Comment deleted
Expand full comment
Comment deleted
Expand full comment
Comment deleted
Expand full comment
Comment deleted
Expand full comment
Comment deleted
Expand full comment
Comment deleted
Expand full comment

This even-handed analysis is so needed -- and I think it also applies to the movement of people treating psychosis as a "spiritual emergency." Thank you.

Expand full comment

There is totally successful "church, but for athiests"! I, and most of the practicing Jews I know, are atheists, love going to temple and singing, bar mitzvah our kids, sing praise to the lord, honor our traditions, and think that literally believing in god is infantile.

Expand full comment

1. Nice analysis.

2. It's pretty much bell curves all the way down.

3. Many people who claim God is talking to them are, at best, misinterpreting their experience.

4. It would be nice to have some basis, experience, or expertise for claiming there is no God. As someone I respect once said, "That God you don't believe in? I don't believe that God, either!"

Expand full comment
May 25, 2022·edited May 25, 2022

"if you’re desperate enough to join the KKK or your university’s Black Student Alliance"

This is too tasteless for a throwaway "murder arson and jaywalking" joke, too short and off-topic for a serious "what are the implications of some races having much better options than others" digression.

Expand full comment

When it comes to the trans point, one stab toward a compromise:

Part of the question is "how broad is the funnel for prompting intervention" and I *do* think it's too broad. The good-faith reason to talk about introspecting on your gender, framing it as common to be fluid/trans is that you think it *is* common, that introspecting doesn't become a dysphoria-cycle, and that it's better to catch GNC kids early, so they don't encounter stigma/big dysphoria.

Whereas I'd rather offer help to kids who have an issue that is sustained, and they feel meaningfully and negatively impacts their lives. I want to avoid inviting people into the funnel if they're tomboyish or butch lesbians (I'll use Alison Bechdel as my example, since she is a butch woman who thinks she might have identified as trans if she were little now, but likes her life as a butch woman!).

An advocate will be frustrated that I am saying people should suffer a bit to rise to the level of an intervention, but that is the tradeoff I favor (just like I favor not offering routine mammograms to low risk women before 50).

Expand full comment

The whole "Hearing Voices Movement" seems like a different take on the same phenomenon that people with "Dissociative Identity Disorder" ("plural systems") are describing. Is it?

Expand full comment

In the first picture, why is X's twitter username redacted/blurred but his Twitter handle/@ isn't?

Expand full comment

"Alcoholics Anonymous makes an interesting comparison: they’re solving this problem in their own way, by being more conservative and unforgiving than the psychiatric establishment would like.'

A number of recovering addicts wrote to me to tell me that this was the most important part of the recovery culture: that unlike with Hearing Voices, the perspective on twelve step programs is very explicitly that your default/instincts are NOT okay, not healthy, not to be humored or sugar coated. The disability rhetoric that has spread from autism to the broader world of mental health insists that you're fine the way you are. AA and similar say, no, you have to change.

Expand full comment
May 25, 2022·edited May 25, 2022

Yeahhhhh.... the thing is, when I was a child and into my teens, I had delusions. It wasn't hearing voices, but it was something in the same general area and I'm not going into more detail.

"But I thought it would be helpful for him to have people he could talk to about his situation who wouldn’t think he was crazy, or try to get him locked up."

While I too do not want to be locked up, sorry but I *am* crazy. Having [delusions of that type] *is* nuts, bonkers, insane, loopy, lunatic, whatever other term would make the Hearing Voices people need a fainting couch. That's why even when I was having them, I *knew* they weren't real and I told nobody at all about them, because yeah you bet that would have got me labelled as crazy. I sort of trained myself out of having them, but it would be easy to slip back in.

And a movement like Hearing Voices would be the worst possible thing for me: a sympathetic group egging me on to continue and indeed expand having my delusions? That I was special and wonderful for having them? That everyone from doctors to the dogs in the street who said I was a nutcase was wrong and evil?

I would have gone so far over the edge that I would have indeed ended up involuntarily committed in our local loonybin. For some people, who have it together and aren't extremely unbalanced by what they are experiencing, then maybe a movement like this is helpful; whew, I'm not the only one out there with this going on.

But for other people, it would be like handing an alcoholic a litre of vodka and slapping him on the back encouraging him to chase it down with this naggin of whiskey.

Sometimes when everyone says "this is nuts", it *is* nuts.

EDIT: I suppose the snarky part of me is going "Interesting how when the NYT is interviewing people about hearing voices, it's this nice middle-class group of presentable, articulate people and not the homeless person smelling of urine ranting on the street, huh?"

Expand full comment

Section 8 explains so many of the pathologies of our culture…I’ve had thoughts along those lines before, but this really crystallized things. I’d be interested if anyone has any pushback.

Expand full comment
May 25, 2022·edited May 25, 2022

Even if they can be a great place for mild cases (edit: and I'm not convinced they are, see Deiseach), their misguided policies will lead them to take in some severe cases who need medical care, not a support group. Violence will result which could have been prevented.

I don't think that their treatment model is applicable to everyone; I think they think it is; this is likely to have dire consequences. HVM is not ready for what will happen when one of their members tries to kill another, is not even engaging with that as a possibility.

Expand full comment

Interesting to hear your perspective on peer specialists. I’m about to start a practicum placement on a psychotic disorders unit with a few peer specialists, so I’m curious to see how the dynamic among the treatment team plays out.

Expand full comment

Re the pressure to be quirky: I think it exists in parallel with the pressure not to be quirky, maybe in disjoint filter bubbles. Just the other week there was a dating advice thread on DSL where some posters were advising people to be bland and normal and not have any weird hobbies. I spent my teens trying to pass as normal, and am now comfortably weird in a bubble of other weird people, but I still feel intense social pressure to hide it whenever I step outside that bubble.

Expand full comment

Good, balanced observations. I liked Freddie de Boer's article, but you make some good points for looking at it another way.

Nice out-of-the-blue Aleister Crowley quote, too!

Expand full comment

I imagine this post will get a lot of excited responses.

It doesn't feel as balanced to me as it does to you. Of course that may mean that it is balanced, and people on all sides of the relevant issues will be equally certain it's imbalanced, aka doesn't privilege their particular positions. Or then again, it may not.

My experience biases me towards the camp that sees various DSM conditions as often better handled without pathologizing them. I'm personally somewhere on the autistic spectrum, and connected with religious communities prone to ceremonial possession, aka channeling. (They don't just hear voices; they provide a mouthpiece for the speakers, variously conceptualized as mostly benign non-embodied entities.)

I'm also in the weird place of supporting the agitation against Autism Speaks, while at the same time knowing a person who works for them.

