About / Top Posts

Welcome to Slate Star Codex, a blog about science, medicine, philosophy, politics, and futurism.

(there’s also one post about hallucinatory cactus-people, but it’s not representative)

SSC is the project of Scott Alexander, a psychiatrist on the US West Coast. You can email him at scott[at]slatestarcodex[dot]com. Note that emailing bloggers who say they are psychiatrists is a bad way to deal with your psychiatric emergencies, and you might wish to consider talking to your doctor or going to a hospital instead.

If you’re interested in this blog but don’t know where to start, try reading any of these posts that sound interesting to you:

1. Beware The Man Of One Study
2. Meditations on Moloch
3. I Can Tolerate Anything Except The Outgroup
4. Book Review: Albion’s Seed
5. Nobody Is Perfect, Everything Is Commensurable
6. The Control Group Is Out Of Control
7. Considerations On Cost Disease
8. Archipelago And Atomic Communitarianism
9. The Categories Were Made For Man, Not Man For The Categories
10. Who By Very Slow Decay

Scott also writes Unsong, a serial novel about alternate history American kabbalists.

Creative Commons License
This blog is licensed under a Creative Commons Attribution 4.0 International License.

176 Responses to About / Top Posts

  1. Testingfrog says:

    Hmm. It looks like there’s no kind of password protection with these commenting identities. All it would take to hijack someone’s name would be the knowledge of the e-mail address they’re using for commenting.

  2. Anonymous says:

    Should this page be visible?

  3. Chinpokomon says:

    I remember you years ago saying that a great Facebook app idea would be for people to anonymously “rate” how much they are romantically interested in their friends. If it was mutual, then the app would alert them to the good news.

    Voila, here it is: http://www.washingtonpost.com/blogs/on-small-business/post/dc-dating-start-up-hinge-expanding-to-new-york/2013/05/06/311d7fba-b411-11e2-baf7-5bc2a9dc6f44_blog.html

    And it’s doing quite well!

  4. jooyous says:

    How do you pronounce “Yvain”?

  5. J says:

    A group of my colleagues and I are impressed by your blog! You’re a grad student studying psychology? Seems like I read that somewhere?

  6. Shane says:

    I tried to email you at the address given above, but it bounced….

    All I wanted to say was that I just added your Anti-Reactionary FAQ to rbutr, and thought you might be interested in it if you hadn’t already heard about it: http://rbutr.com/rbutr/WebsiteServlet?requestType=showLinksByToPage&toPageId=1301038

    The basic idea behind rbutr is to connect critical responses to the webpages they are responding to so that people can easily move from claim to response to counter-response in a natural way (something the internet doesn’t yet easily enable). In this way, we can transform the internet from its current ‘information delivery’ setup, in to a more proactive tool which teaches people to critically reflect on the subject matter that the internet is delivering to them.

    I thought you might be interested in it, and might want to add more of your articles to the system, thus getting your responses in front of the people reading the pages you are responding to?

    You can install our plugin in Firefox or Chrome, and submit any claim-rebuttal connections you find/write.



  7. Ben McLean says:

    Scott, you are a hard man to reach. Your email listed here returns a “Delivery to the following recipient failed permanently” error, and I used leetkey to reverse the text to be sure there wasn’t a mistake. My email was going to say:

    “Hello there. I am one of the founding members and regular contributors on Trekosophy: the Star Trek Philosophy podcast http://trekosophy.com/ now in our third season. I heard you give a demonstration and play a small game of your “Dungeons & Discourse” game on another podcast once and was thinking that would make a great episode for our podcast if you ever had time to come on, explain it and help us through DMing a session. It would both give us interesting content for our show and promote your game at the same time. We usually meet on Wednesdays at 6 PM CST (GMT -6) and have just switched to using Mumble as our communications software. I’ve been meaning to email you about this for a while, actually. Think you could come on sometime? :)”

  8. Anonymous says:

    test edit

    successfully edited!

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  11. Illuminati Initiate says:

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  13. Anonymous says:

    You should talk to that Yvain guy because he needs a hug!

  14. Delight says:

    Sorry if u already answered that question elsewhere, but I just came here, read “IN FAVOR OF NICENESS, COMMUNITY, AND CIVILIZATION” and wanted to donate something. So is there some kind of “flattr”-button somewhere and I missed it? (I read that u link to amazon for cash and already turned of adblock, but I’m not a heavy consumer :P)

    Awesome work btw, it was a delight, tyvm! Have to come here more often 😉

    • Scott Alexander says:

      Thank you for offering. I don’t accept donations, but if you want you can donate to a charity like the Schistosomiasis Control Initiative in my name.

  15. JYS says:

    I think you may find this piece interesting.
    It discusses the tactical, but also substantive value with engaging with one’s ideological opponents, including and indeed particularly one’s most extreme ones.

    A teaser:

    “I think the CDC and other official and mainstream sources of Ebola information are far wiser to give extremists access to the social media they control (like the CDC’s Facebook page) than to deny them access.

    To explain why, let me start by subdividing the people whose comments you call “aggressive, uninformed, rumor-mongering, paranoid, etc.” into two rough categories: those who have something to say that’s worth listening to, and those who don’t. I’m going to argue later that the first category tends to be bigger than we imagine. I think the mainstream has important things to learn from people on the fringes, both generically and with specific reference to Ebola. But let’s put that aside for now and assume that we’re talking about people whose comments are, as the Supreme Court used to say about pornography, of “no redeeming social value.””


  16. JYS says:


    You may also find this interesting:
    The narrow topic discussed here is risk communication in the context of vaccination. (How to communicate risk associated with disease and vaccination to a skeptical or hostile audience in manner that will encourage them to make rational choices.)
    In the context of things you’ve posted before, it could be retitled “Why Andrew Card’s Noble Lie is wrong–honest communication with your ideological foes is more effective in the long run” (I’m well aware of who Andrew Card actually is, but in deference to your desire to obfuscate his identity I will do the same.)

    “Vaccination Safety Skepticism: Public Health’s Self-Inflicted Wound (Part One)”
    (It isn’t a short video; I apologize that I could not find a transcript.)

  17. JYS says:

    Part 2
    Part 3 (I haven’t finished it yet so I can’t endorse it with a clear conscience, but I suspect it will continue to be terrific)

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  20. H. says:

    Nice blog =]

    Take care,



  21. Qp says:

    This is an example of a certain kind of writing style that packs a tremendous amount of meaning into a few short words that once read enliven one’s essence centers with premature thoughts of self affirming, when in fact, that form of egoism can be avoided indefinitely through close scrutiny of words.

  22. RTO Dude says:

    simpler test

    edit: must have screwed up

  23. thepenforests says:

    Test comment – I don’t know how this gravatar thing works.

  24. Stephanie says:

    I read that article yesterday, the “Nerd Entitlement…” article that you write a blog post about and it really triggered all these stupid feelings of self consciousness and feeling ugly and not good enough for men and feeling unlovable, that I felt all the time when I was younger attempting to date as a female nerd. It was bizarre! I thought I was past that but then bam! It hit me like a train. No one will ever love me! So dumb. Grrr, I thought by now I was over that. Like you, I don’t agree with all of the premises of the article, it was just some of the ways she put things really triggered that feeling in me. Bleh, so vulnerable and powerless, that feeling that you are at the mercy of the opposite sex for happiness and self worth and you have no idea what to do to get them to like you, while all around me men were falling over all my cuter, more socially capable friends. And society the entire time is sending me the message that all I need to do is have a vagina and all the men in the world will fall over me, ha ha ha, yeah right!?!

    Anyways, I appreciate your article and it helped me understand why some men are so against feminism lately. I’m not involved in any internet feminism and I find it reprehensible that feminists would be so mean spirited, but I do like that I can have rights now and be a female nerd and be somewhat accepted by society for who I am, though I still am clueless about boys. It actually makes me really sad to think maybe there were some nerdy boys afraid to ask me out because of feminism…I’ve always loved nerds. But, on the other hand, without any feminism I probably wouldn’t be able to express myself because I don’t fit the typical female stereotypes in a lot of ways. I do think it’s pretty hard being a female nerd too, and in a lot of ways harder and in a lot of ways easier, I suppose, like anything. Black/white views never accurately reflect reality, especially when people are involved.

    In any case I’m just as clueless now as I was then about men. So, will you hook me up with 10 nice nerdy guys in Denver, if you know any? But only if they want children, have a job (made that mistake already and got a moocher living with me and me too pathetic to realize I deserved better) and are in a reasonable age range for me (I’m 34). Actually, I don’t know you but your blog post was awesome so if you’re ever in town look me up and I’ll buy you a beer, ok? I’d love to hear about what your experience training in psychology in a female dominated field is compared to my experience training in physics, a male dominated field. That could be my attempt to hit on you or not, depending on your relationship status 😉

    • Giovanna says:

      ” Bleh, so vulnerable and powerless, that feeling that you are at the mercy of the opposite sex for happiness and self worth and you have no idea what to do to get them to like you, while all around me men were falling over all my cuter, more socially capable friends. And society the entire time is sending me the message that all I need to do is have a vagina and all the men in the world will fall over me, ha ha ha, yeah right!?!”

