly more likely to make things for him, give him quality time (with or without her), and give him sex he wants.

          If they divorce, she asks for custody of the children. If he does as well, they get shared custody. Most of the time he doesn’t, so she gets custody and he pays child support. I’ve seen one divorce where alimony was involved (he made about ten times what she did) at it was small compared to his wages.

          This is not obviously slanted in favour of women.

          There’s a few ways it goes bad for men. (Besides the universal ways it can go bad like abusive partners or irreconcilable differences.)

          One is a controlling, nagging harpy of a wife. This is very bad but doesn’t seem to be universal. Asking her to change, followed by divorce if she won’t, is a solution. Tuning her out and avoiding her is a more popular solution.

          Another is wanting something and not asking for it. In some cases, it’s mere stupidity, wanting the wife to be telepathic. The solution is to stop being a moron and fucking ask. In other cases, it’s perfectly justified; many women will freak the fuck out when asked for some common fetishes, for example.

          The usual way it goes bad for women is the raw deal described above, where the woman does most of the chores and that’s taken for granted, and all the… sigh, do I have to fucking call it that… the emotional labour, and that’s completely invisible by design.

          It’s very unpleasant because there are only two ways out, and neither is exactly dripping with lovingkindness. One is to whine and nag about it, which means she gets tuned out until the drama reaches intolerable levels. The other is to go on strike. I’ve only seen that very rarely, but as far as I can tell it doesn’t work; it’s met with incomprehension that the woman doesn’t do her woman-job and at no point does the man think “oh, I should pick up the slack”.

          As far as I can tell, there is no good solution, including “don’t marry men like that”. Men are by and large aware that housework needs done, and many of us are willing to e.g. establish a chore chart and stick to it, or say “I’m willing to dust these stupid decorative cushions I can’t sit on because they’re decorative, but there’s just no way I’m vacuuming every day”. But men who even notice that they’re sadfacing around a girl and expecting her to quietly figure out what’s wrong and help? There’s like three of them and we’re all faggots.

          • Leo says:

            I was trying to keep it short, but yeah.

            All car maintenance. All outdoor work. Outdoor work can easily outweigh everything else if there’s a lot of it, or be exactly zero if they live in a flat.

            Fixing things around the house if he’s handy, or if he’s not, sucking up the humiliation of lacking a skill and calling a pro.

            Good point about assembling furniture, I hadn’t thought of that. Though it’s not very common, maybe half a day of work every few months, day-to-day work is much more work.

            Emergencies too, but those are extremely rare (one should hope).

            To me changing lightbulbs is clearly women’s work, but Google Images shows as many men as women doing it, so we’re both wrong.

            Tripping the breaker or cutting off the water is specialised work? Wouldn’t it be a job for whoever’s standing closest, including kids?

            Getting things off shelves and opening jars are technically work, but if someone’s cooking and someone else’s providing 10 seconds of help, well, it’s pretty clear who’s doing more work. (Also, girls and weak-gripped men: stick a knife under the lid and get some air into the jar.)

            Overall, this looks like a fair distribution of work on a farm, with a lot of strenuous work in the fields and a lot of housework to be done while minding children. It probably stays fair once you have a house in the suburbs with no dangerous outdoor work but a yard and car to maintain, and vacuums and washing machines and only two children. It gets outright silly when you’re in a flat and have no car but the floor still needs mopped and the food cooked.

            I observe that, when there isn’t extremely intensive yard work to be done, women spend a lot more time on chores.

            You argue that men’s work should count more when it’s strenuous, but that doesn’t make sense to me. First, a fair distribution would consider how strenuous it is to the person who does it, and since men are stronger that should count less. Second, I personally don’t mind work being hard and tiring, just that it’s tedious, and I’m surprised other men do.

            You also argue that men do all the dangerous work. That would be fair, but in a modern city that’s less than hour of danger per decade.

          • Nornagest says:

            Tripping the breaker or cutting off the water is specialised work? Wouldn’t it be a job for whoever’s standing closest, including kids?

            I’ve found myself the only person in a house of five roommates who knew to do that. That was in college, though, and maybe people would be more clueful on average by marriage.

          • gbdub says:

            “both the man and the woman work 40-50h/week. (He probably works a little longer but not much.) ”

            Not sure how much that is true – women are more likely to work part time, men more likely to work a lot of overtime. Thinking of my parent’s marriage, they both had nominally “full time” salaried jobs, but she could keep very reliably fixed hours (35-45 a week) and he was consistently putting in 50+ hours a week, sometimes much more. I feel like this is fairly common, and from fuzzy recollection of data I’ve seen it holds up reasonably well. Anyway, you can get a lot of basic housework done in 10 hours (in practice at our house, this meant Mom did most of the cooking and day-to-day cleaning (but this was done by the time Dad got home), Dad chipped in on the weekends, usually spending at least half of one weekend day on the yard.

            Anyway the whole debate is really silly since individual situations vary a lot. And I’m not sure I’ve ever seen a really fair analysis – the feminist articles discount the “heavy lifting” chores and the longer hours, other takes tend to focus on the income split and say “well he’s paying more bills of course he should help less”.

          • Let’s have a low intensity discussion about opening jars. I’ll have to try the knife thing next time.

            I have a bunch of techniques– as implied, a lot of the issue is grip strength. Don’t raise your shoulders– that’s just using your strength against yourself (so that you can feel it?) rather than applying it to the jar.

            I *think* holding the jar near my center of gravity while trying to open it helps.

            Thump the jar lid flat against a counter. I’m not sure how to define this, but it’s a moderate thump. Do not raise the large glass jar over your head and thump it hard. Ask me how I know this.

            Run hot water on the lid– only moderately effective. By the time I’ve gotten a towel around the lid, it’s cooled off.

            Lid grippers– I’ve found a metal one to be helpful, and I haven’t done anything with rubber grippers. I don’t have any opinion about the best lid gripper, but I wouldn’t be surprised if there are people here who do.

            Someplace, I read about a male athlete who lived in fear of not being able to open a jar in front of his wife. I think that if you know enough ways to open jars, you won’t have to worry about that.

          • I don’t know the best lid gripper, but there is a very simple one that’s a loop of rubber attached to a wooden handle and works pretty well.

            My wife’s trick is to put a rubber band around the lid to give a better grip, but that only works for easy cases.

            If all else fails, I have vises in the workshop downstairs.

          • Re: Jars:

            I have one of these model lid-grippers.
            They can chew up the rim of the jars and can leave gouges, so I try not to use it if I don’t have to, but it gets the job done.

            I’m genuinely curious about the hot-water-on-lid thing failing due to heat loss. How long does it take to move a jar from a one-handed grip in the sink with hot water running over the lid to one hand holding the jar and the other holding a towel or other grip-enhancer like a shirt-tail?

          • Defining the marital division of chores in our household is a little tricky, partly because it depends on what you consider a chore, partly because I’m much more aware of what I do than of what she does.

            The very biggest thing she does, from my standpoint, is almost all of the long distance driving, partly because I can read in a moving car and she can’t but more because she is much better than I am at maintaining attention for long periods of time. Long distance driving for us mostly means the Pennsic trip, which is most of five days each way. There is a sense in which we are spending equal amounts of time, but I would hate to have to spend it doing what she is doing.

            On the other side, I do essentially all of the yardwork,, aside from some that my daughter has been doing in the last few years. But then, planting fruit trees is my project, not my wife’s, so it’s natural that the associated work is also my project. Also my most regular source of exercise.

            One ideosyncratic division of labor is that I do almost all of the phone calls to strangers sort of stuff, up to and including investigating how to get a spare key for her car. That’s not a husband vs wife thing, I think, but my personality vs hers–she very much dislikes doing that (as I very much dislike multi-hour driving), and I don’t mind it.

          • Robert Liguori, it occurs to me that I’m probably not giving the hot water method a fair chance, and it would be better to apply hot water for longer and put a towel someplace handy before I start.

          • Anonymous says:

            I prefer the tip of a spoon to a knife. The eating side of a spoon has no inclination to bend, which makes the lever action much better, and because you can’t stab yourself there’s no fear of applying too much force.

            And yeah, gripping the lid with a towel after 2-3 unsuccessful tries, to improve grip.

          • Gbdub says:

            The best thing to use is a bottle opener (like the one on a can opener or “waiters friend” style corkscrew). Changed my life.

            Only problem is with “tall” lids, but those tend to be easier to grip anyway. If it’s really stubborn, and it’s something you’re going to use quickly, piercing a small hole in the lid also works great.

          • SamChevre says:

            In my experience, “dip it in hot water” is a specialty lid-getting-off tool.

            Where it works is where the lid is stuck on with something that includes sugar (which is a lot of things). The key is to put the lid in hot water upside down and wait a minute or two, so the hot water gets between the lid and the jar and dissolves the sugar.

            Everywhere else, I haven’t found it to help.

          • Nornagest says:

            If you have a rubber or soft plastic pot holder, I’ve found they double as pretty good lid-opening tools. They work especially well if the lid is slippery because there’s water on it or your hands, which can easily make lids unopenable no matter how strong you are.

          • Luke the CIA stooge says:

            In my experience the key factor in opening a lid isn’t grip strength but surface area of contact.

            There’s a really unnatural feeling (but highly effective) way of opening lids where you put all your fingers together, press it on the top on the lid and just slightly curl your fingers and palm over the edge. give it a twist and it pops right off.

            Done right an 12 year old girl can open the stiffest jar.

          • houseboatonstyxb says:

            @ Luke
            There’s a really unnatural feeling (but highly effective) way of opening lids where you put all your fingers together, press it on the top on the lid and just slightly curl your fingers and palm over the edge. give it a twist and it pops right off.

            Is there a video for that?

          • LPSP says:

            “she has more stringent standards so that by the time something is dirty enough that he’d want to clean it she already has”

            I wish more people knew/understood this piece of wisdom. It even applies to room/housemate situations, regardless of genders.

          • Hyzenthlay says:

            My partner sometimes does the thing of sadfacing/remaining silent around me in a way that makes it’s obvious he’s distressed, so I end up having to either poke at him until he explains what’s wrong, or just endure the silence. I’ve told him (in kinder words) that I wish he would just tell me what’s wrong to begin with instead of making me play detective, and his response is that he feels guilty for burdening me with his problems and tries not to.

            So, I don’t know how much of it is males expecting the female to provide “free therapy” and how much of it is just the cultural idea that men are not supposed to talk about problems at all, and only doing it when prodded, and either not realizing that the silencing/sadfacing is more unsettling than just talking about the problems, or knowing and just being unable to break the habit.

          • LPSP says:

            I feel it’s critical to ask whether your husband actually wants help or not. If he genuinely means that he feels bad about burdening others, then the right thing may be to not help him.

      • FacelessCraven says:

        I get 98% of my free therapy from guys. The large majority of the free therapy time with women I’ve participated in has been giving, not receiving.

        If “actively stoic” is the “acts vaguely dissatisfied near them” thing, women are pretty good at that as well.

        • Leo says:

          My experience is that guy sighs heavily, girl goes “What’s wrong”, he says “NOTHING I’M FINE!”, she quietly investigates and finds ways to cheer him up discreetly (or occasionally to annoy him to death, it’s not a very reliable process). Girl sighs heavily, guy goes “What’s wrong”, she says “NOTHING I’M FINE”, guy goes to his friend and complains “gah why won’t she just tell me things?!”, and if I’m the friend I answer “because you complain that she nags when she does, you idiot”.

          • FacelessCraven says:

            It’s down to personal experience, I guess. I’ve burned a lot of hours practicing my active listening on female friends. In my experience, it usually starts less with a sigh and a distant expression, and more with them acting a bit off, engaging them in conversation, and letting them work themselves around to the actual point that was bothering them in the first place, then letting them talk it out. In my experience, reciprocation depended on the person; some were better at it than others. Perhaps Unsurprisingly, the one who needed the most was the worst at reciprocating.

            With male friends, I tend to just cut to the chase: “how’s it going, I’m extra crazy this week for reasons x. y, and z. not sure what to do about it. how are you?”

          • Nornagest says:

            “NOTHING. I’M FINE” can mean one of two things. Either it means “I can deal with this on my own, and help or advice will just add complications I don’t want to handle”, or it can mean “you should have already seen the problem I’m having”. Mistaking either one for the other will get you in trouble. In my experience, men are more likely to use the former and women the latter, but not so reliably that you can use it as a heuristic.

  42. Eric Schiedler says:

    This may be one of the most controversial things that anyone can say: “The bond of relationships is a false wish of the false human ego.”

    In other words, the desire for happiness is pursuit of an illusion – the pursuit of it leads to temporary states of elation but inevitable disappointment. The hundreds of examples of patients (and your own personal relationship and dating experiences, including abusive behavior by your attending physicians) struggling with discomfort from “bonds” that fell apart in relationships points to the inherent instability of the nature of pursuing happiness through relationships.

    Yes, human beings are part of a social species. But the evidence people use to support the claim that people can have “strong bonds” in a relationship typically suffers from anecdotal bias, survivorship bias, and moving of the goalposts.

    Eric Schiedler

    • Outis says:

      Just to be clear, I’m not a professional ‘quote maker’.

    • LPSP says:

      I dunno, this seems to just be “edgy” for the sake of it. I don’t think anyone is advocating happiness all the time, just freedom from total chaos.

      • Eric Schiedler says:

        How would you define “freedom from total chaos.” In your view, what does that entail or require?

        • LPSP says:

          Oh, that’s literally just my go-to explanation for the concept of Order. Walls to stop any old nonsense from happening without an inspection. If you live with rules that are explicit and consistent you have this.

    • Leo says:

      There is something to anti-attachment claims, but this is not it.

      First, that something is hard is scarcely a condemnation of it! Overcoming ego is much harder than having a happy friendship, so if you use the failure rate you stand condemned.

      Second, getting happy is not the sole purpose of relationships. I want my friends and partners to thrive (which ideally involves their happiness, but that’s not the top goal) and more abstractly I want loyalty and alliance and troth and understanding, because those are one of the few things in the world that are both good and beautiful.

      Third, I have a general doubt about “this too shall pass”. Permanence is good, but I don’t understand why it’s required for something to have any value at all.

      • Eric Schiedler says:

        Human consciousness brings value into the world, the question is whether certain values have merit or are merely an illusion. You say you value four things that are both good and beautiful, why does that also ideally involve happiness – why can’t you just leave that part aside for your four core values?

        • Leo says:

          Why would you classify any value – say, happiness – as illusory, ever?

          • Eric Schiedler says:

            Having the mental experience (or thought) of highly preferring a value is not an illusion. After all, the preference is being expressed and someone is experiencing those thoughts. But the value being thought of may have no veracity. As an example, some religious people want to clean their aura, or preserve the sanctity of their soul; they value and prefer those states which are concepts that are illusions.

            I notice that you did not answer my question. Even if the values are worth pursuing, why pursue happiness if it is not a necessary and core value?

          • Leo says:

            Happiness certainly is a core value! Observe how we cease very many pursuits (say, keeping pets) when they don’t make anyone happy. Observe how happiness feels pleasant. Observe how wanting and liking are correlated just like pain and damage are. It’s not the only thing that has value (observe how wireheading is sad and repulsive and a tragic waste), but it does have value. We care about more than one thing.

            Observe also how the values you term illusory are not fully so. If your monk learns that souls and auras do not exist, he will learn that keeping a saintly soul is not necessary to avoid eternal torture, but he will still desire to avoid eternal torture; and he will learn that righteous character does not operate through soul-based mechanisms, but he will still desire whatever virtues he used to call “preserving the sanctity of his soul”.

  43. Neanderthal From Mordor says:

    You should study Craig Ferguson’s [awkward pauses]


  44. walpolo says:

    This is even worse in any form of therapy based around investigating childhood traumas. Look, I’m sorry you didn’t like your mother, but have you read The Nurture Assumption? But of course I can’t say that. I just have to play along. And then somebody expects me to come up with something to heal the maternal trauma that I’m not even sure people really have, and then if I do come up with something it feels like a clever fake.

    Scott, are you a skeptic about attachment disorders? My sense is that those are widely agreed to be caused by bad parenting.

  45. gwern says:

    The only problem is when two psychiatrists meet. One of my attendings tried to [awkward silence] me at the same time I was trying to [awkward silence] him, and we ended up just staring at each other for five minutes until finally I broke down laughing.

    “I see you find something funny,” he said. “Tell me more.”

    From Frank Herbert’s “Tactful Saboteur”:

    ‘Your avoidance of gender is most refined,’ Bolin said. ‘I appreciate the delicacy of your position and your good taste. I will say this for now: the Pan-Spechi you seek is not at this time in need of your assistance. Your concern, however, is appreciated. It will be communicated to those upon whom it will have the most influence.’
    ‘That’s a great relief to me,’ McKie said. And he wondered: What did he really mean by that? This thought elicited another, and McKie said: ‘Whenever I run into this problem of communication between species I’m reminded of an old culture/teaching story.’
    ‘Oh?’ Bolin registered polite curiosity.
    ‘Two practitioners of the art of mental healing, so the story goes, passed each other every morning on their way to their respective offices. They knew each other, but weren’t on intimate terms. One morning as they approached each other, one of them turned to the other and said, “Good morning.” The one greeted failed to respond, but continued toward his office. Presently, though he stopped, turned and stared at the retreating back of the man who’d spoken, musing to himself: “Now, what did he really mean by that?””
    Bolin began to chuckle, then laugh. His laughter grew louder and louder until he was holding his sides.
    It wasn’t that funny, McKie thought.