For those who don't know, there are two issues with Autism Speaks. First of all, they are a group of do-gooders lacking any autistic representation, which claims in their name to speak for autistics. (They understand us better than we do ourselves, at least in their own opinions.)

Second, they appear to claim that we *all* need to be "cured" and favour a wonderful (sic) treatment called ABA (Applied Behavioural Analysis(?)) which according to autistic activists basically involves "curing" the autistic person by punishing problematic behaviours until they stop. Done sanely, that might be a last resort, used only for dangerous behaviours - such as physical violence. Done by someone desperate to make autistics normal, it's likely to involve punishing a lot more, up to and including everything the autistic wants to do, enjoys, or has available as methods of self-soothing etc..

With humans involved, and the tendency of neurotypicals to project their needs and desires onto everyone else, not to mention the tendency of parent to want their children to be just like them, I'd be sure the bad version happens regularly, even without having encountered people who claim that it happened *to them*.

It's a mess, and I don't know how to solve it. Some people are messed up enough to benefit from help that has really noxious side effects. Or they are sufficiently dangerous to others that there's good reason to restrict their liberty, e.g. by treating them against their will. Others just need people to stop using their kind of person as a bad example, or demanding that they pretend to be a cookie-cutter example of normality. Most need strategies and tools for improved living, whether or not they are considered to have a psychological disorder - but the tools that will work for them won't be exactly the same as those which work for others, and while knowing what they see as problems may help select good tools to offer, a diagnosis is likely to be helpful in selecting tools, as well as in proactively suggesting tools to address problems they might not have mentioned.

If people were rational, those people could get useful-to-them help whether or not we called them "psychotic", "autistic", etc. - i.e. however we defined condition boundaries. But human beings generally aren't rational in that way; we over-simplify any category we define as Other, and thus tend to try the same things for a violent non-verbal child and a somewhat socially awkward child nerdy child that's fascinated with dinosaurs. And when we reclassify the nerd as non-autistic, we then try to treat them the same way as their sports mad, social butterfly classmate.

Expand full comment

You make an interesting point about the relative severities of different peoples' hallucinations. I can admit to having had a couple of them in my life. They were so ridiculous that I knew immediately they were hallucinations. It's absurd for one's dog to walk up and say "Hello."

Knowing I'd had an hallucination was, well, troubling, but it's not as though they have come with any frequency or regularity. They were many years ago, many years apart, and my dog hasn't said a word since. Perhaps it's still upset that I didn't engage it in conversation.

I wonder whether hallucinations may not actually be more common than is generally assumed. Are we just wired to ignore things that don't conform to our expectations? I've seen that film clip of a person in a gorilla suit walking through a basketball game. Nobody ever seems to notice him until he's pointed out.

Expand full comment


I think that hearing voices is perfectly normal. What's wrong is when you think it's someone other than yourself talking to you.

ISTM that wherever I read or write I hear voices saying what's coming in or going out. And I frequently hold discussions with myself about why this or that song is running through my head. If this didn't work, then Mantras wouldn't work at all. (They don't work that well, but they do affect my thought patterns.)

Just sitting here considering what to write, I find myself wordless until a voice in my head starts suggesting the words I should write (and revising itself).

So. Most mental things are gradient in nature. I would propose (without reading any of their literature) that these "Hearing Voices" people are a rather extreme form of the same experience that I have. The problem comes when they stop owning the voices as a part of themselves. Religious history tells us that that can lead to severe problems. So I strongly agree that your suggestion of the Family approach is worth following up. Actually, anything that will get a dialog going should help, but ideally they need to accept the ownership of the voices. This, of course, requires accepting that they aren't just their conscious mind...but I don't know of an author that believes that. (Consider the problem of writer's block.)

Expand full comment

I wonder what, in this context, would you think of the tulpamancy movement? They don't have any relevant psychiatric diseases to start with, but they self-therapy into hearing very well-defined and agenty voices and consider that to be totally normal and accpetable. They certainly don't want to be "treated".

Expand full comment

An obvious fact but one worth repeating is that psychosis isn't just "cleanly" hearing voices, which as described in this post seems like it would often be fairly manageable if that were the only symptom. There are lots of other aspects -- seeing patterns where there are none, trouble reasoning and using language, paranoia, etc.

And the diseases that can cause psychosis also have lots of other bad symptoms.

Expand full comment

I often talk to myself. It's the only way to guarantee a stimulating, intelligent conversation.

Expand full comment

There’s a dynamic in medical self-help movements that they often accumulate people who feel hard done by the medical establishment. It just takes a few people with a grudge and big personalities to move a group from mutual aid to toxicity, in my experience. And most groups have elements of both.

Expand full comment

I have insomnia and sleep apnoea. These occasionally combine to make me very sleep-deprived.

In that state, I hear voices (I last did a couple of years ago, before that was the time my CPAP broke down in 2015). Usually my mother's voice as she sounded when I was about ten years old (not as she sounds now). Usually just asking if I'm OK, or telling me to go to sleep, or scolding me for not going to sleep - in many cases, resulting in it being harder for me to sleep.

This is not a problem for me; I know that the voices aren't real; I know they are caused by lack of sleep; I am usually lying in bed trying to sleep at the time I hear them; they are not telling me to do anything other than sleep. Sometimes I wake up later on, unsure if I heard voices before I went to sleep, or if I had a dream after I did. Other times, I am more clearly awake and hearing voices.

But, as Scott mentioned, I have very carefully avoided mentioning this to anyone involved in my work or family or medical practice, because I am scared that the result will be antipsychotics from the medical people and family, and losing my job from the work people.

This sense that there are versions of all sorts of psychiatric conditions that are basically just a personal quirk and there are versions that are utterly debilitating - and all points in between - is one I think really matters; I would feel a lot safer talking about hearing voices if I could rely on other people treating them as a minor quirk rather than as a serious medical condition.

Expand full comment

Maybe it's because I'm old, but I personally find "quirkiness" irritating. I could spend hours listening to a person passionately expounding on the history of Australian Aboriginal flute-making techniques, or something to that extent -- because I like learning new things, and I admire passion when it is coupled with competence. But if that same person says, "I've read all about Australian flutes ! Tee-hee !", my only response to that is "STFU". I don't care about things that make you feel special; I care about things that make you actually special.

Expand full comment

A nice data point for Scott’s vendetta against the NYT:


Expand full comment

"The worst failure mode is people who handled ... their condition without medication, ..."