      I know – I know – been there, have always been there, am still there… I empathize. Am a nerd. Have always loved nerds. Sigh, to be like my “cuter and more socially acceptable friends.” Sometimes I’ve felt like, hell, what am I even DOING with a vagina, let alone these cumbersome non-used boobs?

  25. Umesh Patil says:

    How do I put it less embarrassingly…I have been a blogger practically over a decade; but I have not met any other real life blogger personally. Thought if it might interest you to meet me during your Bay Area visit (not because I am anybody, but if you do not mind to expend some cycles for someone to help). If you happen to come to Peninsula (Palo Alto and area south of that) and have some free time, I would like to meet you. For what – say guidance and tips.

    Thanks and best wishes.

  26. Anonymous says:

    Test comment – will it even show up?

  27. maxikov says:

    Test comment #2 – I still don’t understand what prevents them from going through.

  28. maxikov says:

    Test comment #4 – is it email that stops it from working?

  29. I follow David Friedman and he commented favorably on this blog. What do I need to do to subscribe/follow it so that I have access to each new posting and all historical ones?

  30. Landru says:

    ** Lights the “Scott-signal” up into the clouds above City Hall **

    Scott, I guess your name is often taken in vain around the internets, especially after a well-written post that you might regret. You can’t notice them all, of course, but I think this one that appeared today (15 Feb 15)


    may be worthy of your attention. It looks like just your sort of venue, beyond the fact that you’re minorly slagged in the main post. Interesting variety of comments, but could certainly use an SA injection. Go where you’re needed.

  31. Jeff Simpson says:

    Hi, My name is Jeffrey Simpson. I am looking for a possible simplest
    approach to a rather complicated problem. I had previously abused Adderall
    for almost 15yrs, sometimes swallowing up to 14 tablets at a time. I
    relapsed in January of 2014, because I was depressed and have no energy. I
    am currently on Zoloft for depression, which I don’t believe is helping me
    at all, and Serax for anxiety, which keeps the anxiety under control, but
    also makes me very tired and just masks the problem. After being off
    Adderall for 3-4yrs without any meds I was depressed, had severe anxiety,
    a “wired and tired” feeling all the time if you will. I cannot find any
    middle ground as the stress is so overwhelming. Could you kindly send me a sample bottle of your nootropic product , I am new to nootropics and am on a very tight budget. I’d really love to try this product?

    Jeffrey Simpson

  32. Danny Davis says:

    I read your essay “Meditations on Moloch” and I have never read such a magnum opus to the ego.

    It’s brilliantly clever.

    However I believe you make the critical error of thinking that things are not already proceeding along the “god-view” outcomes related to game theory and the prisoner’s delimma. The elephant in the room that western philosophy has ignored is the central eastern mystical question of whether or not the universe is a friendly place. Your essay goes on discussing the perils of human nature; however makes no case whether or not that mark of “original sin” actually exists. It could equally be said that human nature is always good at all times; it just took a “god-view” perspective to see it as such. Or at least that’s what 5000 years of eastern philosophy suggests.

    There is a book that I highly recommend for you. It is called Tertium Organum by P.D. Ouspensky.

    You seem incredibly intelligent and open-minded. Two things that are very rare to find in the same person.

  33. Carl says:

    I’ve recommended your blog to friends as “everything human”.

  34. John5150 says:

    just discovered this site but so far I like what I see

  35. Elio says:

    After all those months of wondering where the author of that other blog wandered off to I finally put two and two together.

    Actually, I figured it out during the three minutes of googling it took me to figure out your name, but since you didn’t actually want to hide that, just for it to be not immediately searchable, I guess that’s fine.

  36. Jacob says:

    I really appreciated the survey you took of the r/nootropics community about a year ago. Could you rerun the same survey again, or maybe even make this an annual event? If you’re interested, I have a small suggestion: I don’t know anything about statistic, but it seems to me that it might be beneficial to normalize each participants ratings by his or her average ratings, could you do that?

    If you’re not interested in rerunning the survey, do you still have the google doc you used to make the survey, and could I use it to re-run the survey myself? Thanks a lot.

  37. Smithd546 says:

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  42. Michael says:

    Your article on HeartMath was very helpful for me in evaluating a recommendation from a holistic therapist. Of course your credibility increased when I caught the Illuminatus references.

  43. Megan says:

    So, “Scott,” I was reading one of your blog posts and I am wondering, who is this guy? So what are your qualifications? Why should I care, basically? Do you have an MD? PhD? Why is there no list of your credentials anywhere on this site?

  44. questioning says:

    Hey Scott,
    I’ve been instinctively pro-choice for most of my life, but a friend posited to me a scenario that I just can’t stop thinking about and was wondering on if you had any thoughts. It’s a bit complex, but (I think) potentially very important.

    The scenario is this: everyone agrees that, before conception, there is no person, and, after birth, there is a person. Murdering a person is the worst moral crime one can do. If I went to a hospital and stabbed a baby that had been born 1 second ago, that would be murder and indefensible. Thus, the proper context for the abortion debate is a disagreement over what constitutes a person and when/how personhood is achieved. We can even model this mathematically: 0 is ‘not a person’, 1 is a person, and we are attempting to settle when/how that 0 becomes a 1, or whether there are decimal places in between.

    Hard-right pro-lifers insist that 0 becomes a 1 at conception: that once conceived, there is a person, and thus abortion is by definition murder and must be banned in all/nearly all circumstances. Hard-left pro-choicers insist that 0 becomes a 1 at birth, and so all/nearly abortion restrictions are bad because they needlessly infringe on rights, such as the women’s right to her own body. Most people, when polled, are hesitant about abortion restrictions in the first trimester, but are significantly more open to such restrictions in the third trimester, so we can infer that most people seem to have some sort of implied exponential function with time-to-birth on the x axis and 0-to-1 on the y axis. Center-right pro-lifers tend to have a more logarithmic function.

    The idea that gets me is that all of these functions (instant jump to 1, logarithmic function, a linear function, exponential function, jump to 1 at birth) seem to be pretty arbitrary; I honestly can’t find ethical principles that can push for one form to be superior to any other functional form. One can argue about the nature of the fetus, the start of a heartbeat, the ability to feel pain, etc, and about what that implies for the start of personhood, but none of these arguments seem to be convincing over any other criteria. By this line of thought, most opinion on abortion seems to be pretty arbitrary. Why should we have limits in the third trimester but not the second? But isn’t it just as arbitrary to limit it in the second trimester but not the first? Given the wash of biological facts and conflicting ethical principles, it seems to me that basically any opinion on abortion can be rationalized in a way that is equally good (or bad) as rationalization for different opinions on abortion. Thoughts?

    • Korakys says:

      You’re setting yourself a hard prior which may not exist: that killing a person 1 day old is indefensible. I think the continuum reaches 1 when a human is about 3 years old (infanticide was super common in the old days). Even though I don’t agree you probably shouldn’t rule out that quantum-like mechanics might be a better model.

  45. Mike says:

    Hey Scott, I’m a long-time reader and I think your blog is frequently exceptional. I recently re-read your post on Moloch and it nearly (actually) brought me to tears. Let me know if you’re ever in NYC; I’d love to buy you a drink (or a falafel, or whatever) if you’re up here.

  46. oOOOo says:

    Tom Riddle, is that you?

  47. Sandman says:

    What a great Sat am find your site was today! I was directed here from Marginal Revolution. I enjoyed the recent “evil cardiologist” piece. And the piece about wildly variable drug costs was eye-opening. I plan to ask our navigators if they’re are advising our cancer patients about this. Btw, I’m a pathologist here in TN. Sounds like you’re an ER doc.

  48. Laura H. Chapman says:


    Just discover your discussion of mindset. I am delighted to find that I am not the only skeptic, especially since the mindset thingy has been thoroughly commercialized by the author and is being marketed to schools as “Brainology” with some god-awful graphics, complete package of worksheets, videos, etc for $6000. I work in arts education and have been looking at the PR being targeted at teachers and kids about having insufficient “grit,” not having a growth mindset, not purring forth enough effort, not practicing enough, not passing the marshmallow test by age three. It is bad enough to hear this mantra of more effort and practice and “can-do” mindset as as if that is a panacea from Secretary of Education Arne Duncan, worse to see the phrase propagated by Carol Dweck with a huge aura of prestige from Stanford.

  49. David J. Balan says:

    Hi Scott,

    My name is David Balan. I used to be an occasional poster on OB and LW. Big fan!