    When two psychiatrists meet / they need no introduction / they misunderstand each other without question.

    • Salem says:

      On hearing of Talleyrand’s death, Metternich is supposed to have said “I wonder what he meant by that.”

  46. VVV says:

    The stuff about medical history-taking is just like being a sysadmin. Anyone who’s had to try to get the user on the other end of the phone to describe what’s going on with their computer (just the symptoms) will sympathize.

    Most people really couldn’t give less of a damn about effective communication.

  47. ExpertWitness says:

    Scott, would you elaborate on your anti-SJ stance? It’s one thing to be against the attitude, rhetoric, and activism tactics of social justice warriors. Being against the construction of a just society is difficult for me to understand. Would you tell me more?

    • Saint Fiasco says:

      It’s one thing to be against the attitude, rhetoric, and activism tactics

      Taken literally, what Scott said is exactly that. He doesn’t like to be told what to think and that he shouldn’t argue.

      Since he especially doesn’t like it when he is told to think something that he things is wrong, the only way he is going to like SJ is if it happens to already be 100% correct in everything, or if they relax the “no arguing” restriction.

    • sweeneyrod says:

      See (among other posts) this.

      • ExpertWitness says:

        I find this argument over-broad. To what extent is stupid Tumblr activism connected to the incontrovertible evidence that police have treated blacks as second class for the entirety of America’s history? To what extent do battles about safe spaces at elite universities implicate the fact that schools in poor urban neighborhoods fail students of all races? How do inconvenient protests (like BLM blocking highways) discredit the multitude of disadvantages that blacks face in America?

        Scott is too smart to deny America’s racial conflict. He readily admits that everyone is racist. I suggest that in his desire to wage a cultural battle against silly internet activists he has missed the big picture.

        We live in a world that privileges some people over others. It’s complicated, but everyone knows that it’s on average easier to be wealthy and white and male than poor and black and female. But none of us chose our birth. We didn’t choose our DNA, our parents, our education.

        If one cares to make society more just, one would notice that the most foolish SJWs are human beings in a lot of pain. As weak as their arguments can be, their sentiment is real. As rationalists, we can use this as an opportunity to steel man, to be empathetic, to imagine how the world looks from a different perspective. Or we can sit back in our chairs, dismiss the brown people whose IQs are too low to take seriously and laugh at their “white allies.”

        • Lumifer says:

          If one cares to make society more just

          Define justice.

        • sweeneyrod says:

          I don’t want to speak for Scott, but I don’t think he disapproves of all movements to make society more just, but with aspects of some specific movements (e.g. those that use the term racism in a nonsensical way).

        • Nornagest says:

          If you really want Scott’s thoughts on race and justice, this post is the place to find them.

          In any case I would encourage doing the inevitable argument in the comments there, or at least in the open thread.

          • Julie K says:

            In any case I would encourage doing the inevitable argument in the comments there

            Old posts are closed for commenting, and anyway no one would read and respond to you.

          • Nornagest says:

            I’m tempted to say “all the more reason to do it there”.

            I’d forgotten about the auto-archival, though.

        • Wrong Species says:

          The evidence isn’t incontrovertible. You saying so doesn’t make it true. For example: http://mobile.nytimes.com/2016/07/12/upshot/surprising-new-evidence-shows-bias-in-police-use-of-force-but-not-in-shootings.html

          • HeelBearCub says:

            My understanding is that the study in question did not consider differences in how often people of different races were stopped, which is a fairly large confounder. There are other confounders as well, such as the fact that all the data in the study was offered to the researcher voluntarily.

            See this Slate article.

        • Anon says:

          If one cares to make society more just, one would notice that the most foolish SJWs are human beings in a lot of pain. As weak as their arguments can be, their sentiment is real. As rationalists, we can use this as an opportunity to steel man, to be empathetic, to imagine how the world looks from a different perspective.

          For someone who casts stones you live in one hell of a glass house. If that argument was any more overbroad it’d be a 1920’s gangster after recovering from a breakup.

          Heroin addicts are human beings in a lot of real pain. They have weak arguments with real sentiment behind them. We could steel man these arguments and imagine life from that perspective.

          However, no matter how much empathizing and steelmanning you do, the fact remains that the heroin addict is arguing to give them heroin, which won’t solve their problems and will only make their situation worse. Their constant arguing to give them heroin additionally makes them look irrational to people outside their situation, because people outside their situation see that giving them heroin is not a tenable and stable solution to the addict’s problems.

          The ills of social justice warriors will not be cured by safe spaces/trigger warnings/rape culture awareness training/whatever the political-policy-du-jour is, the same way a heroin addict’s problems won’t be cured by giving them heroin.

          Your last sentence is overtly malicious and I won’t reply to it.

          • jimmy says:

            It’s possible to empathize with a heroin addict and steel man their arguments and *not* give them heroin, you know.

          • Anonymous says:

            Many people on this site are incapable of thinking calmly and rationally about so-called social justice warriors, or more broadly young feminist women, because they’ve been hurt by someone in that group in the past and aren’t able to get past it. Best to just move on and discuss one of the many topics which this comment section is not totally irrational on.

          • Psmith says:

            a heroin addict’s problems won’t be cured by giving them heroin.

            well actually

          • herbert herbertson says:

            @ Anonymous

            Bingo, and ironically so, since I think most of the bad actors of the Twitterotti are reacting for pretty much the same reasons.

            Scott, to his credit, has settled on the only policy that has the potential to break that cycle (niceness uber alles).

          • nm. k. m. says:


            >Best to just move on and discuss one of the many topics which this comment section is not totally irrational on.

            This is what I find very troubling about the whole rationalist movement, especially that one should self-identify as a rationalist. Feels like after identifying yourself as such, it would inviting to go the “I’m a rationalist and I’m actively instilling rational ways of thinking to make it force of habit, therefore, this particular opinion of mine in this argument is rational” fallacy route as soon as you lay your guard down and meet yourself with a not-so-rational thought process.

            I’d propose that any true lover of rationality should always remember to call themselves philo-rationalis-er (or some other less awkward word construct, if you can think about one), because being rational is hard enough, and one wouldn’t sound so moronic if one fails in being rational and other reasonable people can present reasonable arguments how you are wrong.

        • Hyzenthlay says:

          Scott is too smart to deny America’s racial conflict. He readily admits that everyone is racist. I suggest that in his desire to wage a cultural battle against silly internet activists he has missed the big picture.

          You said it yourself, the sort of toxic Tumblr activism that often brands itself as “social justice” has little to nothing to do with solving actual social problems…so I’m not really sure what your disagreement is with Scott, here.

          If your point is that he should spend more time talking about real-world social problems and less time complaining about SJ…well, it seems to me like he actually posts a lot more often about addressing those big picture social issues (healthcare, income disparity, etc) and only posts critiques of SJ-related stuff occasionally. Those posts just seem to get the most attention…perhaps because he’s tapping into a frustration that a lot of people feel. But nonetheless, it’s really only a small part of what this blog is about.

          I think it’s important to criticize the toxic and counterproductive elements of SJ culture. I also think it’s important not to get too wrapped up in that, because it can lead to an equally toxic counter-culture, but I think for the most part he’s done a good job of maintaining that balance, acknowledging the reality of inequality and the need to do something about it while calling out those who bully and harm others in the name of social justice.

          Suggesting that he’s all about waging a “cultural battle” against Tumblrites is a straw man.

    • Andrew says:

      Saying I’m anti-Republicans in the US doesn’t mean I’m against the concept of a political republic. Similarly, saying I’m anti-Democrats doesn’t mean I’m against the concept of a democracy, etc., etc.

    • CatCube says:

      If I can be excused for answering a question posed to the blog owner:

      Everybody wants a “social, just society.” The issue is that many of us disagree that what the current movement calling themselves “Social Justice” wants is either social or just in their policy prescriptions. The whole thing is two lies for the price of one. It’s mostly a pack of left-wing policy prescriptions that is arrogating a nice-sounding label as a marketing technique.

      The hostility comes from the fact that many of their more vocal proponents are the stereotypical “social justice warriors” who are pairing this lack of sociality and justice with at best a smug, oily, self-satisfaction, and at worst are out to form mobs to destroy those who disagree with them.

      • Whereas HbD is a pack of right wing policy prescriptions that is arrogating a sciencey label as a marketing technique.

      • Mary says:

        “at worst are out to form mobs to destroy those who disagree with them.”

        no, at worst, they are out to form mobs to destroy those they dislike. The disagreement, when it exists, seems a small factor compared to their visceral dislike of people who don’t toe the line.

    • eponymous says:

      I think you are interpreting “anti-SJ” too literally. Like, if someone said they were “anti pro-life”, you wouldn’t take that to mean that they want to destroy all living things. It just means that they oppose the position that is usually termed “pro-life”. Thus, here I would assume Scott means he is opposed to the movements that fall under the label “social justice”, though he would probably agree that social justice is a good thing.

    • Murphy says:

      Given the context I’m guessing it’s the aspect that you’re not allowed to disagree with people in that camp or else you’re branded as evil and as being “against the construction of a just society”.

      Doesn’t matter if their claims/beliefs on a particular matter are based mostly on email forwards and contradicted by large RCT’s. If you disagree with them then you’re evil and against the construction of a just society.

      There’s a strong “if you’re not with us you’re against us” theme with the not remotely subtle threat that if you’re “against us” then you’re a fair target to be attacked in any way. Up to and including getting a thousand people to call your boss and scream at her that if she doesn’t fire you right now then they’re going to plaster your boss across half the headlines on the net that day branded as a racist,sexist, nazi. Or perhaps just murdering your pets if you really piss them off.

      Some people, when they see someone claiming something factually incorrect, feel the need to tell them even if they’re perfectly fine with the groups goals, lies bother them for their own sake.

      They don’t get on well with the former group who immediately brand them as part of the “against us” group.

    • gbdub says:

      Clearly, anyone who opposes Social Justice is an antisocial criminal. I mean, it’s right there in the name!

      • Jill says:

        I know you are kidding. But, seriously, there are big questions here, with regard to Social Justice Warriors e.g. are the tactics they have gotten into the habit of using effective? Or are their tactics perhaps counterproductive, doing more harm than good, taking their social justice cause backwards? Here is an article someone sent me to earlier, by Scott, on this subject.


    • stargirlprincess says:

      Clearly you seem to think Scott is an unusually smart guy. yet he said something you find obviously wrong!

      Perhaps instead of asking Scott you should ask yourself why Scott would say he is “anti-SJ.” Commentators here could give many reasons for being anti-SJ. But you will just argue against those and we will get nowhere. Maybe you won’t argue against the reasons you come up with yourself.

    • Tyrant Overlord Killidia says:

      My problem with SJ is that a lot of them (metaphorically) smugly put on the cape of a superhero, and then declare that anything they do must be good. Because, you know, they’re a superhero.

      It’s analogous to how some people think that everything that cops do is good. Because, you know, they’re cops. So they must be good.

      Sorta like Divine Command Theory, except applied to people. As though DCT wasn’t horrible enough.

      Sure, we need cops and we need justice for oppressed groups, but just because you’re part of that tribe doesn’t mean you’re good by definition. Because then we end up with frivolities like yoga being imperialist, colonialist, sexist, and racist.

    • Bugmaster says:

      I can’t speak for Scott, but personally, my impression of the modern SJ movement is that it is based on a deeply flawed epistemology. Thus, their actions are only loosely coupled to reality. To the extent that they accomplish anything productive — which happens very rarely — they either do so by accident, or by actively rejecting the core premises of their movement.

      I feel exactly the same about all major religions, for exactly the same reason.

      • onyomi says:

        How would you describe the SJW epistemology?

        • Bugmaster says:

          As far as I can tell, most of them do believe that there exists a physical reality that all of us inhabit. However, they believe that the true nature of this reality (or at least those parts of it that apply to human society), cannot in principle be understood in a rigorous way.

          Given the a priori impossibility of any kind of an objective approach, we are left with individual people’s feelings, as informed by their mindsets. When you say, for example, “women prefer yogurt to waffles more so than men do”, what you really mean is, “I experience a feeling that women prefer yogurt to waffles” (I realize that many SJWs would label such a statement as too simplistic or downright problematic, due to its crude approach to the gender spectrum, but let’s roll with it for now).

          Most of the problems in our society stem from the fact that people’s mindsets, and thus all of their feelings, are based primarily (if not solely) on their inborn attributes such as race, gender, sexual orientation, etc. Thus, what you really meant to say was, “as a man, I experience a feeling that women prefer yogurt to waffles”. Unfortunately, people possessed of certain inborn attributes (e.g. maleness) are permanently conditioned to see other people as inferior. This is not their fault, and it is not a conscious choice that they are making — but rather a core assumption built into their very mindset on a subconscious level. SJWs call this phenomenon “privilege”.

          This might be a harmless bias if we’re talking about yogurt and waffles, but it becomes problematic very quickly when we start discussing important issues. For example, consider what happens when a male programmer tells a female programmer, “your code is inefficient”. Given that the true state of the world — and thus the true efficiency rating of the code — is unknowable, what the man really means is, “as a man, I feel that, being a woman, you cannot possibly be as good at coding as I am”. Oppression swiftly follows.

          Similarly, when a privileged person tells a less-privileged person, “I disagree with you on this issue; can you provide some evidence for your position ?”, what he really means is, “I am dismissing your personal experience out of hand because my own personal experience, being superior, contradicts yours”; the word “evidence” simply means, “a story that validates my personal experience”. Given that your personal experience is literally all that you have in this world, this is a huge problem. By denying your personal feelings, privileged people are erasing you from society; if this process is allowed to continue, you and people like you will eventually end up enslaved at best, extinct at worst.

          I could go on about the effect such a worldview has on the SJWs’ approach to art, public behaviour, etc., but this post is probably too long already, so I’ll stop here…

          • onyomi says:

            Sounds a lot like what Mises called “polylogism.”

          • Montfort says:

            Oppression swiftly follows

            Suddenly I envisioned you dismissing a hopeless variation in chess in a thick russian accent.

          • Jill says:

            The big problem with SJW’s is that they claim the right to shut everyone else up. And it’s understandable why they want to claim this right, because, what you said is true, with the “inefficient female programmer” example. And also the example of “I disagree with you on this issue; can you provide some evidence for your position ?” and you’re really dismissing them unless they provide a story that validates your personal experience, not theirs.”

            However, there does need to be dialogue of some kind for progress to occur. But most people can’t find the right type of dialogue that can be respectful of all parties involved and so can work.

            The main people I ever read about who could do this were Arnold and Amy Mindell. I highly recommend this book about the subject. But fasten your seat belt before reading it. It’s not something many people would find familiar or comfortable or easy to do. There are workshops that train people in how to do it. Even with training, it takes a certain personality type to be able to do this kind of thing. Such people should be supported and encouraged because they can do great good.

            Sitting in the Fire: Large Group Transformation Using Conflict and Diversity September 17, 2014 by Arnold Mindell

          • Bugmaster says:

            I looked up polylogism, and that sounds about right — though IMO the SJW mindset may be a little stronger. As far as I can tell, they believe that the lived experiences (and thus, the entire worldview) of a person from one demographic group will remain forever inaccessible to a person from another group; for example, this is the reason why men cannot be feminists, only feminist allies.

            I do have such an accent in real life, so… good job ! 🙂

            I think a dialogue is extremely difficult (if not impossible) to achieve on the global scale, because the SJW epistemology is completely resistant to outside influences. Since one can never transcend one’s privilege, it doesn’t matter what you say, because everything that you could possibly say is a priori tainted. However, SJWs are human like the rest of us, so on an individual level a dialogue is sometimes possible — just as it’s sometimes possible for ultra-conservative Christians to soften their position on homosexuality once they find out that their best friend/child/pastor/etc. is gay.

            That said, I haven’t read the book, and perhaps it proves me wrong. I hope so…

          • HeelBearCub says:

            Pardon me, I may be making an incorrect assumption here, but I will elucidate the argument.

            My sense is that you would happily make an argument against paternalistic organizations that presume to know what you want or is best for you. That you know better what is best for you.

            Lived experience has always struck me as just another application of the broad truth underlying that sentiment. The concept of allies is just a way of reminding people of the broad truth.

            Yeah, stridently arguing that “You can’t be X only an ally of X” can be a jerk move, but the broad principle of “ally” doesn’t strike me as anything inherently wrong.

            One of the issues I have with the conversation around here is that “SJW” is sometimes used to mean “The Scotsmen who are assholes” and sometimes used to mean “All Scotsmen”.

          • “One of the issues I have with the conversation around here is that “SJW” is sometimes used to mean “The Scotsmen who are assholes” and sometimes used to mean “All Scotsmen”.”

            I think of the “W” as making the distinction. Consider the implication of “all’s fair in love and war.” Or the popular political slogan, “War on __.”

            How would you define a Social Justice Warrior?

          • I’m not sure there’s a simple way to identify SJW– you can’t tell in advance how much science there is in a piece of “science fiction” and knowing that a government identifies as “socialist” tells you very little about it.

            I know someone who has identified as SJW, but he doesn’t use the more hostile aspects, and people who don’t believe in compromise drive him crazy. I don’t know if he’s going to continue to call himself an SJW.

            I’ve been in an argument with someone else who claims that Jews aren’t white because white gentiles don’t think Jews are white, and there’s a long history of oppression by whites that Jews shouldn’t identify with. He was surprised that I thought he was SJW, and he doesn’t use their nastiest tactics much. I suppose I can go with “strongly influenced by SJW”.