This line touched a nerve I have been poking for a while, so asking for advice on the internet. ¯\_(ツ)_/¯

In the last ten years, I have been in psychotherapy thrice, a few months each time, all of them CBT to my knowledge. The first time was very effective, the second was in hindsight ineffective, and the most recent one (TEAM-CBT) seems effective for now. During the last one, I learnt some tools and techniques, but I am starting to have doubts as to what extent and how effectively I can apply them on my own in the future after I will have already forgotten most of the experience.

I have explicitly avoided having to take any medication aka going to a psychiatrist. Mainly because I personally know zero people who had successfully done that -- I personally knew zero people who were in therapy as well but it felt less risky (even at the cost of being ineffective) -- and I worry about some sort of dependency/addiction/side-effects. I agree it is irrational, as I don't think that way about doctors/medication treating physical ailments.

Since Scott has been writing a lot on this subject: has he already written something to address questions like this? Like a primer about psychologist vs psychiatrist, and ways to find one? Thank you.

Expand full comment

Just my very personal take on a little part of this:

In school they taught we'd be peer pressured into fun things like drugs, drinking, sex. The only form of peer pressure I've ever consistently received was pressure to identify in ways that made me easier to label.

For years I was encouraged to seek psychiatric help, specifically to get a diagnosis. This was... ultimately good, and I think some people spoke from a place of genuine concern. But I remain convinced that a lot of that pressure was that people had no idea what to do with a person who didn't have a good label.

Likewise, I continue to be encouraged to take on some LGBT+ moniker. To be clear, I am unquestionably a dude with a boring, conventional sexuality. I'm not stereotypically masculine but I've never felt that I'd be happier identifying as some other gender or "refusing" a gender label by labeling myself non-binary. Frankly I just don't consider my gender an important part of who I am. The same is true of my sexuality. I think people just need that crutch to know how to relate to folks, even when I just objectively do not belong in that community.

But this pressure has significant downsides! When I was first diagnosed with ADHD I was added to all kinds of support groups on social media, got all kinds of positive reinforcement from my friends, and my symptoms became objectively worse. I did not "consciously" decide to play up my ADHD symptoms to get positive attention. I just spent a lot of time talking about ADHD and thinking about the positive attention my ADHD symptoms got me, and somehow, "unaccountably" I found myself acting more ADHD. I brought this up with my friends, and they celebrated it, saying that I'd been masking before, and could finally act in accordance with my nature.

It would be so easy to take that road, without even consciously choosing it. Deferring responsibility, inhabiting a stereotype, and helping the people around me feel better about choosing their most superficial traits, or even their weaknesses as their entire personality.

Eventually I'd get accommodations from a job that feared lawsuits, and they'd quietly note to themselves that I probably shouldn't get promoted or get the good assignments. My wife and daughter would learn to accept less from me. I'd quietly replace all my object-level goals with superficial identity politics. I could enjoy all the benefits of being raised an upper-middle-class white man, while still claiming discrimination and oppression. Ultimately I could replace everything real in my life with words, and spend the back half of my life bitter that those words can't shape reality.

Expand full comment

> Some of these people are your typical homeless schizophrenic, but many aren’t. One of my patients was a successful computer programmer

Sometimes people are both! For some definitions of 'successful programmer', at least. I'm referring to Terry Davis.

Expand full comment

This is exactly why I'm an atheist, and why, despite Scott declaring atheism to be no longer cool, I still think religion is harmful to society. There is such a thing as reality, and such a thing as truth. Magic talking unicorns don't become real just because you, a schizophrenic, hear them threatening to kill you. Gays should not be killed simply because your Bible or Quran says so.

Men do not become women simply by declaring themselves as such and coercing everyone to go along with the absurd falsehood. The world is the way it is, and although I'm certainly not the ultimate arbiter on truth, I don't appreciate being forced to agree to absurdities, because as Voltaire said, "those who can make you believe absurdities can make you commit atrocities".

Expand full comment

I can confirm the rock climbing thing, one major reason I did it was because I wanted a funky activity to put on my dating app bios. Incidentally it's a pretty fun hobby that's deceptively easy to get into and with a surprisingly good gender ratio.

I worry that when both men and women are performatively picking up hobbies they don't actually care about just to appear interesting to each other, Moloch is winning.

Expand full comment
May 25, 2022·edited May 25, 2022

I'm somewhat sympathetic to the view that "drugs suck and psychiatry is bad". I wouldn't express my view that way, but I do think that psychiatric drugs are more harmful than is generally believed (and no, I'm not a Scientologist). My views are based partly on the unfortunate experiences of people who are close to me. But I've also been influenced by the work of Robert Whitaker, and especially his book, "Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America". Whitaker admits that anti-psychotic drugs have a place in treating schizophrenia, but he advocates using low doses over relatively short periods of time. Whitaker's thesis is that psychiatric drugs may possibly work in the short term, but they can have paradoxically negative effects if used over longer periods of time (i.e., they worsen your condition instead of improving it). Here's a link to the Amazon page about the book. Whitaker is a journalist, not a clinician or a researcher, but I find his critiques to be convincing. https://www.amazon.com/Anatomy-Epidemic-Bullets-Psychiatric-Astonishing-ebook/dp/B0036S4EGE

Expand full comment

This piece is so great for so many reasons.

9. I’m adding my two cents to the discussion about transness. The teen years/puberty were dismal for me. Gender has a trajectory; as far as I could tell, “female” meant “will eventually have the process of Olivia Newton-John’s character in Grease,” ie, a socially-mediated larva-cocoon-butterfly experience ending in oneself capable of performing as butterfly.

I could tell that wasn’t happening for me but couldn’t tell why. It was long before the verbiage of gender was common. I stumbled on “Stone Butch Blues,” read it in my 20s, thought “that’s kind of like me” and proceeded to do nothing whatsoever about it. I still did not do “butterfly” very well so did self-destruction instead and wrote tortured poetry, some about gender and expectations.

Would medical transition have helped in my late teens? I think social transition, or better understanding of being non-binary, could have saved years of damage. Medical? Not sure. Pregnancy was terrible but I’m glad I had kids. And as a parent of two boys, one of whom is very, very cis-het, bless his heart, I realize there is a whole fabric of experiences of bodily maleness that I don’t & wont share. The whole crossing the legs versus the testicles thing? Just the beginning.