    There is a working paper by Sarah Flèche and Richard Layard entitled “Do More of Those in Misery Suffer from Poverty, Unemployment or Mental Illness?” that I thought you might be interested in, for obvious reasons. I’d be happy to send it to you, but I don’t know how to add an attachment to this email.

    The world is in desperate, aching need of wise, rational, and compassionate psychiatrists. So Kudos!


    P.S. A post that I would love to see someday, if you ever feel like writing it, is how you think the allocation of medical talent among specialties compares to what would be the socially optimal allocation. It seems to me like the allocation is pretty out of whack. For example, my dad spent about six weeks in the ICU before he died, and the intensivists looked to me like they made tons of life-and-death decisions every day, which made me think that probably some of the most talented docs should be intensivists, but my understanding is that it pays relatively poorly, and so (though ours was excellent) the best students mostly don’t go into it. In contrast, some of the high-money specialties that attract a lot of top talent seem like they don’t add nearly as much value. But maybe I’m wrong.

  50. I have enjoyed reading your blog.

  51. Dean Hud says:

    I live in Texas where I find a curious phenomenon. A sizable number of Texans seem to think it is their constitutional right to openly carry a gun… presumably to shoot other humans, as they see fit, to defend themselves or someone else they believe in.
    And yet when I claim I have the right to die, when and how I want, some of these same citizens begin to froth at the mouth at the mere mention of my planning my own death.
    Can someone help me understand this seeming paradox.

  52. Not John Sidles says:

    Test. [b]Bold test.[/b] Bold test 2.

  53. Iron Man says:

    Hi Scott. Is there a way to subscribe to your blog?

  54. rpatel says:

    Scott, I just recently got linked to your blog through a tweet by Paul Bloom. I just want to say I am blown away by your intelligence. I am a graduate student at a top 30 school, and I graduated summa cum laude from a top 30 school, but your mind blows mine out of the water. I don’t know how you have so much RANGE and cover so many ideas with so much depth. It is incredibly impressive. Almost too impressive, as I don’t think I will ever be able to catch up on all your posts. But either way, I just want to say im impressed. Can we switch genes? How do you do this? Are you reading every hour of the day you are not with patients?

  55. Giovanna says:

    I just found “Slate Star Codex” yesterday evening and stayed up reading until 7 AM this morning, which is HIGHLY unusual for me, because I usually fall asleep at around 11 PM. What an absolutely wonderful, intelligent, thought-provoking site! Wishing you all the best. And I’m going to keep hanging around here. 🙂

  56. Belle Milligan says:

    Hello Scott! I really enjoyed your I CAN TOLERATE ANYTHING BUT THE OUTGROUP essay and would like to cite you in one of my college essays but I need to be able to show that you’re credible. Do you have some kind of “about me” section that talks about your education and/or career/achievements? I would very much appreciate it!

  57. Scott, I like your blog.

    Your writing style is somewhat unique. What is your age? Have you spent many years developing this skill?

  58. Skeet M. Singleton says:

    Dear Sir,

    I have read your “I can tolerate anything except the outgroup” post multiple times since discovering it for the first time via a friend two days ago. I identify as a liberal republican who has spent much of his life traveling back and forth from the south, to the east, midwest and outside the country. I have been trying to write a book titled “I’m not sorry I’m an apologist” about how political apologism gets a bad wrap, and then use this as a pretext to bridge both sides of the political divide. (I am failing miserably, but mostly because it is not strictly academic — oh, and I’m a graduate economics student.)

    I don’t have a specific question yet, but nary worry I will find one. In the meantime I wanted to give you a shout out and perhaps find time to Skype for 15-30 minutes, and maybe take your temperature on my attempts to produce a balanced budget that could garner bipartisan support.

    By the way, I also do serious research on cross border effects of monetary policy and fiscal policy, the rationality of “bubbles”, and asset pricing.

    Thank you for your time!

  59. Andy Bell says:


    I was poking around today and came across your article: As iron curtain has descended upon psychopharmacology- https://slatestarcodex.com/2014/08/16/an-iron-curtain-has-descended-upon-psychopharmacology/. Excellent article by the way.

    In fact, it inspired us to create an page on stacks for cognitive enhancement: http://peaknootropics.com/

    I’d be tickled pink if you’d consider adding it to your page.

    I look forward hearing from you.

    Thank you,
    – Andy.

  60. I read your post titled “I can tolerate anything except the outgroup”, and I find it quite thought provoking.

    As a Brazilian, I find that Dark Matter has been materialising around me in a quite sudden way. Where does all this deep seethed right-wing reactionarism come from, which was so well concealed for so many decades? Is it because the local bien-pensants now can no longer have house maids? Or because now they have to share plane trips with those they have traditionally seen as their inferiors?

    What happens when universes clash?

  61. Dr. Toboggan says:

    What the hell is a “slant anagram”? I googled to no avail.

    (Matter of fact there were only 10 results or so, including this page. Talk about obscure.)

  62. Douglas says:

    In regards to your suicide article.

    Just because people might regret their actions does not mean they don’t have the freedom to make them. Almost every smoker on their deathbed regret they moment the began lighting up. Granted, smoking takes far longer to kill and you have many opportunities to quit. But many don’t simply because nicotine is highly addictive.

    Mental illness does not equal incompetency. I would argue that majority of people with depression are in fact competent. That alone should be the determining criteria for allowing their freedom. Whether the suicide is “rational” or not is irrelevant. People have the freedom to make irrational decisions.

  63. Julia Burns says:

    One day after you get as old as I am. you may or may not wake up hungry. With no money and no food. You paid all your wages out in rent, utilities, transportation, and taxes. What does a person do? Prior to minimum wage (1938) my grandfather worked for $1.00 – $10.00 for more than 40 hours per week. He was barely able to feed a family of four. He was a sharecropper before working in the big city. When he was hurt on the job, he was out of luck. My grandmother, who was crippled the majority of her life, ended up working at any job she could get. The minimum wage came along. They had a break for once. They all including my parents have been gone for a while from this earth. I am older and live off of less than minimum wage. Had it not been for my children, I would be homeless. I make a little over about $5 to $10 dollars a month too much to qualify for government assistance. Oh well that is the life I have been dealt. I am not bitter about it because I enjoy everything and have a wonderfully positive attitude. I am sick and had to retire. We you get my age maybe things will be seen differently through your eyes. By the way, why don’t you use your real name? What is there to hide from?

  64. Mikhail Ramendik says:

    I just got into old monumental posts that seem to have their comments closed (or something is malfunctioning here) and wanted to dump a couple of notes on them, in case you would possibly see them as good enough to be permitted.

    Re Anti-Reactionary FAQ: “Michael and Moldbug cannot bring up examples of these countries killing millions of their own people, because such examples do not exist.”

    I’m not a Reactionary (*). But if they cannot, I can bring one up. The Great Famine of Ireland. This was a direct result of British policy and it killed at least a million of the people of the United Kingdom of Great Britain and Ireland -I would call them “citizens” but I think the word did not yet exist in UK law back then. Ireland was emphatically NOT a colony, it was called the United Kingdom for a reason.

    Re the Planet-sized Nutshell: “a real Reactionary would hasten to add this is more proof that progressives control everything. Because immigration favors progressivism, any opposition to it is racist, but the second we discover the hyperborder with Conservia, the establishment will figure out some reason why allowing immigration is racist. Maybe they can call it “inverse colonialism” or something.”

    Sorry but this hypothetical “real Reactionary” assertion is counterfactual, and was so in 2013. While in the USA, Progressives welcome Mexicans who are Progressive, in Europe they welcome Middle Eastern Muslims, who are, in fact, reactionary. At least with a small “r” – but I dowonder if, upon learning more of Islam and Sharia, some Reactionaries might consider a conversion, as the assertion that a 7th century comprehensive system of law would work very well for a modern society is a cornerstone of fundamentalist Islam.

    Fundamentalist Muslims are known in Europe for things like harassing gay people. They are far from leftist, and yet, the leftists do welcome them.

    (*) re Reactionaries, I do share their default distrust of revolution and their admiration for the American Loyalist side (not to be confused with the much more recent movement in Northern Ireland of the same name) – but not much else. For example, while Moldbug seems to think American Loyalism has disappeared, I happen to know where Canada came from, and yes, it seems to work better than the USA. Yup, a very Progressive place – but that’s what many Loyalists actually *were*, what with their distrust of slavery, what with the fact that their Empire abolished slavery 30 years befure the USA and without needing a bloody conflict to accomplish the feat.

  65. test says:

    test comment

  66. Diane Ravitch says:

    Scott, thanks for your interesting and amusing review of the VAM debate.
    You left out one very important point: 70% of teachers do not teach tested subjects and therefore do not have test score data. States have dealt with that critical problem by assigning the scores to them of students they never met in subjects they don’t teach.