            He’s only a dozen years older than I am, so this isn’t just generational change.

            By the way, I *do* think I’m white, and I’ll be goddamned if I’ll let someone else take charge of whether I am or not. I don’t know what I’d think on the subject if the world got really hostile about whether Jews are white.

          • HeelBearCub says:

            @David Friedman:
            That was my point. The W theoretically means something, but frequently SJW as used around here just means one of the following: feminists, black or other activists, Democrats, the left, liberals, etc.

          • Bugmaster says:

            I don’t disagree with that, necessarily, but it’s tangential to my point. My main point of contention with the SJ movement is that, unlike them, I think that there does exist an external reality that can be understood (at least partially) in a quantifiable way. We actually can tell whose code is more efficient.

            This implies that if you base your policies entirely on personal feelings, and if you label an entire demographic group of people as inferior (or superior !) based solely on their gender/race/whatever, then you are incredibly likely to make poor decisions. The kind of poor decisions that make the world a worse place to live for everyone, including yourself, in direct contravention of your own goals. And if your ideology precludes any possibility of updating your beliefs based on external stimuli, then you are pretty much just diving head-first into the death spiral of failure.

            Just to clarify, I’m not saying that non-SJWs are somehow immune to failure, or that they don’t have flaws of their own; of course they do. Nor are SJWs somehow immune to success. They are just a lot less likely to achieve it.

          • Liskantope says:

            @Bugmaster: your assessment of “SJW epistemology” comes from quite a different angle from the way I usually think of it. I’ll have to ponder this. More concretely though, some of your description of SJ differs from my experience, in particular this:

            As far as I can tell, they believe that the lived experiences (and thus, the entire worldview) of a person from one demographic group will remain forever inaccessible to a person from another group; for example, this is the reason why men cannot be feminists, only feminist allies.

            First of all, while I agree there’s definitely a major element of “this group has no way of understanding the experiences of that group” in SJ rhetoric, it only seems to go in one direction: I’ve never heard any mention of women not being able to imagine what it’s like to be a man, for instance. Yet even so, I have yet to run across any SJ person who excludes men from being labeled “feminist” — maybe over the years I might have run across someone like this on the internet who sounded ludicrous enough to be dismissable, but certainly not a single person I’ve known IRL.

          • Nornagest says:

            I’ve never heard any mention of women not being able to imagine what it’s like to be a man

            I’ve seen a couple approaches to this. One, and maybe the standard one (?), is that members of marginalized demographics are so inundated with cultural content that assumes non-marginalized audiences that they do understand what it’s like: male gaze, *normativity of all stripes, etc. If this line of reasoning actually worked, of course, then e.g. Western weeaboos would have a perfect understanding of what it’s like to be Japanese, but I have seen it.

            The other is that they don’t know but don’t care: the problems of the privileged are inaccessible to the disprivileged but also petty and pointless, because privilege.

          • Bugmaster says:

            I agree with what Nornagest said; he phrased it better than I could.

            But I would also like to add that, in isolation, there’s nothing wrong with the claim that a man can never fully understand what it’s like to be a woman (and vice versa). Even if we discard any social factors, at the base levels our bodies are physically different, and thus we cannot truly experience life through the senses of another person (until telepathy is perfected, of course).

            But when you combine this claim with the idea that it is impossible for us to put together any kind of a coherent picture of the world that is in any way independent from our lived experience and thus our feelings — that’s where you get into trouble. Now that you have eliminated any possibility of holding a coherent dialogue, you have no choice but to resort to more… energetic… options.

          • @Bugmaster

            Have the SJ the right to complain that rationalists are refusing to engage with their perfectly good ideas?

          • Bugmaster says:

            Er… Yes ? Everyone has the right to complain about anything. I guess I’m not sure what you’re asking.

            That said though, the “rationalist” label is largely unknown outside of its own enclaves, so I doubt SJWs would complain about it en masse. Even if they were aware of the label, they’d probably lump rationalists together with other straight white cis men.

          • TheAncientGeek says:

            If the SJs can *validly* complain that rationalism, or something else, is a bubble that is not open communication with other subcultures, then there is nothing *uniquely* wrong with SJ in that respect

          • Bugmaster says:

            What do you mean by “validly” ? For example, such a complaint would be internally consistent with the rest of their views (insofar as the concept of “internal consistency” can be applied to those views).

            That said though, I’m not sure if it would be possible to establish “open communication” between rationalists and SJWs, since the worldviews of these two subcultures are diametrically opposed. The world is either knowable, or it isn’t; and I’m not sure if it’s possible to convince a person to change his mind regarding this core premise — one way or the other. Of course, there is always room for civil discussion, but I’m not sure if there can be any outcome other than agreeing to disagree. I could be wrong, though.

          • TheAncientGeek says:

            I’m not at all convinced that SJ’s are the (one and only) problem, or that communication between rationalists and Sjs is the problem. There seems to be a much wider problem of differing world views, which i share to solve precisely because world-views include epistemological concepts, such as what counts as “valid”.

            I also don’t buy the dichotomy of the world being either knowable or not. What counts as the world? The rationalist/STEM side tend to simplify the problem of coming up with a unitary world view by disregarding “warm fuzzies”…values, subjective perceptions and so on, in favour of physical, logical and mathematical truth.

            But that’s crazily wrongheaded from the perspective of someone whose life is dedicated to the pursuance of certain values. (and they are not really in the business of rejecting the objectivity of facts like the melting point of iron, they are just not very interested in them). If there is a fact-value divide, as many rationalists believe, then the objection is fairly valid by rationalist criteria … rationalists aren’t seeing the own contradictions to some extent.

          • Nornagest says:

            I don’t think lived experience is quite as central to SJ ideology as this argument seems to be assuming — maybe in 1990-2000, when SJ was mainly an academic phenomenon and everyone in it had a raging crush on Foucault, but not now, when it’s a more of a folk phenomenon. As philosophy it’s incoherent, yes. But that’s because folk philosophy is always incoherent, not because it has a substructure that rejects coherence.

            On the other hand, TAG, the view of rationalism that you’re putting forth here is bizarrely rigid. It’s a reductionist worldview, sure, but that doesn’t mean that it disregards “warm fuzzies”. LW spent a lot of time talking about human values! Not very successfully, but still. It does insist they ground themselves in reality (viz. “that which doesn’t go away when you stop believing in it”) at some point. That does not strike me as an unreasonable demand — indeed, it strikes me as a prerequisite to addressing any serious problems, since any moves you make to address them will have to take place there.

          • Part of what makes SJ complicated is that only some lived experience counts. For example, if a woman hasn’t run into a lot of sexism, she isn’t supposed to mention that.

            I’m not sure whether SJ is worse about not quantifying than most ideologies, but it certainly doesn’t quantify. For example, it would be worth knowing something about where there’s more or less street harassment of women (and break out the details by the woman’s race if that’s relevant), but SJ isn’t going to be collecting that information.

          • Bugmaster says:

            I alluded to this in my original post, but I don’t think it would be reasonable of us to hold SJWs to rationalist standards. When rationalists (and, arguably, more mainstream cultures to at least some extent) speak about “collecting evidence”, what they mean is something like, “let’s try to build a more accurate model of the world so we can make more effective decisions”.

            But this concept does not exist in SJW and similar faith-based worldviews. When they speak of “collecting evidence”, what they mean is something like, “subvert the opposing tribe by using their own tropes against them”. This is why, for example, SJWs keep using blatantly false statistics: they literally do not believe that statistics have any intrinsic value, or any referent beyound their power to convince people.

            In broader terms, SJWs believe that every form of human communication — including art, music, blogging, gaming, simply talking, as well as arguments about statistics — exists in order to reinforce some sort of a narrative. If this narrative is not focused on Social Justice, then, most likely, it is instead focused on maintaining the oppressive status quo at best, and enhancing the oppression at worst. Thus, it must be fought.

            I should clarify, of course, that SJWs are human like the rest of us, so not everything I’ve said will apply to every single SJW. This is just my impression of their movement in aggregate.

    • Orphan Wilde says:

      Justice at a communal, societal level requires injustice at an individual level.

    • Liskantope says:

      I think the acknowledgment of being anti-SJ without elaboration here is a little unfortunate. I mean, it’s clear what he means if you’re familiar with his writing (ExpertWitness, I suggest browsing SSC archives for SJ-related topics, especially prior to 2015, to get the idea): he means skeptical of a lot of common SJ claims, and critical of SJ rhetorical tactics. I try to refer to this as being “skeptical of / having reservations about SJ rhetoric” rather than “anti-SJ”, which I worry has other connotations.

    • LPSP says:

      Neither society nor justice, nor any permutation of the two still, is owned by the orthodoxy of the movement that calls itself Social Justice. It’s a map and territory thing. A useless map is calling itself “Awesomap!”, and it’s gibberish and corresponds to no territory, real or potential, and Scott is rejecting it. You are now asking “It’s okay to dislike Awesomap!, but are you REALLY against having maps that are awesome?”

      • If only things were that simple! Instead, it’s really easy for people to not notice that they’re being obnoxious and/or abusive, and even easier to not be aware of obnoxiousness and abuse which are committed by second parties on third parties.

        Social Justice points out some of the problems while ignoring the problems it causes.

        You’re absolutely right about the risks of giving something a really cool name, though tai chi chuan has somehow remained useful in spite of being called supreme ultimate fist.

  48. Wow, Scott, your residency series is so good that it manages to shine even among the stratospherically high quality of your habitual posting! Thanks for sharing.

    I agree that psychodinamyc/ psychoanalysis is the worst of the worst. For some bizarre reason I chose to make it a significant part of my doctoral dissertation, and to this day regret the amount of time I devoted to studying such a boatload of crap. You being a rationalist, I can sympathize with the tension of being exposed to the unfathomable amount of irrationality at the core of what has ended being an unmoored cult (although that’s not something new or a result of its evolution: it already was creepily irrational from its very beginning). You may find amusing (or not, it is quite crudely written) my venting about it here: http://purebarbell.blogspot.com.es/2014/12/back-to-freud-gasp.html

  49. Schmendrick says:

    Strangely, a childhood fascination with George Washington seems to have granted me at least a partial immunity to the [awkward silence] tactic. Washington was famously taciturn, and a good portion of the slim little volume of manners and morals he wrote is concerned with impressing upon the reader the necessity of restraint while in public:

    “34th It is good Manners to prefer them to whom we Speak before ourselves especially if they be above us with whom in no Sort we ought to begin.

    35th Let your Discourse with Men of Business be Short and Comprehensive.

    40th Strive not with your Superiers in argument, but always Submit your Judgment to others with Modesty.

    41st Undertake not to Teach your equal in the art himself Proffesses; it Savours of arrogancy.”


    I actually had the first therapist I ever went to try [awkward silence] on me, and so we just sat there for a good couple minutes. Perhaps Scott is grateful that our civic religion is less hagiographic now than it used to be.

  50. Walter says:

    Hey man, is Scrubs a show that a lot of hospital folks watch? It was a super funny show.

    • Ilya Shpitser says:

      I do wonder if Scrubs makes medical professionals wince sort of like Numb3rs makes math types wince. I am learning a bit about hospital operation, and some of Scrubs stuff is surprisingly on point modulo hijinks.

  51. Kyrus says:

    It occurred to me leaving his ritzy office that pretty much every philosophical idea I have – rationalism, belief in science, libertarianism, atheism, anti-SJ – originate in this feeling of revulsion at other people ordering me to believe things that I think are wrong and me not being allowed to argue with them.

    I got a little angry when reading this, because I can relate. I wonder if many people just don’t care much about whether their believes are true or not and instead just care if they are good or bad. Such a person might be mor einclined to be irrational, religious, pro sj,…

    • arbitrary_greay says:

      The object level of beliefs (rationalism, belief in science, libertarianism, atheism, anti-SJ) are not inherently tied to caring about truth/goodness. “revulsion at other people ordering me to believe things that I think are wrong and me not being allowed to argue with them” is more about having a contrarian personality.

      A person might get into religion because they are surrounded by atheists screaming bad arguments for atheism at them and telling them they can’t argue because SCIENCE.
      There are people who are exasperated with the movement because others who call themselves Rationalists keep stopping them from participating in arguments until they’ve read the entire Sequences.
      And not a significant number of people get into SJ because they feel like they’ve been silenced by oppressors–being ordered to believe in things they think are wrong and not being allowed to argue with them.


      • Rebecca Friedman says:

        I’m not sure it is. I don’t think I have a contrarian personality – I tend to be a very obedient daughter and listen to everything my parents say (because I trust them), I tend to really like following a leader (if I trust him/her) rather than making my own way, I honestly never did teenage rebellion at all, etc. etc. – but if someone starts telling me what to believe and that I’m not allowed to argue, I lose my temper, hard. I would say “revulsion at other people ordering me to believe things that I think are wrong and me not being allowed to argue with them” is a quite accurate description of my reaction. The inside of my head is mine.

  52. 57dimensions says:

    If getting patients to talk about what their actual problems are is typically this painstaking for most therapists/psychiatrists I can see why I’ve been considered atypical by most of the mental health practitioners I’ve encountered over the years, I’m never shy about sharing every psychologically relevant detail of my life and upbringing right off the bat, of which there are more than you would think. And I’m not even an over-sharer who goes into mundane detail about inconsequential things, I’m talking about the child abuse (physical and sexual), alcoholism, and divorce that touch everyone in my direct family, which are things that practitioners usually ask specifically about in the basic family history. And then there’s the part where I have to go through every therapist I’ve seen, which medications I’ve been on when, which psych hospital I was in at which time, which high school I was attending/when I was on medical leaves etc. and it usually takes most of the meeting for them to get that timeline straight.

    Anyways, my openness and lack of affect strikes many as odd, just about every person who worked at the last residential program I was in asked me, “Why are you even in here?? You seem perfectly well adjusted and psychologically healthy!” and “You’re telling me you never attempted suicide or self harmed or abused substances?!” I was also tested for ASD, nope; and ‘interviewed’ by this very distinguished psychiatrist guy in front of a room full of other staff and students (this was a teaching hospital) about my lack of emotional expressiveness.

    My ease with talking in therapy is starkly contrasted with my failure to make any progress whatsoever on the behaviors that brought me there.

    • Jill says:

      It’s possible that your therapists have tried everything that could be tried to help you already– especially if you have already been to a lot of different therapists who tried a lot of different kinds of therapy. Not everyone can be helped by psychotherapy.

      But you should discuss your lack of progress with your therapist.

      “Why are you even in here?” in therapy, is something you should really be thinking about and discussing a lot in therapy, as well as what seems to be getting in your way of the progress you want. It usually takes some pretty serious difficulties in life to land a person in a residential program so there’s likely something going on that’s pretty serious there.

  53. alaska3636 says:

    Picturing Scott in an argument about dishes with a girlfriend is amusing. He knows that he is probably right about the dishes, but he knows that is not going to resolve the issue by being right about anything.

    In my own personal experience, who is right or wrong between my lady and I is never the issue. The issue on her side is that she wants to compromise and accept shared responsibility for our settlement; the issue on my side is that I am very confident that I am right and it seems like she wants me to adopt a flawed outcome and take responsibility for it.

    Since my reasons are rarely understood, if I want to resolve the conflict, I have to suck it up, come down to accept a silly, flawed outcome AND share responsibility that this is a relationship decision. Only when I do these things does anything get resolved. We are in pre-marital counseling for these “communication” issues and it seems to help mitigate the size of conflicts. 95% of the time, I am unaware of any lingering issues and I love being around my fiancee; 5% of the time, I am so uncomfortable that I am not sure how a marriage will work.

    • houseboatonstyxb says:

      @ alaska3636

      It is the little rift within the lute
      That by-and-by will make the music mute,
      And ever widening, slowly silence all.

      The issue on her side is that she wants to compromise and accept shared responsibility for our settlement; the issue on my side is that I am very confident that I am right and it seems like she wants me to adopt a flawed outcome and take responsibility for it.

      My partner and I were together 50 years, and each time this happened, things got worse. His refusal to discuss, would feel like a personal snub. Object-wise, I’d take it as an order from him with no questions allowed — or I’d think he didn’t really care about the object if he wouldn’t even talk about it, so I’d keep doing it my way.

      As life progessed and more and bigger decisions came up, each one drove the rift wider. With attitudes so opposed, I can’t imagine such a marriage working for long.

      • Jill says:

        There are some brilliant CD’s by Deborah Tannen about research on gender differences in communication. This goes light years beyond the oversimplified men from Mars, women from Venus approach.

        “Communication Matters – He Said/She Said: Women, Men and Language”

        She also has written a number of great books on the subject.

        • houseboatonstyxb says:

          @ Jill

          I liked Suzette Haydn Elgin’s similar books. She (like me) was from Southern rural culture, Tannen from NY. So along with the men/women differences, I found a lot of Direct/Indirect speech patterns illuminated.

          Some people from the Direct culture like to call ours “Ask/Guess”. Which is kind of insulting to us, who prefer “Ask/Hint” or “Ask/Inform”. There was a good discussion of this on Elgin’s blog, ozarque.livejournal.com a few years back; if anyone is interested, I can look it up.

          • Jill says:

            Oh, yes, The Gentle Art of Verbal Self Defense. I loved those books.

            It is good for people to learn that there are Ask cultures and Guess cultures, so that we can understand where each other are coming from. Otherwise, people play by different rules, but each assumes they are using the same rules, and they don’t know that the other’s rules exist. And things get confusing and upsetting quickly.