I think non-binary people with a uterus who date men can track a quasi-straight-female role for a while and have it work fine. I think there’s a lot of value in the lived experience of being outside important categories. I’ve had my nose rubbed in being different so many times I have no belief that that can be erased; I think “trans men are men” erases a whole stage and genre of experiences that are valuable. To society and to self. Am I ever transitioning medically? Doubtful. Should I transition more socially? Maybe. I got called “sir” last winter in a grocery store and then pitched my voice high and the poor kid freaked out. He apologized at least four times and I thought it was adorable. Long way from the days when seeming trans meant getting beaten up, which fortunately I never experienced myself, only saw. But I can’t get on board with the erasure of the outside ness and the transitionality. I don’t expect an Olivia Newton-John moment in any gender at this point. Medicating the kids will medicate away the gray area, which we need. Those of us in the gray need to describe and communicate about it more. I think a broader social recognition of a gender range is really important. Using medicine to group everyone at either end is a mistake. Plus yeah all the weird lifelong side effects. Also what “masculinity” I have is not due to high natural T; it’s right in the middle for a biological female.

Awakening to one’s transness should not devolve automatically into injections. Letting the first switch flip shouldn’t automatically trip the other ten. Gender is being mediated in sociocultural ways that we ignore at our peril if we make every little kid medically transition.

One of the most male-passing people I ever met maintained her very feminine name, never took T, dated men & had multiple kids. These are all real and valid choices.

Expand full comment

You have completely misunderstood the transgender divide.

The actual truscum argument goes as follows: there are two groups, one group of real trans people and a second group of social-contagion sufferers. There is no similarity or overlap between these groups, no "switch" that toggles individuals between the two. The second group is delusional, and it would be nice if they could be prevented from pursuing medical transition in their teenage years...after that, whatever...you be you.

Expand full comment

Is the distinction mild vs. severe, or is it hallucinations+disordered thoughts/delusions+catatonia vs. just hallucinations? Hearing voices is the marquee symptom of psychosis, but also seems like the most manageable.

Expand full comment

Thanks for writing this, this is the kind of article where if I'm late to work because I read it then it is worth it! Some killer quotes. One omission from the discussion of the group thing is Nationalism, but people don't do that like they used to, in the well off West at least who would identify them selves by country of origin in their three word bio on this site? But Nationalism is pre Diamond Age (Stephenson reference), the Phyles he talks about in that book always fascinated me. Partly because there is unlikely to be a country that I'm really in sync with values wise, but there could be a Phyle.

Stephenson was right on about clothing patterns coming back in fashion after HD TV would prevent them looking crap.

Expand full comment

On transgenderism, I think you've misunderstood the divide. There is a group that seems genuinely (I say "seems" because outside perspective can't ever be sure, but I do not doubt it's true) repulsed by their own body and sex, and really wants to change. This has been in existence for quite a while, quietly in the background of society. Estimates put the frequency at 1/X,XXX or less of the population. Recently, riding the coattails of the LGBT movement, far more people are identifying as trans than ever before. This isn't universal, but there are subgroups where the prevalence is around 1/20 (female teens in the UK) or more. That's two orders of magnitude, or higher, more common than any reputable estimation of transgenderism.

To me, it looks very much like the current generation's Goth or Emo. Which meets the criteria that teens are often looking for - not approved by their parents, cool to peers, different from normal. Lots of teens look for that stuff. There are some other elements making it even more enticing, in that you can get adults at school and other locations to call you by whatever name you choose, and often treat you better than they might otherwise. In terms of teens following fads, it's not overly concerning, and most people move on from it as they develop their own identities and become more comfortable with the person they are. The only issue I see with this is that many parts of society want to encourage real trans individuals, and not allow any discouragement (lest they feel even more miserable than they often do already). This impedes the normal process whereby these individuals move on to other styles, but that's more minor. What is a really big deal is that some individuals who are not really trans are convinced that they need permanent surgery and life-altering medications. Then, they have no option to ever really go back. This would be a problem if the incidence was 1/X,XXX, but it's a massive problem if the incidence is 1/XX.

I feel like we need to put gatekeepers back on the process, which used to be standard, and weed out those individuals who are merely confused and quite likely to change their minds later. I doubt that psychiatrists did a great job of this before, but surely better than 1/XX of teenage girls being pressured to get permanent surgery and told that they really are boys and should accept themselves as boys, even if we know that can't possibly be true (at that level of frequency).

Expand full comment

Thank you for this blog. As always, well reasoned and informative.

I found the NYT piece highly upsetting. Encouraging psychotic people to abandon their medication is immoral and irresponsible.

A “caring” therapist convinced my very ill sister to give up her medication early last year. She’s spent the last 12 months in and out of private and state institutions- her admissions have been both voluntary and involuntary. It has been a traumatic and costly journey. Made so much worse by the fact that no one would have been put through this trauma had her therapist not been so irresponsible.

The journalist who wrote the NYT piece and the editor who approved it should have spent time with the families of the people they hold out as examples of people living without their medication - I’m sure their families have a very different story to tell.

Expand full comment

Heard a joke once. Man goes to the doctor. Says he has anxiety. Says he can't even work. Asks doctor about a cure in a week. Doctor says: "Medication does not work in one week, however Great Inspirational Speaker Pagliacci is in town giving a speech about how he overcame anxiety. Go and see him. That might work." Man bursts into tears. Says: "But doctor.. I am Pagliacci."

Expand full comment

Great article but there really is no reason to be so even handed. Psychosis is not equivalent to other differences people may have. Psychosis is equivalent to, for example, having a broken arm -- something in the brain is not working correctly.

1. Almost invariably there is neurodegeneration with untreated psychosis -- MOCA scores fall, SPECT neuroimaging shows a brain getting worse and worse, even structural MRI which is less sensitive will pick up a brain that is in decline

2. The above #1 does not apply to people who may have this or that belief, ie, to the differences between people -- it applies to psychosis.

3. Patients sometimes say things that could be diagnosed as hallucinations but they really aren't (e.g., "my mind keeps saying to check this again two time or else" eg in OCD)

4. Psychosis seems to occur only in humans -- not in other mammals. (Similarly full causal reasoning seems to occur only in humans, not in other mammals.) It is most probably a design flaw, i.e., occurred because of a tradeoff, rather than a typical disease, hence seems to involve not one but thousands of genes.

Expand full comment

As a European, this extreme hunt for quirkiness that you describe seems alien to my experience. Is it an American thing? A Californian thing? Or is it happening in Europe too and I was simply lucky or inattentive enough to not notice?

Expand full comment

"Cheat Sheet For Reading Popular Media Articles About Psychiatry"

There is one to be written about "neoliberalism" but I'm too lazy to do it. :)

Expand full comment

Can you tell us the sorts of things that the programmer's voices were saying?

Expand full comment

"The DSM says that you can’t diagnose a psychotic disorder if someone’s in a cultural context when they’re expected and encouraged to hear voices - which sure does sound like the experts think cultural context can affect whether you hear voices or not."