    Diane Ravitch

  67. Shino-chan says:

    Just started reading. med student

  68. Just read your piece on Serzone and the lunacy of medical culture with its overblown fears of rare, severe side effects, yet willingness to blithely cause great harm by mindlessly putting thousands on meds like Zyprexa or Seroquel. I am a 58 year old Psychiatrist in Salt Lake City (Stanford residency, Dartmouth Fellowship, a brief academic career at UVa, blah, blah), and I rarely come across something as well done as your piece– brilliant! (I’m skeptical about QALY-type comparisons, but at least its a stab in the rational-empiricist direction). Just so you know, there are some of us docs out there who still use nefazodone– I use it regularly. I give patients the “1 in 300,000 pt-years” figure, tell them “if you’re willing to drive on the freeway, you’re taking a much greater risk of being killed”, etc. I’ve put hundreds, maybe even a thousand, pts on it over the years. Never saw so much as a hint of jaundice, though I’ve had a few who bumped their liver enzymes by a factor of 2 or 3. As one of 2 meds we have available that don’t cause sexual side effects, coupled with its salutary effects on sleep and anxiety, it is MASSIVELY underutilized. I am really looking forward to reading some more of your stuff. Keep up the good work!

  69. dont know where else to post this says:

    Typo in rabbit hole story:
    You see enough geology to give scientists back on Earth excitement-induced seizures for the NEST hundred years, if only you were to tell them about it, which you don’t.

  70. Mark Dominus says:

    I tried to reach you at the address you gave on this page, but the message bounced. Please contact me at mjd@plover.com .

  71. vollinian says:

    Woah I logged onto wordpress and the about page and top posts page have combined into one that is extremely brief as compared to the original two. I think this is a change not only to subscribers?

    Why the change? I personally liked going back to the top page to sift through the “top posts” before.

    • thevoiceofthevoid says:

      Yeah I miss the old “top posts” page 🙁
      It was nice to have somewhat categorized links to a bunch (i.e. >10) of popular posts, as well as a bit of Scott’s commentary on them, and links to other archives of SSC/less wrong content from Scott. I can see why you might want to tidy it up a bit, but I still liked the old one better.

      • vollinian says:

        Yeah, when I discovered SSC I was impressed with Scott’s diverse array of subjects. The “best posts” are of course really good and gave me an idea about what the blog is, then in-depth research was also impressive, and I can visit the Top Page anytime I wanted to reread the dozens of essays. Toxoplasma of rage is missing now. The important ones on SJW are too :/

        • sty_silver says:

          This might be based on the results of the last survey, to have something better than Scott’s own opinion or most clicks. I also loved the Toxoplasma of Rage.

  72. Null42 says:

    Test comment.

  73. hewenttojared23 says:

    I’ve been having an ongoing debate/convo with some friends about Grammarly and how much trust we can put into it’s security/privacy policy.

    This blog seems to have some misinformation re: how long user data is saved for. At best, the info received from Grammarly support team members (particularly that user data is deleted after 14 days) is not official and possibly incorrect. The only official policy that remotely resembles a 14-day storage policy of user data can be found here.

    That said, the 15-day period mentioned here only applies to users who delete their accounts. Given the $110 million Grammarly just raised, I was wondering if you could write a post weighing in on what types of concerns there might be with the company’s data security and privacy policies. My gut reaction to such a huge first round of funding is that they’re doing a great job pitching the value of the massive amount of user data they have (literally every word written by users within apps/programs that integrate Grammarly).

    Maybe my concerns only lie with certain types of private user data (medical/financial). That said, Grammarly’s official privacy and security policies leave much to be desired. Compared to Dropbox’s fairly explicit policies, Grammarly’s seem remarkably wishy-washy. Notwithstanding any possible shortcomings in the TOS, a breach of Grammarly’s servers, however minor, is worrisome. In such a scenario, I wonder whether affected users would prefer to have had their private journals released publicly. The most thorough diary entries are incomparable to an application, marching toward ubiquity, that collects all accessible typed input to be stored indefinitely.

  74. John B says:

    Meditations on Moloch is the best essay I have read in the 21st century. Brilliant.

  75. Carey Underwood says:



  76. Steve Witham says:

    A reply.

  77. raymondneutra@gmail.com says:

    I just discovered this site via a citation by David Brooks on Conflict vs Mistake Theorists. I see lots of thoughtful stuff on this site. Thanks As to Mistake and Conflict Theorists, I think it would help to apply the theories to events in countries where we agree that good progress has been made. My guess is that a mix of both theories apply with conflict mostly via legal and legislative means.

  78. KristinRose says:

    Not sure where to post this request, but here goes: Can you give me a few recommendations for psychiatrists in the Metro Detroit area who do couples counseling?

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  80. Lander says:

    The blog should actually be called Slate Rant Codex – did I find an easter egg?

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  82. multinomial says:

    How do you find time to write, maintain this blog, and be a psychiatrist? Your intelligence and writing precision fascinate me! I am also fascinated by the intelligent responses from other professionals here.

  83. Highschooler23 says:

    Looking for information about heart math, more or less personal experiences with it or use of it in hospitals and patient care. For a school project so anything will help.

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  89. Gafones says:

    Mate, you need to get out more.

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  93. mikeyp says:

    A Plea for Sanity: One Addicts Attempt at Navigating the Addiction Treatment Industry in Ontario
    An Opinion by Mike Paterson
    One cannot opine about potential solutions for substance abuse and addiction in our society without first reviewing the status quo and its assumptions, effectiveness or lack thereof.
    Twelve Step Methodology: The Old Standby
    The treatment model still most sanctioned in this province relies on a twelve-step methodology, even though the success rate for this approach has held remarkably consistent at between five and ten percent since its inception.
    When this is compared to the control group, often referred to as “white knuckling”, or in essence, doing absolutely nothing, it is over performed. This information has been available for decades. This is puzzling to me, as it would be somewhat akin to a doctor continuing to prescribe medication knowing that the placebo does a better job.
    This phenomenon is more thoroughly explored in a book by Dr. Lance Dodes, M.D., with over thirty-five years of clinical substance abuse treatment experience, titled “The Sober Truth”, and I believe the following quote sums it up quite nicely,
    “Any substantive conversation about treatment in this country must reckon with the toll levied when a culture encourages one approach to the exclusion of all others, especially when that culture limits the treatment options for suffering people, ignores advances in understanding addiction, and excludes and even shames the great majority of people who fail in the sanctioned approach.”
    When one considers the overall ineffectiveness of twelve-step programs, one only need an understanding of the basic assumption of the model to comprehend why. This assumption is the concept of powerlessness. This ideation is clearly stated in Step One and is the guiding principle for twelve-step treatments.
    Once understood, one can clearly see that a twelve-step methodology is not a self-help treatment option, as obviously individuals who are powerless are completely unable to help themselves, by definition, but rather an external control model.
    The client’s first line of defense against addiction is their sponsor, and their last line of defense is their “higher power”. At no point while being governed by this model is the individual able or responsible for their recovery (e.g. “your will not mine”). The term “ego” is used to describe when one attempts to take a vested interest in their recovery. In this understanding, the term “ego” may be used interchangeably with the term self-determination (e.g. autonomy), and it is assumed that anything resembling freedom of choice or empowerment results in relapse.
    When this thinking is further evaluated, it becomes understood that no one has ever completed the twelve steps as currently written. The reason being is as follows; An individual enters treatment with the understanding that they are completely powerless, as defined in step one, however, in order to complete step twelve, the same individual must become autonomous regarding the direction of their recovery, or in essence, “drive the bus” in order to complete the final, and perhaps most important step.
    Considering the glaring contradiction in this methodology it is relatively easy to understand the extremely low success rate that can be independently corroborated, not self-reported, pertaining to this treatment option. Once comprehended it is easy to spot the fundamental flaw. If one remains powerless, as prescribed in step one, the individual can only, at best, complete steps one through eleven. It is only if step one is negated that step twelve can be ascertained.
    Not surprisingly, the vast majority of clients who attempt this model are never able to complete all twelve steps prior to relapse.
    When assessing the sponsor-sponsee relationship, at first glance it appears to be in line with the premise of peer support, unfortunately, upon closer inspection, this definition dramatically changes. The sole purpose of the sponsor in this relationship is pre-eminence. The primary objective, counter intuitive to that of peer support, is for the sponsor to fully direct the sponsee through the program.
    Not surprisingly, this approach is often met with reluctance, if not outright refusal, as the client will obviously demand some input on what their treatment is supposed to look like. Afterall, treatment programs are supposed to be client-centered, not facilitator-centered. Apparently, this distinction is lost on those who advocate for twelve-step models as an effective means of treatment.
    Moreover, one must critique the suggestion that twelve-step methodology is a spiritual program. It is not. The term spiritual relates to a belief in something larger than oneself. However, the moment that an individual prays to their higher power, the assumption is that the higher power can hear them, and ultimately, will answer them. It is at that precise moment when spiritual becomes religious.
    One can believe in something larger than themselves, for example humankind, however, it is rather suspect that they would ever pray to this higher power. The reason being is very easy to understand, it is unlikely that humankind would hear their prayers, and even less likely that it would respond through miracle. Therefore, prayer is only a mitigating factor if the individual praying honestly believes that their higher power will respond to their pleas. This is not spirituality, but religion.
    Further, it is stated in step three, that one’s higher power is “a God as you understand him”. This step is also not supported by the facts, as the God they are referring to is overtly Christian in nature. One only need to look at rituals conducted at any twelve-step meeting to understand why. The meetings are commenced with the Serenity prayer and concluded with the Lord’s prayer. Both inherently Christian in both origin and practice.
    Also, meetings almost always occur in a Christian church. The seventh tradition, “passing around the collection plate”, also has its basis in Christianity and finally, step five, takes place in a Christian church where both sponsor and sponsee are participants.
    When understanding the history of twelve-step methodology it is not difficult to comprehend why they transformed from an overtly Christian organization, to one boasting spirituality and any faith denomination being equally supported. Quite simply, their membership numbers stagnated in the nineteen seventies and they needed new recruits. However, with respect to worldwide membership, one must recognize that this approach did not work, as membership numbers did not increase. It was approximately two and a half million then, and it is approximately two and a half million now.
    The reason for this status quo in total membership numbers is directly related to the extremely poor success rate experienced by the overwhelming majority in this program. Effectively, for every new recruit that joins a home group, a current member withdraws due to lack of success.
    One may question why I am being so critical of twelve-step programs as a means of treatment for substance dependency. The answer is simple, this program is employed by virtually every ministry financed treatment or withdrawal management program in the province, regardless of its ineffectiveness. In fact, participation is usually mandatory in order to participate in the program. Essentially, the client must engage in a largely unsuccessful treatment regimen in order to have any attempt at recovery. This is puzzling, as our mandate in Ontario is treatment cannot be forced on an individual. However, not surprisingly, there appear to be two standards, one for substance dependency, and the other for every other medical condition.
    This is an obvious conflict, as public funding in a democracy is supposed to positively affect the largest number of people, not the rare exceptions.
    When considering a few points in twelve step methodology that are proven, in an evidence-based capacity, to be of tremendous benefit to the individual, I must question whether the current application has supportive merit.
    For instance, the focus on reflection and atonement as a means of increasing self-awareness, on its face value, appears worthwhile. However, one must consider whether or not, under current framework, this is successful.
    I have heard many, while chairing a meeting and boasting the substantial benefits reaped from actively participating in twelve step programs, while referring to their success (e.g. increased self-awareness) state something to the effect of “I have one more relapse in me, but perhaps not one more recovery.”
    This statement suggests a complete lack of self-awareness from a recovery standpoint, as what is being claimed is that their motivation is fear of relapse, not increased quality of life. This leads to the requirement of two questions being posed,
    1. What will happen when the individual’s fear subsides? 2. Who would opt to live a fear-based life, if there are better alternatives?
    Another tactic that I find counter to the recovery process used in twelve step programs is that of “returning to zero” after a relapse. Does this thinking apply to anything else in life?
    For instance, if an individual is on a diet, and decides to have a cookie, does that erase their dietary efforts, regardless of how successful, up to that point?
    The logical answer is no. So, I query why it applies to addiction?
    We have known for quite some time that the statistically average number of relapses prior to one obtaining prolonged abstinence is eight. In short, just because an individual lapses, absolutely does not mean that all of their previous successes, learning experiences and efforts have been in vain. This assumption is preposterous!
    Lastly, one must consider the type of meeting or group and how that equates to obtaining the desired result. The research surrounding speaker meetings is as follows, the one who benefits most is the speaker. The audience receives much less benefit as the meeting is not interactive. Therefore, when one is in a treatment or withdrawal management program, those who benefit most from in house meetings are not the clientele, but the guests who chair the meetings. This is obviously non-congruent with the agency’s mission statement as their concern is with their clients, not those who are visiting the facility.
    Since the scope of this opinion is not an indictment for those who advocate for twelve step methodology, I would like to point out the one thing that twelve step programs do better than any other program, and that is, maintain an open-door policy. An individual struggling through addiction, regardless of past successes or failures is always welcome. This policy is steadfastly consistent at all home groups and is never attached to one obtaining or maintaining sobriety.
    Residential Treatment: An Exercise in Futility?
    Another approach often used with a similar success rate is sometimes referred to as psycho educational. It is based on the premise that the primary motivator for an individual struggling with addiction is fear. Anyone who has ever been in a structured treatment program has surely heard something to the effect of “play the tape forward.”
    What is really being stated is, that what governs our behavior as human beings is the fear of potential consequences rendered. I submit, that if this were true, our species would not exist. For the simple reason we would not do anything at all, up to and including child rearing. So, by rational, logical extension, I would not be writing this paper, because my mother would not have had me!
    To further illustrate this point, one need only look at the basis for its framework, operant conditioning. There are two key areas where operant conditioning simply under performs, and they are summarized in the following two points,
    (a) The technique is superficial, altering behavior without examining source (causation).
    (b) Operant conditioning fails when problems are complex, such as depression, anxiety or personality disorders.
    The fundamental flaw in this approach is failing to recognize that motivation is primarily positive, not negative. While a fear-based approach may temporarily change one’s trajectory, it rarely lasts the duration.
    Those who advocate for this model appear to be doing so on the presumption that a distinction can be made between “addictive” behaviour, and “non-addictive” behaviour, as it relates to the severity of potential consequences. This assumption is absurd as there is no such distinction, there is only behaviour.
    To somehow suggest that all behaviour does not render consequences is rather silly. So, one most pose the question to those who believe in this methodology, what is the rational basis for this thought process?