      • Adam says:

        50 years is pretty long.

        • houseboatonstyxb says:

          @ Adam
          50 years is pretty long.

          The first ~25 years we were young and having fun adventures. Middle-aged problems were more serious and worsened the rift. Counseling was not an option for me then, so I didn’t catch on till reading Tannen or Elgin about office stuff, and being told by a friend that he (and other men) would not allow even a brief conversation in which he and I would be equals.

          • Jill says:

            A lot of times people grow into different psychological shapes as they age. And things you tolerated easily before, perhaps because you didn’t know much about other options, become intolerable later on. Needs, attitudes, desires etc. can shift a lot over decades.

            For that reason, marriages can be good for years, and then become lousy– because the people in the marriage changed into different people as they got to know their options, preferences, needs etc. better over time. And then there is no longer a match between the two people any more, since one or both have become someone different.

  54. ExpertWitness says:

    I had a breakdown in 9th grade. My brother died of a drug overdose a few months prior and I had nobody to talk to. I told a teacher I was suicidal. He referred me to the school psychologist. I quickly realized the psychologist had little to offer me. She was listening intently to my words and responded to them programmatically. I could escalate the situation by mentioning my brother, suicide, drugs, self-harm, family disfunction, social alienation, or sexual perversion. Or I could present myself as just another bored, angsty 15-year-old. 

    I repeated this experience with a prestigious psychologist in a luxurious office and a CBT practitioner. At a time when I needed the guidance of an intelligent adult, I learned a different lesson: I alone am in control of my mental health. Therapy was just a game, and my therapists made little effort to convince me that they were on my team.

    I assume the apprehension of your patients stems from the fact that they perceive the therapy session as a game of high stakes poker. They mustn’t misrepresent themselves, because you are incredibly powerful and the consequences of misdiagnosis are significant.

  55. Mark says:

    Hi Starslatecodex.

    I think this new rational and scientific take on psychotherapy might be worth your time to look at. I have yet to see any other therapy like it! Your patients will thank you for it ^-^


    A fan.

  56. alaska3636 says:


    I am curious what you think of Ludwig Von Mises’ methodological dualism regarding the physical versus the social sciences; and, consequently, his elaboration of methodological individualism regarding the social. The first 200 pages or so of Human Action outlines his ideas.

  57. Ivan Ivanoff says:

    > “Look, I’m sorry you didn’t like your mother, but have you read The Nurture Assumption?”

    I had a job interview recently where biodeterminism and parenting came up (he’d heard that I don’t think parenting matters, given the usual caveats) and he made the point that anxious parents can pass on anxiety via the environment they create. What was I supposed to do?

    “Look, I know your wife is a psychologist, but have you considered that maybe a large chunk of psychology and most parenting studies are vestiges of Freudian BS?”

    I stayed quiet.

  58. Greg says:

    “[awkward silence]” reminds me of a technique for rejecting job applicants. This technique applies in the situation where politeness demands that you reject them via a phone call, as opposed to, say, over email. This has worked flawlessly for me the ~10 times I’ve had to do it, and my co-workers swear by it as well. Here’s how it works.

    You say, “Hi is this [applicant]? It’s [me] from [company].” Wait for them to say “hi” back. You say, “I’m calling to thank you for applying for [job] and to let you know that we won’t be making you an offer. It was very nice meeting you, and we thank you for your time.” THEN YOU PAUSE. You wait AS LONG AS IT TAKES for them to say something. Basically every single time they will say, “Ok, thanks.” At which point you say, “Thanks again. Have a nice day.” And then they will say, “Ok, have a nice day.” And then you hang up. Done.

    The big failure-mode is to try to fill the inevitable pause after you deliver the bad news. You may be tempted to say, “Yeah, you were really great in the interview, but it’s just that…” If you say this, everything will fall apart. They may question your decision, or even just politely ask for feedback. You may find yourself lying through your teeth because the real reasons you’re rejecting them seems too harsh to articulate. Even just saying “sorry” opens up a wealth of unpleasant emotions and lines of conversation.

    So you MUST use “[awkward silence]” until they speak, and then you’re both done and you can both get on with your lives.

    “What we cannot talk about we must pass over in silence.” — Wittgenstein

    • anonymous says:

      seems less like using awkward silence and more like enduring it when it naturally arises. There simply isn’t anything more for you to say. Almost completely different imo

  59. I’m pretty fond of “yeah?”, it often comes off a bit more natural than “tell me more”. (h/t Kate Donovan: https://gruntledandhinged.com/2014/08/08/the-humble-yeah/)

    • Sniffnoy says:

      Other equivalents:

      “Go on…”
      “Can you say more about that?”

      More formal ones that are probably less appropriate for this context:
      “Can you elaborate on that?”
      “Can you expand on that?”

      • LPSP says:

        “Would you mind… ?”

        or if you want to be formal AND need to take over Rapture:

        “Would you kindly… ?”

    • Pku says:

      This really depends on who you’re talking to. I usually hear “yeah?” as “that doesn’t interest me.”

  60. Jill says:

    Scott, I am a really good psychotherapist. Okay, so this is the Internet, you’ve never seen me do psychotherapy, and I could be lying to myself and/or to you. But, for the moment, why not give me the benefit of the doubt, and consider some of the things I have to say here? I’m not good for everyone. I can be blunt, which some patients react badly to, and some love. Different therapists’ personalities can make a big difference in the therapist-patient match. If someone needs a different type of therapist personality to interact with, I refer them to another therapist.

    “I am getting good at dealing with annoying attendings, meandering patients, unreasonable requests, and silly bureaucracy.”

    Great, Scott. You’re doing the most anyone can do while in grad school or medical school. That’s the whole point of it right there– to get good at those things.

    “Actual Pathology remains scary, mysterious, and really hard to predict. Hopefully that’s what fourth year is for.”

    I would be very surprised if you learned much about actual pathology in the 4th year either. It’s usually not until mental health professionals get out of school, and then have freedom of choice about which workshops or other learning experiences THEY think have something to teach them, that they learn anything useful.

    Until that time, the usual experience is that you stroke your supervisor’s ego successfully, so you can get your degree or complete your internship, residency etc. successfully. You have to survive to be able to later learn to do things that are useful.

    I see that now you’re stuck with this supervisor, and you have to say to a patient who is really upset about losing his best friend, “Are you sure this isn’t about how you’re worried I’m sort of like a friend to you and one day you’ll lose me?” Don’t despair. One can learn important things from this. Especially if it makes you cringe to do this.

    There are several constructive things that you could learn from this. For example

    1) Maybe in this case, or some other case, it really IS about losing you as a therapist. And you could find this out that sometimes it is about that (although not usually.)

    2) An extremely important skill for a therapist is to ask questions like this, that may be very far off the mark, and then allow the patient to correct you if you are wrong. You don’t have to necessarily be vague and try not to suggest things to the patient, if you can successfully communicate to the patient that you do want him/her to correct you if you guess wrong, and that No is a perfectly good answer to a question.

    And yes, some psychodynamic therapy supervisors are going to make everything into self-fulfilling prophecies. So no matter what happens, it will be seen as proof that their hunch was correct. And to get your good grade, maybe you have to pretend that your supervisor is God on a stick and is correct about everything– and that you have no impressions or thoughts of your own about the patient that might be useful, nor does the patient.

    This is a good thing to happen. Notice how this feels to cringe, and notice what you think about it. This position of having to pretend to agree with the authority is exactly the position you want to learn to NOT put your patients in. So it’s good to be aware of that possibility and the signs and symptoms and feelings of it.

    A lot of what goes wrong in people’s lives has to do with power politics. A lot of the folks that come to you will have been in that situation that you are in with your psychodynamic supervisor– with their parents, their spouse, their kids, their co-workers or classmates etc. And they may have lots of anxiety, depression, anger, shame etc. about it.

    Some of the time it will be necessary for the patient to stay in that position e.g. to earn a grade. But other times, they will be doing it from habit. And they will actually be perfectly free to express themselves and/or to leave, although they may not know that. And they may not be prepared yet to deal with the other person’s anger, disappointment, anxiety etc. at the prospect of an equal relationship, rather than a relationship where the patient is one down or submissive.

    “But when I leave for good, I’m getting him a present, and it’s going to be a copy of The Nurture Assumption. Heck, maybe I’ll give that to all the psychoanalysts I know.”

    Make sure he’s given you your good grade before you give him the present. I predict that it will have no effect on his beliefs whatsoever.

    I got the book and read it since you think so highly of it, Scott. I think still what I think of most research that people do to try to answer questions about how to do psychotherapy– that researchers aren’t asking the right questions yet. So the jury is still out, in my view.

    The very old research on psychotherapy rings true to me– that a lot of what you are doing is showing warmth, empathy (that you care how the person feels), and congruence or authenticity. So you’re not giving a lot of mixed confusing messages (at least you’re not giving them any more once you are out of your training program and are no longer compelled to do things you don’t believe in.) If you give warmth, empathy and congruence, you’re giving more than most therapists do. So if you want to do only that, it should work fairly well for most of your patients. Those qualities can be scarce in modern life and it is a gift to give them to anyone in your work or in your personal life.

    Training programs where you have to please the supervisor suck to a great degree, as you have noticed. But still, you have the chance to learn about power politics. And you have the chance to observe things about patients and what seems to help them and what doesn’t and what works to get helpful information out of them so you can help them.

    Some of the most useful things you observe, you will not be able to share with large egoed know-it-all supervisors you might have, because it might bruise their egos, thus lowering your grade. But you can still learn from these things, and maybe discuss them with peers, if any of them are open to it.

    Here are a few books about psychotherapy by people who I think do a fantastic job of it. They have not waited for conclusive formal research on what to do for patients. They have just seen tons of patients and noticed what helps patients.

    This first book here is about people who do relationships much differently than you do. You don’t have to start doing them this way yourself. But it might be helpful for you to know about this way of doing them. I do them this way and my husband and I are very happy together and have been for years.

    The Intimate Enemy: How to Fight Fair in Love and Marriage Paperback – July, 1983
    by George Robert Bach (Author), Peter Wyden

    Radical Acceptance: Embracing Your Life With the Heart of a Buddha Paperback – November 23, 2004 by Tara Brach (Author) (a psychologist and meditation teacher)

    True Refuge: Finding Peace and Freedom in Your Own Awakened Heart Paperback – January 12, 2016 by Tara Brach

    Past Reality Integration: 3 Steps to Mastering the Art of Conscious Living Paperback – March 8, 2012 by Ingeborg Bosch

    I know, these are not based on research. But if you wait for the conclusive research results, you may not be able to help people much. If you do your own formal research trying different methods– and encouraging patients to let you know if you have guessed wrong about something– then you’ll help a lot more people.

    A lot of psychiatrists just dispense medication and don’t do psychotherapy. That’s certainly an option you might take. I have seldom met a psychiatrist who is good at psychotherapy– not because they aren’t capable of becoming good at it, but because they usually just believe that whatever they were taught in school and their internships and residencies is all there is to it. And it’s not. It’s usually just about power politics– about how to act powerfully and overbearingly toward the intern or resident you are training, and toward the patient. One has to go to workshops on psychotherapy after graduate school or medical school or training programs, if one wants to learn useful things.

    I do think that 200 years from now, psychotherapy will be done in different ways than it’s done now. That we have a lot more to learn about what can be done to be helpful to patients.

    • Mark says:

      Hi Jill.

      Wow. What you wrote is a post in itself!

      We both seem to think that psychotherapy should have a more robust theory that can explain more than just mental health issues. A good psychotherapy should logically come from a good theory of psychology (that also fits into science)

      I would like to humbly suggest you read:

      Im sure it will be worth you and your patients time.

      Thank you,

      • Jill says:

        Thanks, Mark. It looks interesting. I’ll get it and see what I think.

        • Mark says:

          Hi Jill,

          Thank you for consideration.

          The link I posted leads towards the full and complete book online for free (just click on the book). Infact most of the books you will hear of in this book are also completly free to download (on the linked sites). The D.V.D is even free to watch! (:

          Theres no strings attached the author just believes in altruism.

          I hope everything goes well for you.


          P.S please let Starslatecodex know if you like it! (;

          • Jill says:

            Thanks for telling me. I didn’t realize it was free. I did click on the book just now and got it.

            Interesting. Looks so far pretty similar to what I do. I ask a lot of questions, more than most therapists do.

    • John Schilling says:

      Great, Scott. You’re doing the most anyone can do while in grad school or medical school. That’s the whole point of it right there– to get good at those things.

      Dr. Alexander graduated from medical school almost four years ago, IIRC. This is the third year of his residency.

      • Jill says:

        Ok, while in residency then. It’s still required training for your profession, where you have to please a supervisor, who may be teaching you nothing at all and may actually be impeding your learning.

    • “I got the book and read it since you think so highly of it, Scott. I think still what I think of most research that people do to try to answer questions about how to do psychotherapy– that researchers aren’t asking the right questions yet. So the jury is still out, in my view.”


      The Nurture Assumption
      isn’t about how to do psychotherapy.

      • Jill says:

        I know it isn’t. I’ve read it. But Scott here is using it as a guide to doing psychotherapy, as he wants to give it to his psychotherapy supervisor to enlighten him about this– or to enlighten him about Scott’s view that talking about the patient’s relationships with their parents (or with their parent figure therapist) doesn’t help them.

        It actually does often help– but not always. But the research in that book did not ask the right questions to discover that. And of course there was no research there on psychotherapy itself at all– although that didn’t keep the author from making pronouncements about psychotherapy not working.

        People’s lives, problems, relationships etc. are so varied, as is psychotherapy itself, that in many cases it is not possible to ask “the right questions” in a group study. Individualized psychotherapeutic approaches are necessary to help people. It is not a One-size-fits-all sort of thing. Even for people who present as having identical problems, their personalities may be different. And what options they will consider may be different.

        • Adam says:

          I think this is a huge problem for psychiatry, other areas of medicine, exercise science, nutrition science, etc. Science nearly always proclaims treatments failures or successes based on detectable differences between treatment groups and control groups, but it’s impossible to know if something deemed a failure contained anyone in the treatment group with the same physiology as you. This was very, very frustrating as someone into working out when I was younger. Virtually every journal-published study would seemingly have you believe that no exercise technique at all actually works, and yet it is very obvious from personal experience that individualized coaching and training does, in fact, work spectacularly well, even when you’re using techniques that don’t work on large treatment groups of people who aren’t you.

          • Jill says:

            Exactly. As someone mentioned earlier, psychotherapy is very similar to coaching. And if someone did research where they tried to apply standard coaching advice to everyone, it wouldn’t work, on average.

            But individualized coaching– according to one’s goals, problems, personality style, talents etc.– might work like a charm. In fact, it often has, for many of the clients I have seen.

    • Vaniver says:

      I would be very surprised if you learned much about actual pathology in the 4th year either.

      I read Scott’s hope as a joke, but maybe that reading is overly cynical.

    • g says:

      Apparently having a surname ending in -ch makes you write better books about psychotherapy.

  61. Bram Cohen says:

    Having a fraction of patients who can’t be straightforwardly diagnosed with a standard diagnosis and fixed with standard therapies of not much more than 1 in 10 sounds quite hopeful to me, like psychiatry is a real medical field instead of the den of quakery and bullshit it was when I was a kid.

    Your description of psychoanalytic therapy is consistent with my observations: It’s good at promoting psychoanalytic therapy and not much else.

    About your feeling like a fraud when doing therapy on people: It sounds like your issue is that there are all these things which are supposed to be earnest and legitimate, and although you’re doing them properly you feel you’re doing them rationally without truly feeling them. Perhaps it would help if you work on mirroring: Reflect back fear when your patients are expressing fear, and sadness when they’re expressing sadness. I don’t know if it’s a good idea to reflect back anger though. In person you come across a bit flat. Echoing your patients’s emotions more might make them feel like you’re more empathetic and you feel more involved in the process at an emotional level.

  62. Jill says:

    I wish I could remember where I read this; will keep looking. But I read that wheels were used on children’s toys for centuries before they were used for carts and such for adult tasks– at least in some culture, if not for all humanity. Why was that? It was because the person who carved toys for children to play with, had such a low status in the culture, that no one ever paid much attention to what he or she was doing.

    That is the same reason why the majority of psychiatrists aren’t competent at psychotherapy. Because not very many good psychotherapy workshops are taught by psychiatrists. Most are taught by psychologists, MSW’s. family therapists etc. But if a psychiatrist believes that those with a “lesser” degree have nothing worthwhile to teach him or her, then they never attend those workshops and never learn those things.

    • Nornagest says:

      I read that wheels were used on children’s toys for centuries before they were used for carts and such for adult tasks– at least in some culture, if not for all humanity.

      I remember that being true for the pre-Columbian Inca, but I don’t remember it for any other cultures. The explanation I was given — and it might be a just-so story — is that the Inca lived in high, rugged valleys on the west side of the Andes, with lots of rubble and little level ground. Trails could easily be built there but roads couldn’t. To make matters worse, the only pack animals they had were llamas, which don’t have the anatomy or the strength to draw carts or large sledges. (They make pretty good alpine portage animals, though; I’ve gone backpacking with them before.) So in the Inca’s specific physical context, the wheel offered little advantage by itself; to take advantage of it for hauling cargo, you’d need lots of other advances, which they didn’t come up with before Europeans arrived.

      • Jill says:

        I don’t remember if it was the Inca. Perhaps it was, and if so, there was a different guess explanation in the book I read, than the guess explanation in the book you read, about what the reason for it was.