This sounds a lot more like the DSM being culturally relativistic and not wanting to tell cultures their sacred traditions are actually the result of mental illness, plus the usual "well if it's not upsetting the patient, we can't call it mental illness". I don't think it says anything about whether or not anything is actually mentally different.

Expand full comment

If you command Barack Obama to come to your birthday party, and he doesn't, that doesn't prove he doesn't exist. He's a very powerful person, and he's in charge of what parties he goes to, not you.

However, if you don't believe he exists, and he shows up at your birthday party, you'd have to be deliberately ignorant to keep on not believing in him.

So I'm one of those Christians who has heard God. Hi! Just popping in to say that there are a lot of us and we are the way we are because of being unwilling to deny things that have actually happened to us.

Expand full comment

"if someone had been willing to do this to the original hippies we might have saved ourselves several decades of weird art and dumb politics."

I'm sensing this is lighthearted, but still. Why denigrate the hippie movement like this? There is a major war going on right now and the hippies were the ones whose politics were trying to prevent the US from the Vietnam and Iraq wars. I guess I've got too much love for people who thought they were on a breakthrough of the human condition, only to grow up unable to prevent the sad realities, on their deathbed seeing Trump trying to overthrow US democracy. Basically proto effective altruists.

Expand full comment

On your take on transgender individuals: I'd like to offer some counter-evidence to the idea that being transgender is necessarily a cultural phenomena. For one thing, many (if not most?) transgender individuals describe voicing confusion about their gender when extremely young, for some around the time that they start speaking in coherent sentences. If you want specific examples I'd be happy to provide. This does not seem to be the case with anorexia (and other plausibly culturally-induced disorders), which tend to appear later in life, often during teenage years, when most susceptible to cultural influence. Yes, many transgender people "come out" as trans when teenage, but a number of my trans friends tell me that they tried to tell adults beforehand, but were dismissed/laughed at until they found the right words to describe their experience to others. I know of multiple(!) trans folk who didn't realize that other people *didn't* desperately wish to be the opposite gender, and discovering that was shocking. I think the closest analogue here is left-handedness, which appeared on paper to become vastly more "popular" in the 20th century, but which was mainly due to the stigma against it being removed. For a long while, people were "coming out" as being left-handed later in life, but this was not an internal development on their part! They simply weren't able to share that fact about themselves until they were older and in an environment where it was safe to do so.

(This is tangential, but on a personal note, I grew up without once hearing the word "gay" until I was fourteen or so, having grown up in a fairly insular religious community. This did not stop me from being bisexual, but it did stop me from having *words* for my experience until I was much older.)

For another thing, the majority of trans people I interact with online grew up in *transphobic* households, and in fact most are still not "out" to their family members. This is may be due to small sample size (around 10), but it does suggest that being transgender is not strongly correlated with being in a transgender-friendly environment—while publicly *expressing oneself* as being transgender is.

I have some other thoughts, but this comment is getting long, and I need to go to an event, so if you're interested in hearing more when I have the time to continue, please let me know!

Expand full comment

"Whatever your criteria for a mild case are, there will be someone who fits those criteria, but says the condition ruined their life and you are dismissing their pain. Whatever your criteria for a severe case are, there will be someone who fits those criteria but is thriving and living their best life and accuses you of wanting to imprison them in a hospital 24-7. "

Couldn’t the absence of suffering, absence of endangerment of yourself and others and the ability to manage your life autonomously be criteria for mild cases?

Expand full comment

"People hate admitting that some cases are mild, and others are severe."

They don't hate it: they are incapable of comprehending it. It's an instance of being able to keep multiple incompatible thoughts in mind. It's anti-memetic: they literally forget there is a scale involved right after they admit there is a scale involved.

Expand full comment

This very good article also highlights something that should be obvious without even reading the article to anyone not writing this at 2am, like I am, but yet often overlooked: the metaphor about how transgenderism is something taken up by people, is not a deep part of "themselves" in some kind of metaphysical sense, and yet is very much an extremely important part of who they are, and definitely not something they could walk out of if they wanted to, etc., makes me think that a reason why sociology, even when done by people who acknowledge that they are biased, still makes a lot of people feel uncomfortable, is that people actually believe their own culture, the same way people who took up trans culture really are trans, and certainly feel like they are. Yes, it really is very obvious, but I’ve seen quite a few sociology professors who are at a complete loss when it comes to understanding why laypeople won’t listen to them, and I myself had mostly stopped at "it’s because you make me sound like a crazy conspiracy theorist, you fool!" without understanding it as clearly as this article puts it.

Sorry for the clumsy phrasing and uninteresting content, as I said, I’m writing this half-asleep.

Also, are there people who actually do not bother to want a personality apart from being honest, kind, and the like? I’m sort of almost autistic, and I often feel like that on a superficial level, could people with actual ASD actually be that way, or think they are? And would they be fooling themselves in thinking so?

Expand full comment

> The DSM says that you can’t diagnose a psychotic disorder if someone’s in a cultural context when they’re expected and encouraged to hear voices - which sure does sound like the experts think cultural context can affect whether you hear voices or not. Born again Christians are constantly having what would normally get classified as psychotic experiences - I have asked a bunch of evangelicals who say “God told me to X” whether they actually heard God in a, you know, hearing God type way, and they usually say yes.

Related book recommendation: TM Luhrmann, "When God Talks Back: Understanding the American Evangelical Relationship with God." Her book is explicitly about how religious people cultivate the experience of hearing (or otherwise perceiving) God respond to their prayers. I thought it was quite good.

Expand full comment

Love the post. One thing I will push back on, I think the demand for quirkiness or special snowflakeness depends on your environment. My impression of San Fran is that it is the city of quirkiness. When I lived in DC, quirkiness wasn't important, instead it was connections. Now that I'm in Florida, no one care about quirkiness. Obviously Florida has plenty of quirky people, but more people are happy to just confirm and live a relaxing life. These kind of groups seem to be created in San Fran, then slowly move across the country, with Florida being one of their last stops.

Expand full comment
May 25, 2022·edited May 25, 2022

I get a similar vibe here to the one from polyamory advocates who point to how it works just fine in their Berkeley group house full of wealthy high-IQ computer programmers and insist that it's good for everyone. It's possible that a particular personality type can turn mild psychosis into a plus for their life, or at least not a minus. For most people, though, it's likely to be a disaster, and it's a mistake to broadly endorse groups like Hearing Voices for that reason.

Expand full comment

There is an awful lot to unpack here. I hadn’t read the Times article initially so I had to give that once over. I watched Freddie’s response too.

I’m going to have to re-read Scott’s article before I give any opinions. Probably going to need to read Saul/Paul’s account of the events on the way to Damascus too.