    I can only think of one, and it, by definition, constitutes a cognitive distortion. The concept of self-righteousness (e.g. superiority). For one to suggest, that their behaviour is potentially less damaging simply because they do not suffer from addiction, comparatively, is not supported.
    The only basis one can find for this thinking is that of morality. This is a dangerous argument as morality is very subjective. To suggest that those who suffer from substance abuse or dependence are somehow morally bankrupt, when compared to those that do not, is irrational.
    What is even more perplexing, is when it is suggested that these two methods be combined. This is a clear indication of a general lack of congruence in the understanding of the principles that form the basis for the respective models.
    Simply put, the twelve-step model is built on the concept of powerlessness, a clear disease model understanding of addiction, while the psycho-educational model is built on self-determination. A clear understanding that mental autonomy is at the core of the model (e.g. learned social behavior).
    The problem is, one cannot simultaneously be autonomous and powerless, as these terms are contradictory. Any such suggestion is evidence of a blatant lack of competency regarding the subject matter. One must rationally question the qualifications of any who propose such a framework.
    Furthermore, one must ask why, knowing the dismal success rates of these models, would they continue to be used?
    I can only think of two reasons,
    First, financially they are inexpensive to train and implement. In other words, it is not practically about what is best for the patient, but rather, what is best for the taxpayer.
    Second, the decision makers in the addiction treatment industry, are of the opinion that the outcome will be the same regardless of the model chosen. This would suggest, as it relates to addiction treatment, the maxim is, when in doubt, blame the patient.
    What I find most troubling about this, is we do not see this thinking in any other avenue of health science. It appears to be exclusively reserved for addiction treatment.
    Another issue I find perplexing is the societal belief that an individual suffering from addiction can simply admit to a residential stay treatment program and somehow, relatively miraculously some may suggest, discharge a non-addict.
    Perhaps this is a larger retrospective of the “intervention culture” we find ourselves immersed in. However, when considering the success rates of such approaches, one must question their validity.
    As anyone who has been in residential treatment will surely attest, it is remarkably easy to stay clean for a month while one is in the confines of a treatment center, however, there are glaring disconnects regarding availability to, and effectiveness of, aftercare programs.
    The truth is, residential treatment facilities in Ontario, whether ministry or privately funded, do not have any official guidelines for treatment and there are no current official provincial requirements for working in addictions.
    Facilities are simply private organizations that determine through their board of directors, which treatments they will offer (and which they will not) and who can be treated. For these reasons, anyone receiving opioid agonist therapy (e.g. methadone or suboxone), or who cannot be medically cleared to enter a non-medical treatment center (e.g. seizure history) or who is pregnant or under a specific age, are often simply refused access to service.
    Ontario’s Ministry of Health and Long Term Care does not conduct inspections for ministry funded or privately owned residential treatment facilities. Outside of those who work at or are residents of the facilities, there is absolutely no idea about what is happening at the facilities. In regards to provincially run programs, this seemingly includes the funder!
    The only reporting requirements for residential treatment centers are financial, and are to Ontario Healthcare Reporting Standards. This practice is undertaken strictly to document which treatment programs and medical resources are being funded. This practice in no way regulates or monitors program standards or overall effectiveness of the treatments.
    In short, it is the sole discretion of each agency’s board of directors to determine the appropriateness of staff competences and qualifications for the programs being delivered. As well as which programs are offered (e.g. twelve step curricula), which approach their staff will take (e.g. trauma informed versus disease model) and most importantly, which populations are allowed to access their services.
    For almost all other publically funded treatment models (e.g. physiotherapy), there are strict regulations on who can provide the service (e.g. educational requirements) and what services are offered (e.g. evidence based practice). This does not exist for addiction treatment in this province. Furthermore, those individuals seeking treatment in other disciplines are not so descriminently refused access to those services being sought.
    This problematic approach is made no more evident then when one considers those individuals who must stop opioid agonist treatment while in a residential treatment center. As tolerance decreases due to brief abstinence, the likelihood of overdose, and even fatality, if usage is initiated upon discharge, greatly increases. This approach to treatment is literally killing people.
    There is a lot of contested information in the addictions treatment arena and programs are often not tailored to individual needs. For those of us that have been to more than one treatment facility, the obvious similarities in the structure of these programs is difficult to dismiss. Outside of twelve step programming, the remaining classes focus on preventative maintenance, anger management and emotional regulation.
    Perhaps a more beneficial exercise for those wanting to work in addictions to do, as a means of better understanding their clientele, rather than continue to engage in the same exercises, would be to go home and deconstruct the song “A Perfect Day” by Lou Reed. This song is an exemplary illustration of what addiction is, and more importantly, what it is not. In
    the song, the singer addresses his addiction as if it were a living, breathing, entity. His addiction, responds as a peer.
    It is very difficult for an individual or agency to fully grasp the complexities of an issue when their financial livelihood is entirely dependent on them not understanding it.
    Suggested Motivations for Addictions: A Cookie Cutter Template
    The role of motivations as the suggested cause of addictive behaviour must now be explored. The internal motivations most often cited are coping strategies, escapism, rewarding and self-esteem. While I find this level of thinking to significantly diminish the complexity of substance dependency, I will attempt to conduct a non-judgmental glimpse into these factors.
    It is often stated that substance dependency is a consequence of ineffective coping strategies adopted by the user. In order to properly assess this ideology, one must first identify those coping strategies adopted by non-users.
    I will refer to a conversation I had with an addiction worker while in treatment to help illustrate the point. The interaction started with the gesture of the addiction worker handing me a cookie with a “smiley face” upon it. She stated, “that should help cheer you up”.
    I found this statement to be misleading, so I asked her if she had given any thought to the current situation being experienced by the factory worker who made the cookie, and his relative happiness?
    Her response was that, of course she had not, so I proceeded to explain the flaw in her coping strategy, which is, it is eerily reminiscent of the “flamingo defense”. By “putting one’s head in the sand” and pretending there is no crisis, one is simply engaging in avoidance behaviour, however, the crisis has not been removed.
    I further went on to state that this approach is nothing more than rejecting reality and substituting delusion in its place. Obviously, this is not an effective coping strategy, but rather, an aversion technique aimed at avoiding the issue at hand (e.g. the presenting problem).
    I finally queried why she was of the opinion that she was in a position to give advice on effective coping strategies when she clearly had not devised any of her own?
    She had no response.
    I was by no means attempting to hurt her feelings, I was merely pointing out that if flawed coping strategies were the only prerequisite for substance dependency, we would all be addicts. Further, when considering the severity of obstacles faced while in active addiction (e.g. employment, housing, financial consequences, personal safety, etc.) to the norm, one can easily
    argue that addicts have substantially better developed coping strategies than those of non-addicts, based strictly on survival requirements.
    The concept of escapism is often used to help define addictive behaviour. But is there any strength to this argument?
    Once again, a look at the concept of escapism, through the behaviours of non-users is required. One only need look at the way individuals behave while on vacation to understand these phenomena. Surely, we have all heard “what happens in Vegas, stays in Vegas.” If one expands on this understanding it is easy to comprehend that when an individual goes on vacation, often times, it is not only to receive a break in their routine, as defined by daily activities, but also, to receive a break from themselves.
    We have all witnessed, and likely experienced it. While on vacation an individual will act in ways and engage in behaviours, they would not normally partake in. On its face value, this is identical to what a substance user does, the only difference being, they do not need to purchase a plane ticket.
    Since this behaviour appears to be somewhat universal, regardless of substance abuse, can the concept of escapism be used to form the rationale as a basis in explaining substance dependency?
    If the escapism argument had substantial merit, then anyone who binge watches “Game of Thrones”, would, by definition, be engaging in addictive behaviour. As an addict, I take offence to this notion, as few, if any, wind up hospitalized as a result of them watching too much television!
    Regarding the notion of reward being the primary culprit in understanding addictive behaviour, one must look at the diminishing returns experienced by substance users as their tolerance increases, and the subsequent increase in consequences that follow.
    Likely, every reader understands the affect Dopamine release can have on an individual and have heard this used as an explanation for substance dependency. However, as any substance user can a test, while this may be true on the primary use, it is generally not true on succeeding uses. Simply put, higher and higher dosages are required for lessor and lessor results. If the concept of reward held true, once the user could no longer obtain the desired result, they would simply cease usage. However, this is rarely the result.
    Further, one need only consider the “Thank God It’s Friday” population to better understand the shortcomings in the reward argument. Many individuals “reward” themselves after a week of work and other obligations, by over indulging on a single occasion (e.g. Friday night), however, even if this occasion may occur repeatedly in schedule, for most individuals it
    does not consume the entirety of their lives. While this may be considered substance misuse, it cannot be considered substance dependency.
    A poor approximation of self-worth, or low self-esteem is often cited as a valid understanding of substance dependency. While this may have some value as an understanding of substance use at the initiation age, approximately age fifteen in Ontario, it does not offer much in the way of an argument when considering prolonged substance use until much later in an individual’s life.
    While it is conceivable to consider a youth succumbing to peer pressure in an attempt at bolstering their self-esteem, it is a much less convincing argument when applied to an adult. This becomes especially apparent when considering that many do not live in line with their values while in active addiction, and therefore, the net effect on one’s self-esteem through substance use will ultimately be a reduction in self-worth, not an increase.
    The role of “will power” as an effective means of maintaining recovery is often cited as crucial. This writer is of the opinion that its value is overstated. In this context, will power amounts to nothing more than an individual depriving themselves of what they truly desire. How long can this charade continue before the resistance fatigue wares down their reserves, seemingly depleting them of the resolve to continue down the path towards recovery?