        I do think that status is something that confuses people many times though– thinking someone or something has a certain high or low status, and then acting accordingly. Of course it does work sometimes, but other times turns out to be wrong. Certainly books on persuasion have many examples of people being persuaded to do things because someone instructs them to, who has or seems to have authority, high or celebrity status etc.

        Of course, the case I mentioned would be sort of the opposite of that. Not paying any attention to useful information because the person teaching it is believed to be of too low a status to know anything worth knowing.

      • Chalid says:

        @Nornagest I think the explanation you cite was popularized by Guns, Germs, and Steel.

        • Nornagest says:

          Wouldn’t surprise me. Though a little Google shows that toy wheels are known from Olmec artifacts, too; those guys lived in the rainforests in what’s now southern Mexico, which is a totally different environment. So the mountain thing is at least an incomplete explanation. (The pack animal thing would still apply, though — even moreso, actually, since llamas are not native that far north.)

      • Mary says:

        One also notes that llamas are much better at stairs than horses are. So once you build your trail in the easiest possible manner, the wheels have no way to go up.

    • Scott Alexander says:

      Dr. David Burns is pretty good IMHO. Have you ever read any of his stuff?

      • Jill says:

        Yes, I’ve read his stuff, like it very much and use it. I tend to be eclectic as a therapist and use a number of different techniques and schools of thought– partly because patients are different in what they are willing to try or what seems to make sense to them. For cognitive therapy, Burns is great.

    • God Damn John Jay says:

      I wish I could remember where I read this; will keep looking. But I read that wheels were used on children’s toys for centuries before they were used for carts and such for adult tasks– at least in some culture, if not for all humanity. Why was that? It was because the person who carved toys for children to play with, had such a low status in the culture, that no one ever paid much attention to what he or she was doing.

      From Wikipedia:

      4500–3300 BCE: Chalcolithic, invention of the potter’s wheel; earliest wooden wheels (disks with a hole for the axle); earliest wheeled vehicles, domestication of the horse

      I would be very surprised if toymaker was a discrete profession 6500 years ago and I would be even more surprised if we knew what their relative status was in society. Its a neat story, but it smells funny.

      • Jill says:

        Well, if I locate the book again, I’ll let you folks know.

      • nydwracu says:

        A better example is academic archaeology.

        (I once went to a bushcraft convention, and ended up talking to a guy who made stone tools. He had a set speech about how academics thought [used to think?] that a single stone axehead took days to make; IIRC, he said they were under the impression that they were always sanded down. Then he took two big rocks and used one to bang chunks off the other until it was close enough to an axe head for sanding. Total time: about an hour.)

        • Nornagest says:

          Experimental archaeology is a thing — I took some archaeology classes in school, and one of them was largely spent knapping obsidian — but I don’t know what kind of status it enjoys among the rest of the archaeology community.

    • Mary says:

      eh, probably the real reason was that wheels are not such wonderful things as they appear to us, who have good roads. Mud and stuff can make it much easier to pack everything on the back of the mule.

  63. Bugmaster says:

    I’ve never been to a psychiatrist (though perhaps I should), but I’ve seen regular doctors. As far as I can tell, every single one of them is basically running a tech support script in their heads; and it’s a pretty basic script, at that. It doesn’t matter what your symptoms are; unless you are bleeding profusely from several stab wounds (though maybe not even then), the doctor will ask you the same questions, and order the same tests. When the tests come back, he will prescribe some medication chosen seemingly at random from a set of 3..4 possible items, and dismiss your concerns. If your symptoms persist, you will repeat this cycle several times, and there’s a chance that, eventually, the doctor will attempt to deviate from the script and figure out what’s wrong with you (if anything).

    It’s easy to dismiss such behavior by saying “doctors are stupid and lazy”, but a better explanation might be, “the script works 99% of the time, so the doctor would be irrational not to follow it”. Perhaps he situation is the same in psychiatry ?

    • Jill says:

      If you go to 2 M.D.’s for a medical condition, you are likely to get the same or a similar treatment. That may be the same with most psychiatrists. But a lot of psychiatrists do meds only and do not believe in psychotherapy at all.

      But with psychotherapists overall the script approach is not so at all. A psychodynamic therapist, a cognitive behavioral therapist, a therapist who does Eye Movement therapy, a therapist who does bioenergetics, one who does Thought Field Therapy which is an acupressure self-tapping method– these are all very different from one another. There is no one script, although perhaps cognitive behavioral therapy is somewhat more popular than others.

      • Jill says:

        I have a relative who had my husband and me pretty concerned until we just had to accept the fact that we have no influence. He’s an intelligent person, quite capable of learning new skills, with a lot of responsibility in his career. But his psychiatrist just prescribes medication and does not do psychotherapy himself, nor does he believe in it.

        This relative probably does need continued medication. But he has tons of family relationship problems, super poor communication skills, and obvious deficits in other skills that could help him if he learned those skills. He and his wife and other relatives stress each other out a great deal, in ways that could be changed, if he were open to that. We live far away in a different state, and at any rate, he is not open to our influence. But it is sad to see problems not being looked at, much less being solved, and thus continuing to get worse– because the psychiatrist he sees does not believe in psychotherapy.

    • Adam says:

      Are you talking about general practitioners? Most of the medical problems I’ve had have been orthopedic and this hasn’t been my experience at all. Whether by measuring strength and flexibility imbalances, ordering x-rays and MRIs, or conducting nerve tests to see where electrical current was being impeded, they have consistent been able to tell where a nerve was trapped or impinged on, where I had soft tissue damage, whatever, and then fix it.

      • Jill says:

        I am talking about some general practitioners and some specialists too. It sounds like orthopedists are doing better, at least for you, that the specialists I’ve been to.

        Gastroenterolgists are the worst– well, not the people, but their training, or the state of knowledge in the field. A lot of the problems they fail to treat adequately are easily solved by naturopaths who recommend over the counter digestive enzymes and/or hydrochloric acid pills to be taken with meals.

        Gastroenterologists seem to think that digestive tract distress can be caused by too much stomach acid– and it can be, and they prescribe pills for that. But apparently digestive tract distress can also be caused by too little stomach acid, or by the body’s having lost its ability to produce adequate digestive enzymes.

  64. anonymous says:

    Do you have any inside tips for getting a psychiatrist to stop asking you if you want to kill yourself? I tried hinting that I knew that giving the wrong answer could get me locked up and so I wouldn’t be honest and it was pointless to ask, but it didn’t seem to work. It sort of seems counterproductive to keep asking me every fifteen minutes, like you’re actually trying to nag me into suicide.

    • onyomi says:

      I recall a university psychiatrist’s office that made me fill out a questionnaire every time I visited. Though this was sort of interesting in that it generated a graph whereby the doctor could tell me I must be feeling better since the numbers were up, I was always annoyed at how it tried to trick you into admitting thoughts of suicide three different ways. This was clearly there so they’d know whom to send home from school, since forcing over-achieving college students to live with their parents for several months is so good for their mental health.

      “Have you thought about suicide this week?” My internal response was “well, not till now!”

    • CatCube says:

      Probably not. If they don’t ask you if you are going to kill yourself, and you kill yourself, the doctor opens himself up to liability for not following the standard of care. If you lie, that’s on you.

      ETA: I also recall from the suicide prevention briefings I’ve had that a surprising number of suicidal people will admit to contemplating suicide if asked directly, so we were encouraged to ask directly if we think we’re dealing with somebody in crisis. So now healthcare providers ask every time to get those people help.

      Of course, the fact that it’s asked constantly now may have changed the percentage of people that will admit it when challenged.

    • Jill says:

      You said “I tried hinting that I knew that giving the wrong answer could get me locked up and so I wouldn’t be honest and it was pointless to ask”, you are likely scaring your therapist, making them think that you may be on the verge of suicide but just not willing to say so (yet– maybe they think you may admit it in the future.)

      If you are on the verge of suicide, it’s the therapist’s responsibility to do their best to keep you from doing it– yes, by committing you if you actually have a plan to do it. If you just have thoughts about it, but no plan, that would not get you locked up. They would just try to help you out with the problem. So that is why they keep asking you about it– because they are responsible to help you if you are suicidal. And because you have not made it clear if you are.

      If you are not going to be honest with your therapist, you are wasting your time and money in psychotherapy.

      • anonymous says:

        I have good insurance and my time is worthless, but thank you for your concern. I would like to be honest with my therapist, which is why I want to know how to keep them from asking if I want to kill myself.

        • Jill says:

          I meant being honest with your therapist, no matter what questions they ask you. If you have to be able to choose what questions they ask you, that doesn’t work either. Of course, some questions would be inappropriate.

          But that one is a reasonable question because of the responsibility the therapist has. The therapist can’t help you if they don’t even know if you’re about to off yourself. They can’t just not ask you the question.

          Look at what Scott said about all the soul searching he did when his patient attempted suicide. If your therapist is scared your going to commit suicide, then that is going to be an obstacle in the way of them helping you.

          E.g. sometimes a person will have thoughts about suicide– but not have an actual plan. In that case, there is no need to have the person go to a hospital. But the therapy in that case that would be most helpful, would be a discussion of what’s going on with your life or your feelings or thoughts about your life, that leads to thoughts about ending it all.

          Sometimes a person can take the situation that makes them feel like ending it all, and try some other choices in that situation. And sometimes that may shift things and make things get better. But they won’t be able to delve into that and problem solve with their therapist, unless they talk openly about what they’re feeling, thinking, experiencing etc.

          • jimmy says:

            Of course, if you can’t be open with your therapist about X, they’re gonna have a real hard time helping you there (though it’s not completely impossible). However, they’re also going to have a real hard time locking you up against your will. Sometimes you have to make a choice, you know?

            Let me put it this way:

            If I agree with you that any suicide attempt I might make would be a bad decision and that you should lock me up, then great, we have no problem and I won’t hesitate to answer your question. However, if I *disagree* with you and that you’ll use your power to overrule my preferences (whether by stopping my suicide attempt or by just locking me up when I wasn’t actually going to do it), then why, from my perspective, should I be open with you? What makes you think your arguments here would feel at all compelling? “tell me if you’re planning on committing suicide so that I can imprison you and thwart your attempts”. Um, yeah, I’ll pass, thanks.

            Because then you can help me? We have to agree on what “helping” me is first before I can trust you with that one – or at least we have to agree that you know better than I do. Dollars to donuts those conditions aren’t met in anonymous’s case.

            Because you consider yourself “responsible” for my suicide attempts? Sorry, but that ain’t my problem. It may help explain why the otherwise empathetic therapist is acting against my will and dismissing my concerns, but it doesn’t make them not an adversary (within this one bit, that is).

          • Jill says:

            Jimmy, of course a patient has the choice of being honest or not with their therapist . But if a person wants help, and they withhold the information necessary to help them, then they can’t expect to get any help.

            They’re likely putting the therapist in a situation where the therapist can’t help them.

            If a person is going to attempt suicide, and does not want to admit it or be talked out of it, they are probably not going to get much out of therapy.

            Exactly what are they expecting to get, in this situation? What are they doing there? E.g. are they trying to prove that no therapist can help them, by making it impossible for the therapist to help them, given the therapist’s legal and professional obligations?

            Or perhaps they are wanting to go to a therapist to feel connected to another human being who cares about them and would be willing to help them–even though they don’t have enough trust to share the info that’s necessary to help them any more than just by giving them that human contact with a caring person.

            The therapist does have legal and professional responsibilities that can’t just be sidestepped or ignored.

            It’s like going to the dentist and saying “I don’t want you to touch my teeth.”

          • It’s plausible that a suicidal person needs to have a therapist who knows that they’re suicidal in order to get effective help from that therapist, but is this true?

            It seems to me that a person might want help with their psychological problems in the hopes of no longer being suicidal while being concerned about the risks of being institutionalized and/or the therapist freaking out.

            This is hypothetical. I’ve had quite a bit of suicidal ideation, much of it tied to SJW, but I don’t get anywhere near making a plan.

            I don’t forgive SJW for any of it– they expect the ill effects of their ideas to be passed over because SJW means well. In their terminology, this is called expecting to be judged by one’s intentions or believing that intention is magic, and they only attack people who say they mean well when it’s someone who isn’t an SJW. They don’t apply their standards to themselves in their dealings with outsiders.

            One thing that helped me pry myself loose (at least partially) from emotional vulnerability to SJW was realizing that they misuse the word “ally”, or at least they have a nasty interpretation of it. Normally, “ally” means mutual support. In SJW dialect, “ally” means someone who gives all the help and sucks up most attacks* SJWs feel like throwing at them.

            *I’ve seen SJWs occasionally tell each other to dial it back.

          • Immortal Lurker says:


            The problem is that the therapist has the power to lock up anonymous against their will. You are 100% correct that leaving your therapist in the dark will make it harder for them to help, but I think that anonymous has already considered this. Anonymous has examined their preferences, and decided that they prefer less help to the possibility of getting locked up. So anonymous lies when their therapist tries to find out if they are suicidal.

            EDIT: This logic works best if anonymous has problems besides being suicidal that they want help with. /EDIT

            However, they think (correctly in my opinion,) that they can get slightly better help if their therapist is in the dark about how suicidal they are, as opposed to being lied to about how suicidal they are. So anonymous wants their therapist to stopping asking.

            But there is a catch 22. Only a suicidal person who doesn’t want to get locked up would want their therapist in the dark about how suicidal they are.

            @green anonymous

            I can think of two solutions, which are rubbish, but might generate some ideas.

            1) Find out if there are any official criteria for committing someone against their will. If you don’t meet those criteria, you can stop lying and everyone wins. If you do meet the criteria, pretend you are just below them, to minimize the amount of lying. If the criteria are vague, which they probably are, you’re hosed.

            2) Get a large number of suicidal and non suicidal people together, and have them sign a pact to not tell therapists that they are suicidal iff a suicidal person in their situation would get committed for answering honestly. This breaks the catch 22, because non suicidal people will now want their therapist in the dark about how suicidal they are.

            And a third, non-rubbish solution:

            3) Ask Ozy about this. Click “Thing of Things” in the side bar, which will take you to their blog.

          • Murphy says:

            Generally if you go to the dentist and say “I don’t want you to touch my teeth.” then even if your teeth are rotting out they’ll say “are you sure? it would be a good idea to sort those out” but if you insist they’ll shrug, give you some high-powered toothpaste, maybe some antibiotics and mouthwash and leave you go about your life.

            If you fall over in the street having chest pains and are likely suffering heart problems and tell them “don’t touch me, don’t take me to hospital and don’t cut me open” then they can’t just ignore your wishes and do it anyway and if they do they’d be in massive legal trouble.

            Your profession is uniquely hostile from the point of view of someone who doesn’t want to have treatment forced upon them.

            I can be honest with my knee surgeon, if he decides I really need surgery and I don’t like the sound of it then he has no power to force me onto the operating table.

            I can be honest with my dentist, he can’t tie be down and rip out my teeth against my will.

            A therapist though, you talk as if you think of yourself as no different to those other professions when in reality you have a lot more terrifying power over your patients.

            I’ve been lucky enough to never need a therapist but in any context where I were required to go to one I’d know that they had power equivalent of a loaded handgun pointed at me under the desk and my answers would be influenced accordingly.

          • jimmy says:

            Jill, yes, I thought it was pretty clear that I agreed with all of that – if you aren’t open about X it’s harder to get help on X. It doesn’t help people like this anonymous though.

            Sure, there are some people who may just want human connection – or to prove that they can’t be fixed. However that’s an awfully uncharitable assumption and I think it’s pretty easy to see why someone who genuinely wants help would be hesitant to be open when it may mean that their shrink is legally required to get in the way of their plans and lock them up. Maybe you think the decision should be obvious, but in general it absolutely is not.

            If, heaven forbid, I was ever in a place where life didn’t feel worth living, I would be looking for a hopefully competent trained professional to help make my life worth living again. However, unless this is magic-land where I can somehow be 100% confident that they’ll fix me up, the choice to open up with the therapist involves accepting a nonzero risk of a living hell. Not exactly a trivial decision, you know?

            Therapists have legal responsibilities, true. And if I were a particularly clear-minded suicidal person, I might recognize that the therapist has legal requirements and isn’t willing to get locked up over me, and that hoping for more is a lost cause. However, this also is very likely to end in me not coming to therapy at all (you might go to the dentist either if he locked you up when you said the wrong thing, teeth be damned).

            Ideally, what I’d want is someone with therapist skills who wasn’t obligated to be my adversary when I say the wrong thing. Ideally I’d want someone with whom being open had no risks of them acting against my best interests, as I see them, so that I *can* get help.

            If there are laws against that, then it is what it is. However, I’d still be looking for someone that recognized the perverse incentives when they saw them and did what they could to minimize that risk to me without putting themselves at risk.

            Does that make sense at all to you?

            @Immortal Lurker
            >2) Get a large number of suicidal and non suicidal people together, and have them sign a pact to not tell therapists that they are suicidal iff a suicidal person in their situation would get committed for answering honestly

            That’s what I’d do anyway. My answer to “Hey, should I lock you up against your will” is and always will be “you’re a moron if you think I’m going to answer that”, even if I can truthfully say “no, I’ve been a good boy” – though perhaps more polite and diplomatic as the situation calls for.

          • Murphy says:

            My SO works in mental health and I always found the “have a plan” criteria a little worrying from my point of view. Sure, I get the logic, someone who’s sort of suicidal but has no plan is much less of a risk than someone who’s got every detail worked out.