Expand full comment

This disagreement comes about because we have a weird system where some people who get mental illness diagnoses truly suffer from their "illnesses" and find them unrelievedly bad, while some people who get mental illness diagnoses truly do not suffer from them at all. And many people probably see both pros and cons in those characteristics and experiences that get labeled mental illness.

It might make more sense to save the label "mental illness" for only characteristics/experiences that are distressing or disabling, but that's not the world we live in. We don't really have a way to talk about people who are very weird without labeling those characteristics as an "illness." And yes, it is possible to get a mental illness diagnosis without being distressed or disabled by those characteristics. I don't think Freddie gets this. Some of us had diagnosis thrust upon us, and those people are naturally the ones largely driving Hearing Voices, neurodiversity, autism pride, and critical psychiatry in general. But it isn't that those people don't recognize that disabling and distressing mental illnesses exist—but the culture already pays enough attention to them. For everyone who glorifies mental illness and trash talks psychiatric drugs, there are 100 people who think that anyone with a mental illness diagnosis is dangerous and unstable unless they are on drugs and in therapy at all times.

>But the opposite of this are the people who think psychosocial interventions and acceptance are the only possible solution for anything and trash talk the meds every chance they get.

Who are these people who think no one should ever use psychiatric drugs? Cause I've read a LOT of critical psychiatry stuff, and I have literally never heard anyone say that no one should ever use psych drugs. This seems like a straw man. People do point out that these drugs have often very large downsides that don't get discussed or acknowledged very often in most doctors' offices or in the culture at large. (When I asked a doctor about the side effects of an SSRI, her sole response was "eh, you might get drowsy.") But the vast majority of critical psychiatry/Hearing Voices people acknowledge that people can legitimately and reasonably choose to use psych drugs after being informed of their risks and benefits.

Expand full comment

I appreciated this discussion. I think as a culture we have become too tolerant of deviant behavior in public places while at the same time demanding excessive conformity in opinion in offices and educational establishments. The dividing line on medical coercion has to be based on behavior and whether it is harmful to the person himself or to others around him. It's not an easy line to draw but denying that many harmless people hear voices or see visions which don't need to be medicalized is almost as harmful as failing to provide restraint to those who are dangerous.

Expand full comment

Excellent piece, but as I read it, mentally copy-edited this sentence: "Study after study has shown you will be happier if you go to church." Shouldn't it read like this? "Study after study has shown people who go to church are happier."

Expand full comment

I have Aphantasia, meaning I have no mind's eye. When I read a book, for example, images do not ever pop into my brain and indeed until I learned about Aphantasia it never occurred to me that reading text could possibly cause a human to picture anything other than the text. Hearing voices that are not there seems remarkably like seeing things that are not there. Why is the former considered a sign of mental illness while the latter is not? I guess the obvious but unsatisfactory answer is that "the majority is always sane".

Expand full comment

“Right now, our society demands you be a Special Snowflake. Women who aren’t quirky enough are “basic bitches”, men who aren’t quirky enough are “yet another straight white dude”. Just today, I read some dating advice saying that single men need to develop unusual hobbies or interests, because (it asked, in all seriousness) why would a woman want to date someone who doesn’t “stand out”?”

There’s empirical backing for this. In “Don’t trust your gut”, Seth Stephens-Davidowitz writes:

“The mathematician and author Christian Rudder studied tens of millions of preferences on OkCupid to learn the qualities of the site’s most successful daters. He found—and this was not at all surprising—that the most prized daters are those blessed with conventional beauty: the Brad Pitts and Natalie Portmans of the world. But he found, in the mounds of data, other daters who did surprisingly well: those with extreme looks.

Think, for example, of people with blue hair, body art, wild glasses, or shaved heads. Why? The key to these unconventional daters’ success is that, while many people aren’t especially attracted to them, or find them plainly unattractive, some people are really attracted to them. And in dating that is what is most important.

In dating, unless you are drop-dead gorgeous, the best strategy is, in Rudder’s words, to get “lots of Yes, lots of No, but very little Meh.” Such a strategy, Rudder discovered, can lead to about 70 percent more messages. Be an extreme version of yourself, the data says, and some people will find you extremely attractive.“

Expand full comment

I had an interesting experience with a mushroom overdose (described in several of my blog posts below) and it gave me interesting auditory and visual hallucinations for a while (which I have now fully recovered from), so I think that I have an interesting perspective to add to this discussion.





In hindsight, I realize that those were just another aspect of my personality that "split* from my ego, and needed to be reintegrated through discussion and understanding. Now that I'm fully recovered, I don't need to talk to myself out loud, because I've reintegrated that aspect of my personality into my core persona. Nevertheless, it would have been EXTREMELY damaging to my mental and emotional health if anybody had overheard me and attempted to put me on any sort of psychiatric medication against my will. In fact, I would go so far as to say that if anybody HAD tried that on me, I would want to kill those people - not only at the time that they were doing it, but also now that I am fully recovered. (Granted, while I was going through that traumatic experience I would probably have wanted to torture them to death slowly, and now that I am fully "myself" again I think a quick death by firing squad would be more appropriate, but GENERALLY speaking my feelings about this have remained the same.)

I don't think that there's ever any need to medicate somebody for being "weird." As long as they're able to obey the law and their condition is not a danger to themselves or others, society should have no business interfering with them. "Making sure other people feel comfortable" is never a good reason to exercise state control over somebody else's personhood, and people who feel otherwise are simply evil human beings. Nobody has an inherent right to feel comfortable, certainly not at somebody else's expense.

Expand full comment

Has Freddie ever interviewed Scott or vice versa? That would be fascinating.

Expand full comment

"People need personal mythologies. “I am a guy who works a McJob and is bad at it, and that is all I am” isn’t going to cut it psychologically. “I am a guy who works a McJob by day, but my hallucinations give me a higher level of insight into the problems of the world than all these people who are superficially more successful than I am” is just healthier, as long as it doesn’t get taken to a grandiose extreme."

This phenomenon is nothing new. Henrik Ibsen's famous play, from 1884, The Wild Duck, examines exactly this topic. There is even a supporting character, who is said to be "daemonic". We never really learn what this means, but it's dark and mysterious and he is apparently proud of it. I imagine him as the 19th century equivalent of a Hearing Voices member. At the end, we learn that one of the main characters, who is a doctor trying to help people in any way, encouraged his pride in being a mysterious daemonic figure:

"What the devil do you mean by daemonic! It's only a piece of gibberish I've invented to keep up a spark of life in him. But for that, the poor harmless creature would have succumbed to self−contempt and despair many a long year ago. "

Expand full comment
May 25, 2022·edited May 26, 2022

Oh this is too convenient

I've been thinking recently about DID systems, and how the people who experience a non-singular life may be better suited for thinking through concepts that are difficult for a persistent individual ego.