    Often times, not long. Abstinence may occur periodically, but eventually, return to status quo, or active addiction seems the norm. How many readers would consider themselves to be chronic relapsers?
    Many have indicated to me, and I would agree, that substance abuse is done as a measure of obtaining “effect.” In short, heavy amounts of substance are consumed in an effort to gain impairment. If this is true, then the only way to maintain abstinence is to no longer require impairment, not deprive oneself from acquiring it.
    When considering the role of external motivators, the concept of “triggers” is often cited. Two popular explanations are; people, places, things and H.A.L.T. (hungry, angry, lonely, tired). A brief exploration into these ideas will now be conducted.
    The basis for the argument on people, places, things proceeds as follows; avoidance of these factors reduces potentially dangerous situations, relative likelihood of relapse. In short, to improve the odds of maintaining sobriety, aversion is at the forefront. Is there any merit to this argument?
    On its face value, there is not. The simple reason being, an individual cannot avoid living their life indefinitely. While one can temporarily postpone encountering these “pitfalls”, such as when in a residential treatment program, eventually, the individual must return to their daily activities of life. These activities will certainly include, commuting to and from work, employment, relationships (both professional and personal) and all the rest.
    While meeting one’s requirements for daily living, it is inconceivable that person will not encounter people, places, things, unless they live on a desert island in complete isolation. While this writer does not have statistical data relative to survival rates for those attempting to survive in a void, my guess is, the numbers are not good.
    Usually what is experienced by those who focus on external motivators as the principal culprit, is a rather unfulfilling life. The reluctance to attend staff parties out of fear of relapse. The unwillingness to attempt a meaningful relationship. Never spending time with old acquaintances, and the like. The reason I take issue with this approach is that it is not sustainable.
    Further, it seems to suggest a plan of action that every addict knows does not work, namely, a geographical cure. Those who opt for this approach seem to be of the opinion that a change in scenery will rectify the problem. A new city, a new job, new friends will somehow magically change the outcome. The problem with this level of thinking is the lack of acknowledgement of the common denominator in the equation, the individual. Ultimately, the addict is still an addict.
    I will not spend much time addressing the H.A.L.T. (hungry, angry, lonely, tired) argument, as if any of these factors were honestly precipitating factors for addiction, the entire human race would be addicts. This is clearly not the case.
    Substance Dependence Versus Substance Abuse: Similar When Viewed from the Outside
    Up to this point the terms substance abuse and substance dependence have been used interchangeably. I would now like to differentiate the two. This will not be done in accordance with DSM criteria, but rather just through observational relevance and my own personal meandering experiences.
    When considering the substance use continuum as an appropriate measure in exploring an individual’s growth into substance dependency, many assumptions are made, most of which I have not found to be true for dependency, however, plausible when explaining abuse.
    What is rightfully suggested is that as substance use increases, functionality often decreases. also, consequences often grow in severity. However, what is also suggested, is that an individual can create dependency through repeated usage. I find this to be rather suspect and not entirely supported.
    One only need to consider a substance dependent’s (e.g. addict) “first use story” to understand the discrepancy. There is not an internal reason (e.g. internal locus of control) that will ever stop the addict from using, once use is initiated. Only external stimulus, namely, “run out”, “black out”, “pass out”, “kicked out”, “overdose”, “seizure”, “coma”, “fatality” or “handcuffs.”
    Conversely, the substance abuser, may “toe dip” when initially using, and will likely require larger doses to attain the desired effect, however, they often come to a point where they are able to cease usage due to mere choice. Addicts do not “toe dip.” Their first use resembles their most recent use, and every use in the middle.
    If substance dependency were nothing more than an increase in usage, both in terms of frequency (e.g. using days) and dosage required (e.g. tolerance), then by definition, all of those who engage in substance misuse (e.g. the T.G.I.F. crowd) would inevitably become addicts. This is not supported and is obviously not true.
    To better understand the difference between substance abuse versus substance dependence, a more accurate explanation of the metrics used is required. The factors that are generally accepted as those relevant are, consequences, compulsion, tolerance and withdrawal.
    When considering our understanding of consequences, some would attempt to argue that any negative impact on one’s life is enough of a measuring stick to indicate addiction (e.g. dependence). I do not share in this thinking. For substance use to be classified addiction, I would argue consequences must be life altering/threatening, not just inconvenient.
    Therefore, while financial expenditures or relationship hindrance are inconvenient, they are not life threatening. If the definition of consequences as it relates to addiction is “watered down” enough, then any over indulgent behaviour that results in any unwanted outcome (e.g. the weight gain accrued from over eating during the holidays), would be classified as dependency. The problem with this understanding is that it greatly diminishes the harm experienced by those that are actually addicts.
    Gaining ten pounds is rarely, if ever, a life altering event. However, consuming food to the point of diabetes, hypertension, obesity, et cetera, is. Therefore, we must be much more restrictive when using the terms addiction or dependency, or risk them losing all meaning.
    The same argument can be made regarding our method of classifying the term compulsion. In some circles, it appears that the term craving can be substituted. To clarify the difference, as this writer understands it, I will use a simple comparable. A slice of cheese cake is a craving, heroin is a compulsion.
    While this illustration may appear overly simplistic, the understanding of what distinguishes compulsion from craving seems to be misinterpreted by many. What occurs physiologically in the body during compulsion (e.g. rapid heart beat, increased blood pressure, increased visual acuity), does not occur during a craving.
    Once again, the basis for which term is used is directly related to severity. The symptoms of compulsion are those experienced while in “fight or flight” mode and are a reflex of the Automatic Nervous System. They are reactionary and therefore, cannot be learned.
    By contrast, the symptoms experienced during a craving are much less physically impactful, and seemingly, have more to do with the anticipated outcome.
    Tolerance can also have many measures. For instance, an increase in duration or frequency. However, as a metric for addiction, the more appropriate measure is dosage. A larger dose of whatever is being sought, in any single use event.
    One should be able to understand the distinction, but if not, I will attempt to illustrate. By this definition, there are few television addicts. The reason being, those engaged in the behaviour are still only viewing one television set at a time. For tolerance to increase, they would need to move on to viewing two television sets simultaneously, and then four sets, and so forth, in order to obtain the desired effect. An increase in viewing time is not sufficient to equate an increase in tolerance, only an increase in duration. This is why “binge watching Game of Thrones” is not addictive behaviour, only time lapsed.
    Conversely, when considering gambling, the addict will make larger and larger bets in order to feed the addiction. This has nothing to do with potential winnings or losses, but only as an indication of increased tolerance.
    Lastly we will consider withdrawal. As a metric for addiction, withdrawal must have physical parameters. For example, while withdrawing from significant alcohol consumption or Benzodiazepines, withdrawal can be fatal. While the physical withdrawal from opioids is rarely life threatening, it is generally the most physically uncomfortable and longest lasting withdrawal one can experience. Gambling addicts experience an array of physical impairments from sleep disturbances, to appetite suppression.
    Similar effects can not be experienced when “withdrawing” from lack of shopping. In short, there is absolutely no such thing as a “shopaholic”, and any such suggestions, are to diminish the withdrawal experiences faced by those in actual withdrawal. This is why there is no observation area designated for television “bingers.”
    If we allow the terms craving to be used interchangeably with compulsion, tolerance to be downgraded to mean duration, withdrawal to encompass emotional dissatisfaction and consequences to be defined as any inconvenient event as a result of, then we are reducing what addiction is, to nothing more than a generic umbrella term equating over indulgence.
    Therefore, when considering the distinction between substance abuse versus substance dependence, one must consider the requisite biological (e.g. genetic) factors that form the requirement for the condition to exist. Plainly, without the genetic predisposition for substance dependency, an individual can abuse substance without ever becoming an addict.
    This leads to the concept of “drug of choice” (e.g. D.O.C.). I find this understanding to be erroneous. While an addict may have preferences in relation to substance, substitutions are
    very readily made. The concept of choice is dubious, as it is really only an exercise in availability.
    The purpose of distinguishing between substance dependence versus substance abuse is not to diminish the severity of potential consequences caused by abuse. It is merely to allow for a more thorough examination of approaches used for treating the conditions. It is rather easy, both empirically and statistically, to see where current methods used in the treatment of substance dependence do not produce the desired results.
    The fear in grouping together conditions that do not have similar causations nor similar outcomes is that we will continue to attempt non-beneficial treatments by applying what may have a decent success rate for treating one, and a dismal success rate when treating the other.
    Also, a more realistic approach needs to be used when considering what actually can be effectively reduced, namely, potential consequences. At current, there is a general lack of effectiveness when attempting to handle some of the elements associated with addiction. For example, compulsion and tolerance can really not be adequately addressed from a treatment perspective.
    Therefore, we are better served to focus on those elements that can be addressed. When considering consequences and withdrawal, both are better treated when employing a model that focuses on harm reduction and public health, not criminalizing addiction and a continued futile effort at forced abstinence.
    Social Determinants: The Role of Wealth on Substance Dependency
    The belief that economics has a bearing in substance dependency is also sometimes suggested, and likewise not very well supported. All that can be gathered from usage patterns are that those with more financial might may opt for more expensive substances (e.g. bourbon and cocaine), while those with less economic resources may be forced to choose more cost-effective means (e.g. crystal and Listerine). However, the end result is the same.
    I am sure we have all heard of a “bad” neighbourhood as the culprit in substance dependency. In these neighbourhoods substance use is more visible and related crimes (e.g. possession) appear to be more prevalent. However, the increased visibility is often more a reflection of precarious housing then increased usage rates. Those who have stable housing can simply use in the privacy of their own dwelling.