            But if I ever felt even a mite suicidal and was answering such questions with utter honesty with no filter then my answer would have to be “[astonished look] of course,[list of detailed plans]”.

            apparently most other people don’t semi-automatically work out how they could do things they don’t actually want to do.

            For context I could probably reel off fairly detailed steps for [how to secretly dispose of a body estimate ~90% chance of success] , [how to rob my employers blind ~99% chance of success], [how to assassinate a politician ~10% chance] , [how to send anonymous tipoffs and leaks to some authority while under surveillance ~99% chance] etc etc etc despite not actually wanting to do any of those things.

            being honest and simply reeling off a half dozen ways that I could kill myself quickly, reasonably painlessly and with almost certainty of success would get me branded as someone who “has a plan”.

            So if I didn’t want to end up locked inside a ward with ~20 people so crazy they couldn’t avoid being committed I would lie and say “nah, not really”

          • Lumifer says:

            @ jimmy

            The thing is, the decision to commit is (1) not irreversible; and (2) initially is usually for a short period.

            Basically, if a shrink thinks you’re actively suicidal she might force you to be committed to a mental hospital for a few days. No one is interested in permanently locking up people who once upon a time were suicidal (among other things, it’s expensive) and being actively suicidal is frequently a short-term thing.

            So your risk is not that you’ll get a life sentence in the insane asylum for mentioning you’ve been thinking of suicide. If it turns out you care enough to get out of that mental hospital, it’s going to be pretty easy.

          • Jill says:

            Immortal, I definitely agree with the first solution, of finding out the circumstances under which someone can be committed, so you know the law.

            Everyone has the choice of how open or not to be with their therapist. And generally the therapist can help more if they know more about what your problems are.

            If a person does decide to hold back info from their therapist, then they should tell them everything else they can get themselves to tell, about what bothers them and how they experience that. So that the therapist has as much information as the patient can get themselves to give. It’s hard to work in the dark.

            The solution about trusting a whole group of people seems like it would be problematic. Because if you can’t trust one therapist, can you trust a whole group of people? And some of these people, you are saying, would be suicidal people, so this information might be an undue strain on them, making their lives unnecessarily harder.

          • Jill says:

            Of course, if a patient figures it’s in their best interest to lie to their therapist, then they will do that. However, there are times when they are just lying out of habit or unnecessary mistrust.

            It should be easy to get information about under what circumstances a therapist in your state or country or province, would have an obligation to admit a person to a hospital. As you say, the laws are what they are. You can’t expect your therapist to ignore them.

            Even if one decides to be dishonest with one’s therapist in some respects, which I do not recommend, it is good to be as honest as one can get oneself to be, about whatever problems one is experiencing. Because that is how you can get the most help.

          • jimmy says:


            Sure. It’s not about how far they go against your preferences and it’s not about how right they are to do it. Sure, it’s worse if its permanent than if its for a day or few and it’s worse if they’re doing it willy nilly as opposed to for good reason, but that’s not the point at all.

            The point which Jill doesn’t seem able to comprehend is that from the perspective of someone who doesn’t want to be open about suicide with someone that is going to act against their preferences, *any* step against their preferences is reason to not open up. We can argue over the exact magnitude and scope, but it’s probably not worth doing until the point has been seen that there is an effect here and that shoulding it away is dumb.

          • Lumifer says:

            @ jimmy

            *shrug* It’s a trade-off. Since you are going to a therapist, presumably you want something from her. You are also willing to give up some things (your time, to start with) for that. Whether you’re willing to risk involuntary commitment for a greater chance of getting what you want from the therapist depends on your values and on the circumstances, obviously. I don’t think there’s any general answer.

          • Jill says:

            I’ve been a psychotherapist for many years and have never once needed to commit someone against their will. I do work with less disturbed people though, most of whom have never been in inpatient mental health treatment.

          • Immortal Lurker says:


            Then I think we are in agreement, with the possible exception of whether the green anon in particular should withhold information.

            The pact idea does have problems. People who signed it and later want to be committed couldn’t do it without breaking the pact, as you said. The pact looks very similar to insurance behind a veil of ignorance, and my gut feeling is that the “premiums” would be too high, which is another problem.

            But trust is not one of its problems.

            Actually, lets ditch the word “trust”. After signing the pact, none of the signatories have gained the power to hurt you. Someone could sign this pact with a million people who were known to all be liars and thieves. Even with a 90%+ defection rate, the catch 22 can be avoided.

            If very nearly everyone defects, you are slightly worse off than before, because you will mistakenly think the pact protects you when it doesn’t.

          • “Ideally, what I’d want is someone with therapist skills who wasn’t obligated to be my adversary when I say the wrong thing. Ideally I’d want someone with whom being open had no risks of them acting against my best interests, as I see them, so that I *can* get help. ”

            Possibly a priest?

          • Nornagest says:

            If you fall over in the street having chest pains and are likely suffering heart problems and tell them “don’t touch me, don’t take me to hospital and don’t cut me open” then they can’t just ignore your wishes and do it anyway and if they do they’d be in massive legal trouble.

            I’m told that the thing to do there is to respect their wishes exactly as long as they’re conscious and coherent enough to tell you about them. Once you have someone that’s not responding, I understand you have a reasonable presumption that you can give care, even if they were telling you not to five minutes ago, unless there’s actually a formal DNR tacked up somewhere.

            Of course, by that point they have a lower chance of survival. But it was their choice.

          • Matt C says:

            Is it practical to visit a mental health therapist anonymously?

            I figured if I ever really wanted to talk to a pro therapist I would call around looking for one who accepted anonymous patients and pay in cash. For me, this would be about staying out of the system, but it could also help people concerned about involuntary commitment.

            However, I’m not sure this is practical, and it might even be illegal or against a professional code of conduct. Anybody know?

          • jimmy says:


            Exactly. The point is that it’s a trade off, not necessarily the client being dumb and needing overruling. Once it’s seen as a trade off you can start looking for ways to minimize unnecessary loss as well as working on where you want to draw the line.

          • Garrett says:

            Part of the difficulty for patients is that (depending upon state law), any form of involuntary commitment may make someone a Prohibited Person and thus barred from buying/possessing firearms. If that’s something that matters to you, would you want to take that risk?

          • Murphy says:


            In a great many places that would make cutting the person open very illegal unless the people involved also lied through their teeth and claimed they never heard any coherent statements from the patient refusing care.

            I’ve seen some fun threads on reddit with people saying “oh you just wait till they’re unconscious” followed by someone from the legal side running through all the various laws they’re breaking.

            If you ever decide to ignore refusal of medical care make sure you lie through your teeth and claim they just mumbled incoherently or else you could end up very very screwed. (dependent on local law of course)


            Other practical aspects: if you want to get life or health insurance ever, ever, ever mentioning suicidal feelings to anyone medical could jack up the price. Until you mention it to a doctor of some kind it’s not happened as far as insurance can be concerned.

            Being committed can make you practically uninsurable for any reasonable rate.

            Thankfully outside the US in countries with vaguely sane healthcare systems this is less of an issue but it’s still an issue.

          • Nornagest says:

            I was told this by an EMT, in a training course. I am not medically or legally qualified myself, and I might be misremembering, or this might be true in my jurisdiction but not yours… but if you’re right and none of that applies, then that’s a pretty dramatically wrong thing to tell someone in a context like that.

          • Garrett says:

            Nornagest is generally right.
            In EMS we frequently deal with the principle of
            Implied consent.
            People who are unresponsive are legally presumed to want lifesaving care unless otherwise indicated. If we are called to a situation, we are required to act in the best interests of the patient. Usually this means providing medical care and transport. We also have a Duty to Act.

            To make matters more complicated, there are only certain types of legal paperwork which can allow us to refuse to provide care to an unresponsive patient.

            In most cases, if we encounter a patient who needs medical care and doesn’t want it, we fill out some paperwork and have a doctor speak to the patient. Once done, we leave. However, we’re required to come back if called again, and the whole process starts anew.

            Also, if we think somebody is going downhill rapidly, we can simply stall the refusal paperwork until they become unresponsive at which point we are required to care for them and transport.

            Finally, if we think that something’s really wrong we can ask the police to take them into protective custody (and if they agree per their own policy) and have the police have us transport them for evaluation. This is usually used to address issues of consent with minors when parents aren’t available, but I have had to do it once with an adult.

          • Garrett, does this mean that people who really want DNR should have it tattooed someplace where it can’t be missed, possibly on their faces?

          • Garrett says:


            You’d have to check your State’s law. Where I am, in order to be a valid DNR is must be the original copy of the right form, signed by the patient and physician, and covers only the specified cause of death (If you have terminal cancer but get hit by a car, we pick you up and haul). A tattoo would not be honored by default.

            The other issue is “why are we there?” If you are dying at home, alone, EMS won’t show up. If your significant other is there and honors your wishes it’s also not a problem. It’s when you have panicked family members who call 911 and insist that “something be done”, and possibly hide the DNR that we’re more-or-less obliged to act.

            Now, if you want to avoid most of the hassle you can get yourself an Advanced Directive (your doctor should be able to set you up with the paperwork). Pretty much, it spells out what you want done in the event that you can’t make decisions for yourself any more. You can also get yourself a healthcare power of attorney to make decisions for you as well. Now, this will not stop EMS from taking you to the hospital – the law pretty much errs on the side of us taking everybody there. However, once you are there (assuming the paperwork can be found) your wishes will be honored. This likely means a low-acuity bed, hospice, or home until your situation changes.

            Hospitals have lawyers, grief counselors, social workers, and everything else. In the field we have two people, a doctor on the phone, and that’s about it. The State doesn’t want us to deal with nuance when it comes to life-or-death decisions.

          • anonymous says:

            @jill or maybe they are after some fucking therapy, seeing as how they are contemplating suicide. Did that faint possibility occur to you?

        • LHN says:

          One thing that helped me pry myself loose (at least partially) from emotional vulnerability to SJW was realizing that they misuse the word “ally”

          Yeah, it didn’t take many “How to be a good ally” articles for me to conclude that the writers were using the word for something more like “client”.

          (Which, to be fair, is a millennia-old usage, going back at least as far as the Delian League– “Congratulations! You’re now an ally of Athens! Athens will henceforth make all policy decisions.”– and I expect rather further.)

          Which was about the point that while I’m friends with a fair number of individuals who tend in that direction, and am occasionally (if decreasingly often) on the same side of a political question, I was actively uninterested in adopting the identity of “ally”.

          • It looks like it took me a lot longer for me to see the problem with being an ally. My earlier version was “If you grovel hard enough, you get to be an enforcer”.

            I found that I felt better when I stopped reading anything which started with “Dear white people”. It wasn’t just that I wasn’t reading things that were probably toxic for me, it was that I’d set a boundary.

            Another large topic is that a lot of people who consider themselves SJWs aren’t nearly as nasty as the ideology permits them to be. I take this to be an indication of their psychological health and innate decency, but then I would, wouldn’t I?

            I use this venue to talk about how bad SJW is, but I also think some of their goals are legitimate, and they turned out to be surprisingly correct (at least I was surprised) about the gender binary being a very bad model for a lot of people.

          • Lumifer says:

            the writers were using the word for something more like “client”

            I think of it more along the lines of “you belong to an inferior caste, but we’re willing to tolerate you as long as you are obedient and make yourself useful to us”.

          • Jill says:

            Yes, whether someone is a SJW, or whatever they are, it’s important to stand back from nasty people and not to feel obligated to give in to others’ unreasonable demands. This ally position sounds like it may be an unreasonable demand.

            SJW’s or others may have good causes, but that does not necessarily mean that they have psychological health, as you mention, or that their actions are constructive in the sense of furthering their goals rather than causing unnecessary difficulties for themselves and/or others.

            They can have goals but go about trying to implement them in ways that don’t work.

          • I’ve heard SJWs argue that no better tactics were available to them if they wanted to try to achieve their goals at all.

            I don’t have a strong opinion about this.

          • Jill says:

            Yes, some SJW’s might actually believe that no better tactics are available to them. And they could be wrong about that.

            A lot of people don’t know that they don’t know something that would be helpful to them. It’s like that quote about how “It’s not what you don’t know that hurts you. It’s what you know for sure that ain’t so.”

            Interpersonal communication in areas of oppression and heavy conflict is very difficult. Few people can do it well, SJW’s or not.

            That book I recoed earlier, Sitting in the Fire, by Arnold Mindell, is about that. If you ever read that book, you will notice how challenging such communications are– and how you likely have never even once witnessed anyone orchestrating such a communication in the skillful way he does.

      • Garrett, thank you for the intormation.

      • anonymous says:

        in this case the word role would be more logically-polite than responsibility, which is sneaking in an assumption about a question the answer to which is clearly not a point of shared consensus between you and the person you’re speaking to. And would, if the answer you insinuate in there without any attempt at actually establishing it, is accepted, prove that what you argue is correct, and that the person you’re replying to is selfish and inconsiderate for imagining they could admit to being desperate to someone they were hoping could help them (and paying, probably handsomely, to attempt to do so)

      • mochana says:

        Mark Atwood, based on my experience, that’s not the type of planning they mean when they ask if you’re planning suicide. They’re looking for concrete intent to act, e.g., “I’m going to take the whole bottle of ABC pills and then throw myself off the XYZ bridge tomorrow night at midnight.” The intent, details, and schedule are all necessary components. Simply having ideas about how you might commit suicide if you wanted to does not merit committing you against your will. (Though it might result in additional questioning.)

        Source: a therapist who took my question “Sooo…. what do you mean by a ‘plan,’ exactly?” at face value.

    • whateverfor says:

      Disclaimer: not a psychiatrist. Psychiatrists almost certainly would disagree with my advice.

      There’s no way around the question, just lie about it. You can discuss everything honestly up to that point, and then just say that you do not plan to kill yourself. If you want to discuss suicidal ideation, say it happened in the past (if this isn’t your first experience with depression) and not now. “In the past I felt worthless and wanted to die, now I feel worthless but have decided not to die”. That’s probably not even that false, there’s a reason you’re going to the psychiatrist and not just bailing.

      You can break that rule and be fine, but it’s not worth the risk if you’ve only got vague sentiments and not plans.

      • Adam says:

        You know, this happened to a Soldier of mine once when I was still on active duty. He answered “yes” to a suicidal ideation question, then quickly clarified that he had misunderstood and meant he had once had ideations when he was in middle school. They committed him anyway and he was stuck there for five days. Luckily, medical treatment in the military is free, so he got a short vacation and we had a nice laugh when they let him out.

        However, a friend of mine on the outside got into a fight with his girlfriend in which he blacked out due to medication he was taking, then took himself to a hospital because he was terrified he might be a danger to people, and they detained against his will for a week and then discharged him with a $50,000 bill. It’s not a laughing matter when the state can force treatment on you that you don’t want, and then force bankruptcy on you afterward.

        • Jill says:

          Gosh, really awful experiences these people have had. These are highly unusual, and yet no one wants to go through such a thing. Most people wouldn’t want to be confined against their will.

          Every patient, of course, has their own choice of what and how much to share with their psychotherapist. One can get more help if one shares more. So it makes sense to share as much as you believe is safe to share.

      • Garrett says:

        My solution: “As a matter policy I decline to answer such questions.”

  65. Anonymous says:

    I spent more than a hundred hours and over ten thousand dollars in therapy and came away no better off than when I started. If they aren’t all scammers, at the very least they tolerate scammers in their ranks.

    • suntzuanime says:

      I’ve had similar experiences with doctors. And computer repairpersons. Just because someone doesn’t always succeed at fixing every problem, that doesn’t mean they’re necessarily scamming. Although I will say I have a great deal of respect for dentists, who have actually helped me in exchange for the money I have given them.

      • Anonymous says:

        If there’s any computer repairman that doesn’t figure out in the first — say 20 hours — that there’s nothing he can do and says so and instead keeps on going for hundreds of more hours a) I never met him and b) sounds like a scammer to me.

        • Jill says:

          Someone can fix your computer without your active cooperation. Psychotherapy is very different from that.

          • Anonymous says:

            Regardless of why therapy isn’t working isn’t there a professional, or at least moral responsibility, at some point to stop taking money if you aren’t doing any good?

          • Jill says:

            Well, yes. However, there is a lot of ambiguity in this field. So it can be unclear whether it’s helping or not. If you yourself are convinced that it isn’t doing you any good in any way, why are you choosing to still go?

          • Anonymous says:

            Partly because some therapists lie to you and say “I think we made a lot of progress today!!!” pretty much all the time.

            Is there any self policing at all? Do therapists ever face professional discipline boards for bleeding patients dry?

          • Jill says:

            Your therapist may actually believe you made progress. If you don’t think so, it’s your responsibility to tell them that they are mistaken about that. A therapist is not clairvoyant. How could they know you are not making progress if you do not say so, even when they are guessing out loud that you ARE making progress?

            If you will not participate in the process of your therapy, there’s not much you can get out of it.

            The field is ambiguous, so it’s hard to tell sometimes if progress is being made– especially if the patient won’t even say out loud that they are not making progress.

            It sounds like you are upset with your therapist and wish they would be condemned by some institution for “bleeding you dry.” But there is is still the question, unanswered, of why you keep going if you are getting nothing out of the therapy.

            Also, it sounds like you are expecting a great deal from your therapist, and not expecting much at all from yourself. It’s not like you are a computer and your therapist is like a mechanic, fixing it without your help or participation.

            Is that maybe the crux of your problem here? I could be wrong here, but perhaps you expect too much of others but do not challenge yourself to do everything possible to solve your problems, and everything possible to help your therapist to help you solve them.