To that end, I was wondering if it would be beneficial to group many such DID systems/tulpamancers into a society, where they could live in a way that was compatible with their internal experience. In human society, it's basically mandatory that you structure your life around a single ego, even if you have to fake it(SSN,Bank account, Passport,Lease, Etc). What observations would these people be able to make if they could live life in a way structured around multiple egos, where they wouldn't have to act as chameleons half of the time? I bet they could come up with some interesting stuff.

What I have in mind is something reminiscent of Castalia from 'The Glass Bead Game'. A class of thinkers sponsored by the state to maintain, advance, and disseminate a tradition of knowledge. A similar example from fiction would be the Keepers from dath ilan. Honestly, I think the benefit of such a society would far outweigh the costs, even if it only ended up providing insight into these mental states.

Expand full comment

The cases on the edge are interesting. We no longer consider synasthesia a form of hallucination and instead view it as a sensory quirk. I hear music in my head all the time which is intense enough that I sometimes have telling whether there's music playing in the next room or it's coming from inside my head, and differentiate by checking if I can control the music at all, which I can moderately if it's coming from inside my head but not at all if it's external. In practice it's much more common that music which I assumed was all in my head was actually playing than that I thought something was there which actually wasn't. I don't identify this as hallucination. I think of it as simply intense imagination. But something which was either more intense or happening to a person who wasn't completely clear that the music was imagined might unambiguously qualify as hallucination.

Expand full comment

Many Thanks!

Expand full comment

Nicely done.

Expand full comment

If you've ever used DMT, it seems to become obvious that the human brain can easily 'rephrase' any sensation or idea to fit through entirely inappropriate bits of its architecture - including 'entities' that seem to be formed from plugging random abstract categories into whatever machinery you normally use to model the behavior of other people or animals. Some portion of the contents of our dreams may be similar to that phenomenon. Which makes me believe that at least some of the 'voices' cases stem from disrupted connectivity between other regions whose traffic simply ends up accidentally rerouted through 'hardware' responsible for speech recognition. Mild cases are probably a lot more humane to leave alone rather than treat with antipsychotics, smashing that channel as well. Makes me wonder whether if this were better understood it could be that trying to restore the original connectivity via something like repeat directed TDCS along the intended pathway would be seen as the proper thing to do rather than damping every single connection in the brain to get at a single glitch.

Expand full comment

Very minor tangent. I have never other than here seen the word “woo” used to refer to (I take it) new age nonsense or the like. Is that usage, which is different from the ordinary meaning of attempting to obtain reciprocal romantic interest, (a) a common meaning that I have just missed, (b) a regional meaning from the west coast, or Michigan, or wherever, (c) a meaning that is distinctive to the “rationalist” community or some other group, or (d) an idiosyncratic usage by Scott?

Expand full comment

Thanks NYT, for without you I never would have found this blog!

It is so amazing these days to meet a truth-seeker, who in good faith tries to investigate two sides of a contentious and polarized subject, and tries to reconcile them (not for one, but for two contentious subjects!). Thanks, Scott.

I was seeing a psychiatrist a few years ago. After 10 sessions or so, to my surprise, I was the one who brought up meds, not him. We had a discussion about several options, I choose one and have been taking them ever since, and they make my life better. I don't like to put some chemical into my body daily, but hey, what can you do? Life is a game of trade-offs...

Expand full comment

There are some great pieces I'd normally want to dig into, but overall this article is simply to uncohesive, uninformed and tasteless around a sensitive topic.... My tipping point was when Scott called IFS "woo-y" whilst speaking in a myraid of other assumptions and rather absolute statements.

This is your blog and your perspectives are yours Scott, and mine include using IFS and acupuncture to recover from severe physical and mental developmental trauma without medicine, and then become a mental health professional to help other patients find their path to healing. I'd be curious to talk about mental health when your perspective has been informed by a broader set of perspectives... or can at least hold back on the callousness that was in this article.

Expand full comment

Makes me think of college application essays. In order to be admitted here, write an essay on all you're grateful for in your life.

No wait, it's always the opposite. Whoever can best list their grievances gets in.

I'm not sure this focus is the best thing for developing life strategies.

Expand full comment

Kay Redfield Jamison approaches this question in 'An Unquiet Mind' (1994), and 'Touched With Fire' (1996). She recommends a combination of chemicals and therapy for symptoms. I believe she's a therapist. So, no magic bullets there, but she does cover the idea that quashing a little madness may also arrest any savant-ish 'genius' that often comes with it.

Civil service agencies frequently acknowledge 'personal' days, in addition to sick days, only obliquely suggesting they might be important. With all the disinformation, war, and disaster in play, we really need to recognize that mental health is physical.

Expand full comment

>My starting point for any discussion of this, which I feel like it’s really hard for a well-informed and well-intentioned person to disagree with, is that at least some large subset of transgender people aren’t consciously faking it. That is, they genuinely have the experience of feeling like they are the other gender, they’ll be absolutely utterly miserable if forced to live life as their birth gender, and telling them “no, just snap out of it” will not work, at all. I think it’s hard to know transgender people closely without coming to this conclusion, unless you have some kind of really galaxy-brained take beyond my ability to even imagin

>So what’s left for the people who believe transgender is a “social contagion” or about “special snowflakeness”? If I had to steelman their position it would be something like: there’s some switch that can be flipped by social pressure and wanting to look cool. Once the switch is flipped, you’re transgender in some pretty real way: you’re not faking it, and you’ll be miserable until you’re allowed to gender transition. Still, being transgender makes people worse off on net, so society should try to avoid flipping that switch.

This is not a good steelman I don't think. It's difficult to distill the issue I have with the trans movement into one argument because the trans movement is really four or five different and mutually incompatible movements in a trench coat. When I try to steelman the trans movement I end up with something reasonably close to what I believe was called transmedicalism, the idea that there is something akin to body integrity disorder that some people unfortunately have where they experience extreme dysphoria at certain body parts and desperately want to modify those to reduce their pain. I find that steelman pretty strong and difficult to go after but it's a motte to a "Gender bailey".