    Also, when comparing crime rate statistics between poorer neighbourhoods versus more affluent ones, it is not that the crime rate necessarily diminishes, only the types of offences change. For example, in wealthier areas the number of car related offences (e.g. D.U.I.) tends to go up. This is likely due to the fact that wealthier people can afford to drive, whereas poorer people cannot. However, it is not a good indication of substance dependency from a statistical standpoint.
    Medical Interventions: Discriminatory Societal Viewpoints
    While taboo for some individuals, advancements in addiction medications have been substantial in recent years and should be touched on briefly. Medications such as Naltrexone and Gabapentin show tremendous promise.
    While the success rates vary from patient to patient, and can be extremely dramatic in some cases, the overall median seems to fall in the fifteen percent range. An overall reduction of approximately fifteen percent when compared to the control group.
    Those figures improve when the overall treatment includes regular exercise, proper diet and sleep hygiene, as well as being coupled with some form of continued after care support program. For those that argue medication is somehow a “crutch”, the only comprehension I can draw from this statement regarding their intent is that somehow, mental autonomy has been reduced to nothing more than a simple choice. Dismissing all other variables (e.g. environmental, social, biological).
    This presumption seems absurdly naïve when one considers the following question, what is clinically distinguishable between severe alcohol withdrawal and schizophrenia?
    The answer; absolutely nothing! So, by comparison, if addiction is nothing more than a moral decision, then logically understanding, so is severe psychosis.
    I have often heard comparables such as, addiction is not cancer. Curious, I can draw many similarities. First, following successful cancer treatment, the patient is not cured, the cancer is merely in remission. Meaning, the disease is not actively killing the patient at the moment, but unfortunately may return at any time.
    The same can be said of addiction, following successful treatment, the patient is in recovery (remission) where the disease is not actively killing them, however, may return at any time (e.g. relapse to active addiction).
    Some attempt to argue addiction does not meet the disease criteria as there is no cellular damage or mutation. Apparently, they have not been informed of Cirrhosis, liver Hepatitis, Wernicke-Korsakoff Syndrome (wet brain), Hepatitis C, “Crack Lung” and collapsed veins, to name a few.
    As a final grasping at straws effort to demean the suffering addict to nothing more than a morally bankrupt individual, who succumb to their own devices, the inference of self-imposed inflictions is used. To which I respond, many diseases are self-inflicted.
    For instance, type two diabetes, many cancers, and all S.T.I.’s. However, all of these individuals get are support and empathy. The benefit of the doubt. While it appears the
    addict, is the one remaining marginalized group in Canada for which it is seemingly socially acceptable, if not outright encouraged, to be discriminatory.
    This brings us to the notion of having to obtain “rock bottom” in order for a treatment to be successful. Since this approach is not used in the treating of any other patient or ailment, one must conclude that those who lobby for it are of the opinion that addicts do not deserve treatment, but rather punishment. Or, put another way, atonement is the cure.
    Think about it, do we, for example, take away a diabetic’s insulin, and then wait for them to lose a foot before deciding that they are worthy of treatment?
    Obviously not. It is this learned understanding of addiction that is the problem. When treatment fails the suffering patient (e.g. addict), we are told to not question the appropriateness of the treatment, but instead, the virtue of the addict. It is as though the belief is that the onus for a failed, misunderstanding of treatment ideology is somehow the sole responsibility of the client.
    The Role of Family Influence: When in Doubt, Blame the Addict
    Family influence, while a touchy subject, must now be explored. How many times has it been suggested, relating to a fractured relationship, that causation equates substance usage?
    This may hold true in a minority of extremely chronic cases, where abstinence may not be possible, but only degrees of harm reduction or abusive cases, but much of the time, it appears that substance abuse is a symptom of causation. The suggestion that the opposite is true is almost as if the non-using party(s) wish to exonerate themselves from any participation or responsibilities relating to the deterioration of the relationship, and in lieu of their involvement, they place blame on substance misuse or addiction.
    This last statement was not made to remove the onus from the substance abuser, as this is obviously a most pressing issue. It is merely to suggest that relationships are continually changing and dynamic in nature and to suggest that one party receives all the blame is not rational. This thinking is in no way going to be of benefit in creating an environment conducive to recovery. This is made no more evident than when the using party ceases use, and the relationship does not improve, or seemingly gets worse.
    There are two statistics that help to verify this point,
    (a) The average age of initiation for drug and alcohol use in Canada is fifteen. The percentage for substance dependence has held remarkably consistent at ten percent since we began to monitor it. This poses two questions,
    I) Why is substance use so prevalent among youth?
    II) Why do the overall numbers for substance dependence, on a broader global scale, not shift in relation to external stimulus?
    One would assume that during times of crisis these numbers would increase dramatically and during times of prosperity they would decrease dramatically. However, this is simply not the case. While there is some fluctuation, it is generally not as dramatic as would be expected and soon returns to the status quo.
    (b) The divorce rate in Canada is forty one percent, with the average marriage lasting approximately thirteen years. One can safely assume that most of these failed relationships did not involve substance misuse or dependence.
    It is fully appreciated why much of the culpability of a failing family structure would be placed on substance abuse, it is rather easy to rationalize. The problem with this approach is that it does not allow for further exploration of the cause and effect relationship between causation and substance dependence. Without a better understanding of this, we cannot expect much in the way of improvements pertaining to the way we approach treatment options. In short, it is very difficult to treat a condition without a full comprehension of what is being treated. Just because B comes after A in the alphabet, does not necessarily mean that B was caused by A!
    Onward and Upward: If It’s Broke, Fix It
    When considering the required changes needed in the treatment of addictions, one need only look at a universally accepted premise of active addiction. The use of the term “insanity” to describe existence while in its clutches.
    “Insanity”, while in active addiction is often defined the following way, “doing the same thing over and over again while knowing the end result”.
    This accepted understanding must also be applied to treatment if one wishes to gain any traction. In short, we fully comprehend what does not work, yet we keep on using these methods. By previous definition, this constitutes “insanity”.
    While treatment is never “one size fits all”, when considering public health policy (e.g. ministry funded treatment), the mandate must be that treatment options best reflect the needs of the many (e.g. majority of clients), not necessarily the needs of the few (e.g. the rarity of clients who succeed using current sanctioned models).
    Since the baseline for ineffectiveness of current treatment has been established, this result warrants exploration and implementation of different strategies. Henry Ford did not stop progress with mass production of the Model-S, for the simple reason, it did not meet the needs of the clientele. Instead, further advancements were employed, resulting in the creation of the Model-T. The only reason stopping such progress is our reluctance, if not out-right refusal, to do so. Change is difficult, which is ultimately why we continue to cling to failed methodology. However, those who suggest they are free of bias, and subsequent loss of objectivity, significantly de-value the influence of their socialization.
    What harm is there in critically analyzing the status quo, if the end results are not on par with expectations?
    Going forward, the approaches that show the most promise, relative assessment and treatment, appear to be the Biopsychosocial Model and the Stepped Care Approach.
    Specifically, the Biopsychosocial Model seems best suited at analyzing why usage has become so prominent (e.g. assessment) and in the event of a relapse, could be used to help identify what behaviors tend to precede a physical relapse. This approach could certainly be incorporated into an ongoing self-analysis as part of an aftercare program, or as an expansion on current assessment tools such as GAINS or ADAT.
    The Stepped Care Approach, is defined as,
    (a) Treatment should be individualized with regards to a client’s needs and problems;
    (b)The treatment selected should be consistent with current knowledge about effectiveness;
    C) The treatment that is chosen should be the least restrictive (considering the physical effects of treatment on the client and the client’s lifestyle and resources). A consequence of the third principle is that more intensive treatments are reserved for more severe problems.
    The Stepped Care Approach is in line with the understanding that one can never tell an individual with substance use disorder what their recovery is supposed to look like. There simply is no “one size fits all” template. If attempts are made to coerce a person, they will simply dis-continue treatment.
    This seems to fit with the belief, as it relates to recovery, that clients are where they need to be, and cannot be made to go any faster, or in any direction they do not want to go, as frustrating as this may be for those individuals on the outside looking in.
    Further encouragement can be found in what appears to be a change in societal opinion away from institutionalization and into the realm of peer support. Many of the issues discussed in this opinion are very thoroughly addressed with in the peer support framework. Individuals do recover, are worthy of recovery and therefore, deserve are best efforts, including advancements in addiction treatment understanding, to facilitate this process.
    One final note that would be remiss if not discussed is that of the current political platform in this province that continues to criminalize addiction. One need only consider the tremendous results from models applied by other nations, including Portugal, German and Swiss models, as a sound frame of reference when reconstructing our own policy.
    Efforts aimed at maintaining a “war on drugs” approach have proven to be ineffective at producing the desired outcome, and therefore, it is our duty to scrutinize such approaches. They are not only to the detriment of the suffering individual, but also, the negative ramifications are felt by all citizens.
    When considering the required changes in social policy, one must recognize the unintended consequences rendered by continuing with a criminalization framework. Two instantly come to mind, first, the creation of the Fentanyl crisis by increasing regulation on Oxy Contin, and second, the rebirth of the “P2P” method for the manufacturing of methamphetamines after prohibiting the sale of pharmaceutical grade pseudoephedrine.
    The resulting consequences are larger in both scope, public health concern, law enforcement requirements and cost than the original problems. In short, the road to ruin is often paved in gold.
    Harm reduction strategies geared towards improving public health, and not towards criminalizing addiction need to be increased, including the implementation of additional safe use sites as their success rates at reducing fatalities and decreasing the spread of infectious disease are well documented.
    Further, when considering the cost of publicly funding such approaches, it is economically the most cost effective, and therefore rational approach that can be used to combat addiction relative the taxpayer.
    I would like to close this opinion with a quote from Albert Einstein,
    “We cannot solve our problems with the same level of thinking that created them”

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