            If that’s your problem, and you know it, then you should tell your therapist “I don’t challenge myself enough to solve my problems. I sit back and wait for you to solve problems I have not even told you about, as if you could read my mind. Can you help me to change this bad habit?”

            To some degree, the patient gets out of therapy what they put into it. If you aren’t open about your experiences in life, and about whether you feel you are making progress in therapy, then a therapist can’t read your mind to help you with that.

          • Jill says:

            If you are suspicious of your therapist and you sit back and think how awful they are for “lying” to you whenever they are mistaken about something they say, and you don’t tell them they are mistaken, that’s not going to help you.

            You may have a habit of interacting with your therapist in some ways that are keeping you from getting help e.g. you may assume they have ill intent toward you rather than inquiring about what their intentions actually are– about what they are saying, doing, not saying, not doing etc.

            I don’t know your therapist so I can’t be 100% sure. But chance are, they are doing their best to help you– not trying to do you harm. If you think they are trying to do you harm, or even not doing their best to help you, then consider the possibility that you may be mistaken.

            Good therapy is a partnership where each person has to put in a lot of effort, and to be willing to endure some discomfort, and to try to develop as much trust in the other as is realistically possible, in order to work toward the patient’s goals.

          • Anonymous says:

            If the relationship between the patient and the therapist is akin to that with a used car salesman then the industry should be upfront about the fact that the buyer needs to beware every second of every interaction.

            I work in an industry with a fiduciary duty, I know what that looks like, and you aren’t describing it.

          • Jill or anyone, what’s known about processes for getting clients past habitual mistrust?

            To simplify matters, I’m going to assume that the therapist is trustworthy.

          • Jill says:

            I don’t know what industry you work in, but chances are that it is clearer what is going on and whether duties are being met or not, than it is in psychotherapy.

            I did not say that you need to beware every second of the interaction. You don’t have to. You only need to challenge yourself to do your part, rather than expecting the therapist to do everything– and you can ask for your therapist’s help in challenging yourself that way.

            But if you are convinced that you have been open enough about what you are experiencing, and that you are not sabotaging your own progress in some way without being aware that you are doing so– then why not discuss this and your apparent lack of progress with your therapist? Aren’t you deceiving your therapist by not discussing it and by allowing them to think you are making progress?

            Or you may propose a short break from therapy. If you miss it, then ask yourself what is it that you miss? It’s possible that the therapy is doing more for you than you realize. Maybe you will even end up shortening the break you meant to take.

            Or, if, in being honest with yourself, you realize you may be blocking your own progress, then ask your therapist to help you to be more open about things you are willing to be open about e.g. to let them know when you think they are mistaken about your making progress, or about anything else. And to let them know more about what is going on with you, in life and in therapy.

            Bad habits can be broken. People often come to therapy because they have bad habits. And then their bad habits of how they interact etc., might get in the way of therapy. But that can usually be fixed in therapy, if one can be open about it.

          • Jill says:

            Nancy, it can be a long process helping a patient to get past mistrust. Some therapists have the patient discuss their experiences of trust, mistrust, betrayal etc. in their lives– whether in childhood or recently, whether from peers, parents, employers whatever.

            Sometimes, we react with the same sort of mistrust, or expectation of betrayal of trust, with a therapist, as we have done in our lives before. If our trust has been betrayed severely or a lot in our lives, we may react to the therapist with mistrust a lot.

            It can be a great help to the therapist if the client knows they have the trust issue and says so.

            Both the therapist and the client have to get comfortable with the whole issue, and the process of the patient learning to open up more, at first a tiny bit and then more later. when they are ready. The patient needs to learn to become open about what’s going on in their lives, and in therapy.

            Both patient and therapist have to become comfortable with misunderstandings. E.g. maybe the patient jumps to the conclusion that the therapist being silent means that the therapist is wanting to exert power over them– because of mistrusting the therapist. It would help if the patient can talk about that sort of thing– at least eventually, if not at first.

            Just becoming aware of it is the first step. “Oh, my therapist did _________, and I am thinking s/he is trying to dominate me or lie to me or do me harm. Is it possible that I’m mistaken, and that s/he is actually trying to help me in some way, in order to do his/her job? Maybe I am scared to talk about this yet. But I’ll notice when it comes up, and when I am ready, I will talk about it and see how my therapist responds. ”

            And somehow the patient needs to come up with their best guess of whether the particular therapist they start out with, is the best person to help them deal with trust issues. If you’re not making progress after a number of months, is it because the therapist’s methods and reactions aren’t helpful? Or is it because you haven’t challenged yourself to become more aware of feelings of mistrust and to become more aware of shutting down or getting mad or jumping to conclusions, or doing whatever else you may do when you feel mistrust?

            There’s a lot to this, but those are some examples and general ways to work on the issues.

          • Anonymous says:

            This was years ago. I have no intention of throwing good money after bad. And since the industry apparently has no ethical or competence standards I won’t be patronizing any of her colleagues either.

            Colleges, which are far from the least ethical institutions, will at least flunk out (and forgo the revenue from) students who are most clearly getting nothing out of it.

          • Jill says:

            Nancy, and of course, the more one trusts one’s therapist– if the therapist is trustworthy– the more help one can get with determining whether people in their lives are trustworthy, and trusting those people. And the more help one can get with anything, because the more one can be open about what’s going on and what ones needs help with.

          • mochana says:

            Jill, I think what you’re describing is a lot of responsibility to put on a struggling client. Someone who hasn’t been through therapy before probably doesn’t know what progress in addressing their issue feels like, and would probably believe a therapist who says “We made so much progress today!!,” especially if they do feel a bit better leaving their office than when they arrived.

            I went to several psychologists when I was a teenager, and at the time I certainly didn’t see myself as an active participant in my own recovery. I had the impression that I should simply answer the questions they asked, take the specific actions they requested I take, and essentially wait for them to perform their mysterious acts of healing without my undue interference, in order to get better as soon as possible. That impression led me to waste a lot of time obediently answering questions about my mother and taking multiple-choice tests, while waiting desperately for some sort of magic intervention.

            If I’d been told in the first place what the expectations from my side were, I would have interacted with these therapists very differently (and probably decided right away not to work with the first few). I don’t see how I was to know that I needed to invest active effort into recovering, have my own goals for being in therapy, ask my own questions and hold a true two-way conversation, speak up when I doubted the therapist’s recommendations, etc. At the time, the only background information I had was my school counselor’s recommendation that I see a therapist for my issues.

            Like yellow and green anonymous, I still hold some resentment toward the therapists I saw who didn’t have the foresight/professionalism/experience to ask a new client what they wanted out of the relationship or encourage an adolescent to treat them as a collaborator rather than an authority figure. I realize now (especially after reading your comments) that I wasn’t contributing adequately, but I feel strongly that these professional therapists should have guessed that I was unfamiliar with the process and given me guidance on how best to work with them.

        • Jill says:

          Oh, I misunderstood you, Anonymous. I thought you had a current issue. But you just wanted to vent, which is fine. I’m sorry to hear that your experience in therapy was disappointing to you, back when it happened. I hope you are able to find what you need in life, through whatever means appeals to you.

          Psychotherapy is not for everyone. And even those who can benefit from it, need the right kind of therapist for a match, and need to find ways of being open about what they are experiencing e.g. to let the therapist know when they are mistaken about something about you, such as whether you are making progress. Not everyone is willing to be open, or is even capable of doing so.

          There are many different ways to heal from bad experiences and/or to find fulfillment or happiness in life. Psychotherapy is just one.

          • Jill says:

            BTW, I appreciate your sharing your experience in psychotherapy. It is informative to hear how patients view either successful or failed therapy.

            It is not actually possible for a therapist to deceive a patient by telling him/her they are making progress when they are not. It’s the patient’s therapy. They will KNOW if they are making progress or not– maybe not immediately, but after a while, and especially if they discuss what’s happening and focus on their goals for therapy. They will know if they are reaching them or not.

          • I’ve seen a therapist say that depressed people are bad at noticing whether they’re making progress, and some sort of formal mood-tracking is very helpful.

          • Jill says:

            Nancy, yes, that is true in the short run. In the long run, they either become less depressed, or they don’t. And either way, they know it, in time.

          • Perhaps a slightly different angle, but I think part of depression is having trouble imagining and remembering more positive states, so mood tracking can be a good tool for remembering that one can feel better, and even that it’s not so unusual to feel better.

          • Orphan Wilde says:

            Jill –

            It’s hard to tell the difference between a reduction in negative-mental-context (depression) and having an unusually good day; interpreting events in a more positive ways feels identical to having more positive events happening.

          • anonymous says:

            It sounds like you’re making that up, Jill. What guarantees that the patient will know? What guarantees that even if they do know, they won’t stop knowing if their therapist, -the expert, -who they have come to, perhaps in desperation- tells them otherwise? Perhaps with the great confidence with which some or all therapists are prone to speaking on subtle matters they understand little better, no better, or indeed worse than, anyone else.

            It would certainly be convenient, if the laws of physics prevented such a thing happening, but unfortunately that sounds like bullshit.

            Therapy is a fraught profession Jill. (perhaps not all the time but)

            I had the impression from one of your comments that you had faced that.

    • Anon says:

      As a counteranecdote, I bounced through a half-dozen therapists who were all bad until I found someone I liked talking to. I spent a few years and a few thousand dollars in therapy and managed to survive high school as a direct result. I think my money was well-spent and that therapy directly helped.

      My only problem is that my college’s counseling center is heavily understaffed, and I haven’t been seeing anyone since. I really should fix this but have no idea how.

      • Jill says:

        Can you get on a waiting list to see a counselor at your college counseling center?

        That’s fantastic that in high school you went through the work of sorting through different therapists in order to find a good match. Good for you. There are many different types of therapy and therapist personalities. Most people don’t realize that there is not just one standard procedure and way of doing it.

  66. Georgian says:

    On your non-answer guilt:

    I’m sure you’ve seen a wide range of people’s problems from the very minor to the life shattering ones. Now if your first instinct is to say “Have you tried not worrying about that?” then perhaps your non-answer is appropriate to their non-problem. Maybe they’re looking for more “Tell me more’s” and less “I told you so’s”. Some people might want their hands held a little while they explore their own problems.

    In general I think all young professionals think they’re frauds or phonies when starting out since they discover that some aspects of their career are easier than school.

    Just my two cents.

    • Jill says:

      “I think all young professionals think they’re frauds or phonies when starting out.”

      Well, a lot do, perhaps most. It’s more of a danger in some fields than others. In mental health, it’s easy to feel that way, because it is not cut and dry like e.g. engineering. In fact one quality that is helpful in being a therapist is a high tolerance for ambiguity. Scott is wise to not jump quickly to the conclusion that he understands a patient’s problem. Problems are often not what they initially appear to be.

      There is also the issue of hierarchy and power politics. And the way that hierarchy and power politics interact with ambiguity. Psychiatrists are the highest status mental health professionals, but perhaps the least well trained in their training programs.

      Why? Because psychiatrists are high in power, in a situation where it is ambiguous what it is they are supposed to be doling. So because of their power, they can get away with doing almost anything or nothing. And if they are supervising students or trainees, then they can get away with insisting that the student do almost anything, and that the student act like they believe in what they are doing.

      This is sort of like the situations that SJW’s crusade against. (But whether what SJW’s actually DO about the situation is helpful or not is an entirely different question.) You don’t know you have “white privilege.” It just feels normal to you. You don’t worry about what color you are, in a group of people, if you are the same color as most people in the group.

      Scott’s psychodynamic supervisor is not unusual at all in any type of mental health training program. He probably has no idea that he is trapping his trainees with his own power over them, and impeding their learning. He probably is a nice guy, a caring individual, who believes that he is teaching his trainees to learn how to do psychotherapy well and to help their patients.

      A lot of power politics goes on unconsciously. In fact, if you are a psychiatry resident who thinks the unconscious does not exist, and does not cause one to behave in ways that cause difficulties for ourselves and/or others– then just look at your supervisors. Just notice if they could possibly be acting from unconscious drives for more power, or acting from unconscious drives to have more certainty than actually exists in life, or in their profession.

      Even if the psychodynamic supervisor is wrong about Scott’s patient, his own actions are evidence that some other parts of psychodynamic theory are true– the ones about the unconscious.

      In fact, the situation that the supervisor imagines between Scott and his patient has a certain parallel in the relationship between Scott and him, the supervisor. Scott is frustrated by having a supervisor who is closed to what’s actually happening between Scott and his patient. The supervisor has too much theoretical baggage to be able to see reality.

      The supervisor has unconsciously abandoned Scott, rather than being present for Scott as a mentor in touch with the realities of patient care. This whole supervisor-therapist-patient triangle is really affected by the supervisor’s abandonment of reality and thus his abandonment of his realistic mentor role, which thus causes Scott to really abandon his patient, because he has no choice. He has to abandon reality, and the patient, in order to pass the class.

      So it is not that the patient is afraid Scott will abandon him. It is that the supervisor has already abandoned both Scott and the patient.

      The constructive side of this is that in this situation, one can learn a ton about the subconscious, power politics, what patients may be feeling and doing and thinking when they are in a situation where they are trapped or feel trapped, how supervisors or others can act on their unconscious drives to have more power and not realize they are doing so etc.

      • Nornagest says:

        Well, a lot do, perhaps most. It’s more of a danger in some fields than others. In mental health, it’s easy to feel that way, because it is not cut and dry like e.g. engineering.

        Trust me, it’s very easy to feel like a fraud in engineering, even if you’ve been doing it for a decade. In software, the usual scenario goes something like this: you train for four to six years, maybe build up a Github portfolio, get a job. The job turns out to be completely different from anything you trained for, because no one ever learns anything in school about working in teams, or on large systems or legacy code, or with any of the clunky-ass enterprise tools that executives insist on standardizing on. You scramble to keep up. Your colleagues are also scrambling, but most of them have been there longer, and even the ones hired with you are trying to keep their own anxiety out of work and mostly succeeding. So you always feel like you’re doing worse than you should be, even if you’re not.

        I think it probably happens in every skilled profession.

    • Garrett says:

      “In general I think all young professionals think they’re frauds or phonies when starting out since they discover that some aspects of their career are easier than school.”

      You haven’t met nearly enough engineering students.

  67. Jill says:

    It strikes me, after reading Scott’s post, other people’s replies, and thinking about all this– what a big part power politics plays in our lives. It is an extremely common situation for a psychotherapy trainee to be quite realistically overwhelmed by the power and authority of their supervisor. The reality is; If you don’t please them and do/say what they want, you don’t pass the course.

    And one of the reasons why psychotherapy fails when it does, is also power politics. The patient is overwhelmed by the real or perceived power and authority of the therapist. Perhaps the therapist really is power driven. Or certainty driven, and they use their power to conform to what their textbook school of therapy tells them should be true, while ignoring the patient, so that they can always be certain and “right.”

    Or perhaps the patient is overwhelmed by imagining the therapist to be powerful in a negative way, but perhaps the therapist is trustworthy and it is just the patient’s misunderstanding that is coloring his/her view of the therapist. Maybe they don’t want to be there, e.g. if they are a minor sent by their parents– in which case there is also a child vs. adult authority/power issue.

    Perhaps due to the ambiguity in the field of psychotherapy, the patient thinks “The therapist knows what is supposed to happen here. I am supposed to sit back and wait for them to acted upon me, as if I had a broken leg.”

    Or “Oh the therapist knows what I need, in order to heal. They just aren’t giving it to me. They want to control or dominate me.” Maybe that patient has been around a lot of people who want to dominate or control them, and the patient is overgeneralizing their experience to the therapist, when it may not apply.

    Power or the lack of it– and certainty or the lack of it or the tolerance or intolerance for it– these are big deals in our lives.

    • Acedia says:

      I was never afraid of my therapists (even though I actually was involuntarily hospitalized once). My problem was always that I wanted the therapist to like me more than I wanted to be helped. I was usually successful at getting them to like me, but this came at the expense of not being completely honest and also led to parts of sessions being wasted on enjoyable but irrelevant chitchat.

      • Outis says:

        Well, if your therapist didn’t like you, he may stop having you as a patient. Are you not afraid of that?

        • Acedia says:

          That’s more about not-disliking than liking, I think. I’m talking about a desire to establish inappropriate friendships.

    • Outis says:

      How are any of those examples of politics?

  68. LHN says:

    True story – last week an attending yelled at me for not knowing some minor detail about uraemic encephalopathy. Later I couldn’t find the detail he’d mentioned, so I asked for a reference, and he said it had been discovered by one of his friends at the big university hospital where he used to work, but the friend had died before he could publish his findings.

    While it’s obviously not proper publication, I wonder if you should specify the detail so that there’s a chance that some doctor somewhere might find it in a Google search, replicate it, and publish?

  69. Ryan Nolan says:

    That nurture assumption book sounds like pretty quack extremist primitivism stuff. Parents would just raise their children correctly anyway, regardless of the circumstances/context? Even one in which their parenting was rendered literally meaningless? What a joke.

    And the very same “subversive response” means that the parent’s personality is governed by their genetics, and their parenting, and so on. The parent can’t even fail to parent except in the way their genes force them to, so this book couldn’t impact their parenting either positively or negatively. In other words, the parent does not need to find out that they are in fact not responsible for genetics, because they will simply be governed by genetics either way. They won’t become enlightened by you handing them The Nurture Assumption, and if they did it would only be the illusion of enlightenment that couldn’t be effectively acted on in any way. So says this ridiculous book, at least.

    • Nornagest says:

      You’ve clearly made up your mind, but the usual claim is that outcomes in the absence of abuse are roughly half genetic and half non-shared environment. What “non-shared environment” means in this context is a little subtle and can’t quite be rounded off to “not parenting”, but you could write a whole post about that. Anyway, the take-home is that this is not a genetic determinism argument.

      It’s not even really a “parenting doesn’t matter” argument — everyone agrees that abuse or serious neglect will totally screw your kids up. The claim is more that the details of more-or-less normal parenting style — spanking vs. non-spanking, for example, or sports vs. music lessons vs. “go play outside” — have no measurable impact once the kids reach adulthood.

      • Ryan Nolan says:

        The spanking parent sounds pretty abusive to me. I’m not sure how it wouldn’t effect a child.

        ” everyone agrees that abuse or serious neglect will totally screw your kids up.”

        The Nurture Assumption book disagrees. An abusive parent is abusive because of their genetics, not because they decide to be abusive. The abused child is effected not because their parent is abusive, but because their genetics have lended them genes that cause them to act out abusively against their children.

        The decent parent just happens to have been lended decent parent genes that allow them to give off the appearance of raising their child correctly, even while the child is secretly being effected principally by their genes and not by the parent’s parenting.

        The “half and half” argument is hysterical on its face, but good luck to you with slicing those halves up in just the right way so as to leave spanking on the table as perfectly reasonable.

        • Nornagest says:

          I should have known that example was going to get me in trouble. Not interested in debating it, anyway. But if you want to focus on that and ignore the point I’m actually trying to make, it’s your funeral.

        • Murphy says:

          That’s a finely built strawman you have there. But did you have to beat it so? his straw coat is all mussed up and his straw head is caved in.

          How might we separate it? Practically speaking? Probably by looking at the impact and whether children who’ve been occasionally spanked but not otherwise beaten or abused have higher rates of psychological problems than children who’ve not been spanked in otherwise similar households.

          And generally such comparisons find nothing significant.

          If you lump together the kids who’ve been spanked with the ones who’ve been seriously maimed and abused then studies trying to get the result they want will find something in the same way that you’ll find people who are guilty of [murder, rape or jaywalking] tend to commit more assaults in future.

          I’m not a fan of spanking and neither were my parents but people come up with endless ridiculous claims about it mostly based on nothing but poorly informed feelings.

          But I get the impression that this is a religious belief for you so nothing will ever make you consider anything you don’t already agree with seriously.

          You’ve decided how the universe is.

  70. Elimelech says:

    I am sure you have been warned of trying [awkward silence] on Finns. They can wait eons.

    CBT-shaming! Actually, towards triteness I have a near pathological aversion. But realizing that what I find trite other’s may have never heard in their lives helps me cringe less.

    I personally think schema therapy is excellent and not especially gimmicky.

    On another note, you reminded me of a particularly laughable psychotherapist from Broom of the System by DFW:

    DR. JAY: So it would be safe to characterize yesterday as just not a good day at all, then.
    MS. LENORE BEADSMAN: I think that would be a safe assessment, yes.
    JAY: And how does that make you feel?
    LENORE: Well, I think sort of by definition a day that isn’t good at all makes you feel pretty shitty, right?
    JAY: Do you feel pressured into feeling shitty?
    LENORE: What?
    JAY: If a bad day is by definition one that makes you feel shitty, do you feel pressured to feel shitty about a bad day, or do you feel natural about it?
    LENORE: What the hell does that have to do with anything?
    JAY: The question makes you uncomfortable.
    LENORE: No, it makes me feel like I just listened to a pretty meaningless and dumb question, which I’m afraid I think that was.

  71. Thesoephus says:

    Regarding “psychodynamic therapy”, all established intellectual institutions in history have been dominated by quackery and power dynamics, with, sometimes, rarely in fact, bouts of progress in the discovery of “objective truth”. The only exceptions to this rule I can think of are the hard, hard sciences – mathematics and physics – and even those faced entrenched interests and superstitions. Algebra was very much looked down upon in Europe until it became impossible to be snooty about it, for example. Without doubt the field of psychotherapy is currently terrible overall, but probably not much more than scholasticism at the height of the Ancien Régime, and much like the medieval intellectual system, psychotherapy will evolve towards better outcomes for people/patients only if it is in the interest of the power structure (in place or emerging) to make it evolve. Otherwise I am very pessimistic. Patients have no power and no influence, something that was rightly noted in a comment above; and psychotherapy being non-popperian, field results can be twisted to infinity. If change comes, it must come from inside the medical or the State establishment. Hopefully the new generations of doctors simply grow tired of ancient systematic theories like freudism, or freudism is rendered functionally obsolete by technological developments. Or politicians begin to notice that psy patients are not, on average and on the long haul, made healthier and more economically productive by psychotherapy (I would be interested to see good studies on this, with follow-up of patients ten, twenty years later, etc).

  72. Freedom says:

    Awkward silence is also a well-known technique among lawyers taking depositions. If the witness’s answer is not as complete as the lawyer would like, the lawyer simply does not ask the next question and looks at the witness expectantly. The witness is then likely to jump in and expand on the answer. If the witness is represented by capable counsel who is aware of this technique, however, the witness’s lawyer will interrupt the silence and say something like “Is there a question pending?,” taking the onus to speak off of the witness and putting it back on the examining lawyer.

  73. Niklas says:

    Sometimes I worry I might be the worst person in the world to do psychotherapy. My coping strategy is to not talk about or react to my emotions and wait for them to go away.

    I find this surprising; I’d have thought writing SSC posts was at least sometimes part of your coping strategy (this one included).

    (I don’t mean this as a snark or anything, in case it comes off that way.)

  74. Baul Ploome says:

    I’ve often wondered if Clinical Psychologists and other variations of of career Psychotherapists invest this detail of thought, bordering on an oddly empirical manifestation of Catholic Guilt, into the momentary feelings and emotions elicited by the fleeting, rare instances of their own successful copulation and orgasm.

    Further, I wonder how exactly they go about selecting a mate, since I can imagine an unsightly demonstration of intellectual fencing and dramatic pauses erupting between two nude mates of the same occupational echelon.

    Copious masturbation, it’s the only way.

  75. The Obsolete Man says:

    “My coping strategy is to not talk about or react to my emotions and wait for them to go away. This usually works.”

    Thanks for this statement. It sounds like it could be a great nutshell statement regarding Acceptance and Commitment Therapy. Any thoughts about that? Any exposure to this at the hospital by any of the staff?

  76. Tom Evans says:

    The “Nature Assumption” is not an assumption for those of us who have experienced and then in therapy re-experienced early trauma and have clearly seen the links between those experiences and the formation of personality traits. Traits, anxieties and mentation that then evaporate. The disparities between the various schools of therapy are increasingly distinct. And while most therapists enter into the field with noble intentions (and many with a need to address their own difficulties) many enter into its economics as a motive and agenda hidden even from themselves.

    It is a sad commentary on our Western non-society that we have to pay someone to be a professional quasi-friend and advisor. As far as socialization goes ours is aberrant by a factor that is off the scale. Children raised with their peers instead of a mixture of ages. Infants neglected so mom can get back to work. Many, many children raised without a male presence. What needs to change is not therapy but the culture , and its economics that keep entire populations dependent, submissive, anti-social and infantile.

    • jimmy says:

      I agree that you can actually see the links and watch the anxieties/etc evaporate and that “stop guessing and *look*” is a very very important point that most people don’t realize is possible, but it’s still compatible with parenting not much mattering. See Thursday’s comment (“I wouldn’t be surprised[…]”) for how that could work.

    • Jill says:

      Are you saying that you don’t like the capitalist economic system and its associated types of parenting, education etc.? Dependent, submissive, anti-social and infantile kogs are much easier to plug into the capitalist machinery, to be compliant workers and consumers. And they are very easy to Divide and Conquer, by the economic Powers That Be.

    • “Children raised with their peers” is mostly a consequence of the way the public school system is organized. That’s not capitalism, it’s one of the socialist elements in our system, a means of production (of schooling) owned and run by the state.

      I agree that it’s a bad system. But I’m not sure what you mean by “its economics that … .”

      • HeelBearCub says:

        Right, because most private schools don’t divide classes by grade…

        This isn’t a public/private divide, it’s a large school population/small school population divide. When a one room, rural school house served 10 to 30 total children from the surrounding community, there was no choice but to have mixed age schooling.

        When you have 1000s and 1000s of kids to educate in one community, someone is going to come up with a way to do that more efficiently by designing schools intended to serve more than 20 or 30 kids total. Then you have to very consciously choose to keep cross age interaction part of the mix.

        • Murphy says:

          Pretty common in rural Ireland and the kids coming out of that kind of setup tend to do poorly. They often have no or few peers their own age to compete with and their teachers can’t practicaly speaking teach material for 12 different age groups at the same time. Even if they split their time evenly between students they end up with their teacher teaching to the appropriate age for about a half hour a day.

          teaching kids with kids their own age (if you’re stuck with having to teach a group and don’t have the resources to tutor every individual) is one of the few things the school system got right.

          • John Schilling says:

            I counter your unsupported assertion with my anecdata: My mother was educated in one of the one-room schoolhouses common in rural Minnesota, and went straight on to an ivy-league university. And inspired several of her cousins, nieces, and nephews to do likewise, all of whom seem to have been academically and professionally successful.

            Perhaps we could get some real data on the matter, preferably accounting for the obvious cofounders?

          • Skivverus says:

            Age correlates with subject competence, but I’m not sure the correlation is strong enough for classes to be organized by the former rather than the latter principle. I suppose organizing by age is easier when it comes to administration, and it’s fairly entrenched when it comes to social expectations, but…

          • Colin Fraizer says:

            Re: obvious cofounders

            Like Steve Wozniak or Larry Page?

          • @Skivverus: Other reasons to make classes divided by age groups:

            * For social reasons, it is good that a child has the same peers in different classes and as the child grows up.

            * Younger children need supervision moving from class to class, which is easier if they all move in a group.

            These factors suggest a system roughly the same as ours but with more grade skipping.

        • It may or may not be true that age segregation works best (is cheaper?) for large numbers of children. Has this been tested? Has it even been casually checked, or is it just one of those things which seems reasonable?

          A large public school district could still have mixed age classrooms.

          I eventually switched from complaining about public schools to complaining about conventional schooling, since a lot of private schools are structured like public schools.

        • I wrote “mostly a consequence of” because many private schools are also age segregated–but most U.S. K-12 is public. On the other hand, the Amish have a substantial system of one and two room private schools which are age mixed. And seem to work pretty well.

          I don’t agree that with large numbers age segregation is the natural result. You could easily enough have a system where the ten year old who is good at reading is in a class with average twelve year olds and fourteen year olds who are slow readers, the ten year old who is interested in carpentry in a shop class with twelve year olds and fourteen year olds (a class most kids don’t take), and so on.

          Age segregation, aside from its other disadvantages, means that the level of ability in a given classroom is less uniform than it would be if you sorted by ability instead.

        • Agronomous says:

          I think standard American schooling is one place where the opposite of Chesterton’s Fence applies.

          Call it “Chesterton’s Garbage Fire”: if you’re walking along and come upon a raging garbage fire, you should consider all kinds of reasons someone might want that fire there and that it might be good to have it there—after you put it out.

          For what it’s worth, the K-12 schools I went to mostly segregated by age (with everyone 12 as of September in the same class, etc.) but made per-subject exceptions to keep kids of the same ability together (e.g. some of us 8th-graders took Math in a class with mostly 11th- and 12th-graders).

          Grouping kids by ability is awfully close to “tracking”, though, and the flames of the garbage fire clearly spell out, “Tracking is Evil”.

          The schools my kids go to lump three years together in one room. Part of the reason this works is that each child is going at her or his own pace anyway, which is a big part of Montessori.

          Again, I cannot stress sufficiently how bad an idea it is to start from the standard American K-12 model and try to tweak or reform it. That’s like trying to salvage Astrology through a reform program.

          (Education Realist may disagree; someone should say his name three times into a mirror to make him show up here….)

  77. Colin Fraizer says:

    What if blog readers try? Will that screw up your goal?

    Not that I’d try just to screw with you…

  78. Jill says:

    There was a section, I think it was on this thread, about how a political candidate sometimes accuses their opponent of something that the political candidate himself is doing. Although occasionally the candidate may be intentionally being “the pot calling the kettle black”, most of the time they are not. The strategy works quite well, but that doesn’t mean he is aware of why he is doing it.

    This is most often an example of the defense mechanism of projection, in which a person avoids facing the flaws in himself by “projecting” them onto someone else (sort of using that person as a movie screen to project one’s own flaws onto), in this case the political opponent. This is a normal defense mechanism, used by everyone some of the time. It is one of many examples of the useful parts of Freud’s ideas and psychodynamic theory and therapy. We all do things that we’re not aware of doing, and defense mechanisms are are prime examples of that.


    Of course, we are more psychologically healthy when we can face the realities of who we are, rather than projecting our flaws onto someone else– IF we can stand the stress of doing so. But often a person can’t stand that stress– or their subconscious mind thinks they can’t– which is why they do it.

    E.g. we humans are basically cowards. We all exist today because our ancestors ran away from predators rather than trying to fight them. We’re almost all cowards but we don’t want to admit it. So we project our cowardice onto somebody else and dislike it there. A politician who is particularly cowardly is highly likely to project that cowardice onto his opponent, rather than to face it in himself. But that doesn’t mean he knows he is doing this. He probably really does think– at least in his conscious mind– that his opponent is the coward and that he is the brave one.

  79. Ilyushechka says:

    [Inspired by Jill’s fine post, above]  The following (typical) blog-o-sphere exchange shows defensive cognition at work.

    Q  “What is the difference between a gamma’s snark [meaning, abuse from a low-status male] and something like that from an alpha/sigma [meaning, snark from a high-status male]? Is the motivation important?”

    A  “Yes. One is defensive, the other is dismissive. Yes, motivation is dismissive. The alpha/sigma is indicating that he does not care. The gamma is trying to hide the fact that he cares very much indeed.”

    Against this defensive justification stands a plain moral principle that Tom Sawyer advocates to Huckleberry Finn:

    Huck  “When I start in to steal a [watermelon], I ain’t no ways particular how it’s done so it’s done. What I want is my [watermelon], and I don’t give a dead rat what the authorities thinks about it nuther.”

    Tom  “Right is right, and wrong is wrong, and a body ain’t got no business doing wrong when he ain’t ignorant and knows better.”

    The entire chapter in which this exchange occurs is well worth reading.

    Can’t the entirety of Huckleberry Finn be read as extended exposition on the self-blinding elements of defensive cognition? Doesn’t Twain realistically, and sympathetically too, give all of the characters in Huckleberry Finn — including even the King and the Duke — voices that sympathetically articulate their projective moral self-justification?

    Wasn’t Twain among the very first social justice warriors to appreciate the unbounded comedic potentialities that are inherent in defensive cognition?

    In abandoning rational cognition, in favor of empathic cognition, Twain’s narratives have acted (for the past century and more) not to “solve the problem” of racism, but rather to “dissolve the foundations” of racism.

    And for this transformational psychoanalytic insight, Twain’s enduring reputation as a great writer is well-deserved, isn’t it?

    • Jill says:

      Yes, I love Mark Twain. Incredibly insightful. I started reading him as a child and kept going.

      Twain was incredibly aware of what he and other humans were doing and how and why.

  80. anonymous says:

    Still, I have to do it, because my attending grades me and if I don’t pass psychodynamic therapy I don’t get to graduate. So I do it, and then my attending declares he was right all along based on extremely strained interpretations of whatever happens next.

    I am really sorry this happened. I would rather have appendicitis again than have to do that.



    Really that’s horrible.

    That reminds me of the

    “[don’t] talk about or react to my emotions and wait for them to go away”, strategy.


    there’s just a lot of horrible things in this world with no good in them. Trying to find an underlying hidden meaning in them would be exactly wrong. ! I think that’s probably how people lose their minds: they try to fit something mindlessly, entropically wrong, or worse, into an underlying order.

    I feel that my mind could be destroyed if I mistook something like this for another fact to be enveloped into the harmonious whole of reality, rather than a distinct glitch, malfunction. I wonder if people who don’t have the aversion to being told what to think, and that they can’t argue, just accept being cracked in this manner as a basic, unavoidable, part of existence, hopefully to be worked around, but folly to attempt to avoid.


    Anyway, you have my sympathies and even more of my respect. Soldier on man

  81. Greg Pandatshang says:

    Personally, all I wanted from life was to make a decent living by using old-school-yet-not-quite-analysis psychodynamic psychotherapy to help people, just like the characters in Spellbound or Dressed to Kill. But my dreams were dashed when it came to light that per science psychodynamic therapy is not necessarily an effective way to help people. I’m also not sure I could get paid very much money to do that. Whether these facts are related, I don’t know.

    P.S. I continue to pay somebody else a serious amount of money to use psychodynamic therapy on me. I have advised myself that this kind of thing might be better suited to me than it is to most people, and even then I sometimes wonder. I enjoy it, at least.

  82. sentient_guillotine says:

    I feel dazed by ch. V.. well, I knew psychoanalysis is weird, (used to deal with this kind of a “doctors” in my teenhood, I felt aura of “authority” emanating from them) but this first-hand evidence of complete, outlandish, mumbo-jumbo weirdness of it just made me stare mindlessly at the monitor for a few minutes.