In the "Gender bailey" we go from the fairly difficult to mis-selfdiagnose symptoms like a terrible urge cut off parts of your body that feel wrong to some fairly squishy claims of some essential soul like feature that people have access to which informs them of their proper social role, and these social roles seem suspiciously like sexist caricatures. My issue with trans social contagion/snowflakeness is that when I put myself in the shoes of a kid today, or just my own shoes from a couple decades back, and I try to seriously answer the question "am I transgendered?" I can't see how an answer either way can be falsified. Even taking the assumption that there is a thing to "feel like a man" or "feel like a woman" we are each only endowed with one of those states and have nothing to compare our state to in order to categorize it. So kids are going to fall to second order things to answer this question. Many kids who are going through those awkward puberty times who would have gotten through and been better off for it might take the totally ordinary confusion and angst as evidence that their problems are caused by their gender.

Kids make stupid things their identities all the time. When I was very young my family went to a restuarant that normally served chicken tenders that I loved but for whatever reason they were not able to produce them. So my parents tried to get me to have a burger instead. In the petulant way of children I, being quite cross at not getting my favorite meal, declared that I hated burgers(which I had never had before). And for many years after not liking burgers was somewhat of an identity marker that I, to my embarrasment today, took seriously. Kids will latch on to anything as an identity, if you give them one that comes with a community and a tool like being able to call anything against you 'transphobia' I don't see how kids aren't going to fall hard into that identity group. I'm almost certain I would have as I had my own feelings of not fitting in with the other boys. And that's really where my objection to the trans kids phenomenon lies, I'm absolutely terrified that if I was a kid today I would have fallen down that rabbit hole and I worry for all of the kids like me today who are going to end up permenantly altering the course of their lives.

Expand full comment

My father has been involuntarily and continuously in a psych institution since I was 8 and he was 36 in 1993. Schizophrenia with Christian-themed hallucinations that he thinks are real. He thinks he can channel the spirits of Jesus, Joan of Arc, Leonardo da Vinci, etc. He complains of his freedom of religion being violated by the institutionalization. Every time I see him he asks me to contact celebrities or congressmen to pull the right strings to get him out of there. Often he's too medicated to even get out of bed to see visitors, but when he does get out of bed he's doing elaborate rituals to combat demons and hatching plans to get out. Once in a while he gets better enough to go to a sort of on-site halfway house, and then relapses and goes back to the psych ward. He still beats all the staff at chess.

He had an acrimonious divorce from my mother in 1990 and then made a good living flipping houses for a few years. He went to some sort of convention for "clairvoyants" in 1991, which sounds like a predecessor to the Hearing Voices movement. He met his second wife there. The details of how he got committed in 1993 are still unknown to me, but it involves being convicted of arson. He complains of his second wife being possessed by demons shortly before the episode, which probably means they got in an argument or something. No idea if the arson was intended to hurt anyone or was just an anti-demon ritual or an insurance fraud. The cultural context that told him his hallucinations were real and important spirits probably made him a lot worse through making him not want to take his medication properly and more likely to act on the hallucinations. (He probably also got some chemical induced brain damage from repainting / remodeling many houses.) Being his biological son gives me a ~10% base rate of getting schizophrenia but since I'm 37 years old with no sign of it yet that updates down to below 1%.

Expand full comment
May 26, 2022·edited May 26, 2022

The half-dozen times I've smoked weed over the years I've experienced what I believe is much like schizophrenia: what starts as my interior monologue quickly shifts into a slightly different voice which I realize I'm not in control of, and it scares the fuck out of me to discover that my interior monologue "isn't me". The moment I realize I can't control that voice a new interior monologue begins overlapping the previous one which is now another voice, and then that interior monologue turns into another voice I can't control, and another starts, and so on and so on for hours. It terrifies the shit out of me. The voices don't tell me to do bad things, but they terrify me because it feels like someone else is doing the thinking in my head, not me.

Luckily, the cure for me is to not smoke marijuana. But I feel massive sympathy for those who can't control voices in their heads.

Expand full comment
May 26, 2022·edited May 26, 2022

This spurred a thought which is a small sidetrack - Effective Altruists have a self perception that not only are their ideas are weird, but that they themselves are personally weird. In my experience, EAs are not really that weird? My picture of the median EA is someone who dresses in casualwear, needs a haircut, works a 9-to-5, gives their money to charity, tweets about current events, goes to little houseparties where talking takes precedence over music, and gives a bit of side eye to those rationalists they get lumped with (who are some real weirdos, let me tell ya). When everyone else is jockeying to stand out by being weird, EAs seem to be the weird ones out for trying to move in the opposite direction! Or, maybe it's easier for everyone in a social circle to all pretend we're all unusually weird together so nobody has to admit that none of us are actually that weird, in which case we'd have nothing to bond over. In that case sorry to fellow EAs for blowing our cover.

Expand full comment

> Still, being transgender makes people worse off on net, so society should try to avoid flipping that switch.

Says who? Besides you could use this same logic about LGBT people to justify abhorrent laws like Don’t Say Gay in Florida. And in fact, that is exactly what’s happening. I’d argue that trying to prevent the switch from being flipped is far worse on net, leading to a host of concrete terrible outcomes for transgender and LGBT people. If a few guys who wouldn’t have become a girl, become a girl… that’s the price of freedom. That’s what I’m told after every school shooting so gun nuts can keep their weird hobby. At least transgenders don’t massacre crowds of people on a regular basis.

Expand full comment
May 26, 2022·edited May 26, 2022

"We can admit that you don’t need a “personality” beyond being responsible and compassionate."

A passionate secular "Amen!" to this!

Re. the man who wanted to overcome his anxiety in a week, I think that if he was coping with his anxiety enough to be functional, he should have given a talk on how he coped with his anxiety without overcoming it.

Re. Scott's transgender dichotomy, there is another dichotomy in play. Last year, I was picked up at a party by a trans woman who didn't tell me she was trans until shortly before we reached her bed. We had a long conversation then, and she said, with sadness and bitterness, that she avoided the trans community as much as possible. She had been born intersex, and lived as a man for a while, but decided (partly because she could never match the masculinity of her macho older brothers) to become a woman.

She actually wanted to be a woman, and /worked/ at becoming a woman. Then in comes the contemporary trans activist community, saying (for the most part) not that men can become women by taking on the female gender role, but that gender roles aren't "real", and so a man can identify as a woman without bothering to act out female gender. A lot of what she saw in the new trans community was former men who had felt like failures as men, and didn't really want to be women; they just didn't want to be men anymore. But they thought that not being men meant they were women. They didn't know that being a woman is more than having a woman's name and wearing pink.

In other words, they felt that being a man was hard work, but being a woman was not. And she felt like this was shitting on all the work she had done to learn femininity after adolescence, and insulting all women, cis and trans, as being nothing but inferior un-men. She cried while telling me this.

So where Scott describes a dichotomy between trans people who are happy changing genders and people who probably shouldn't change genders, she saw a dichotomy between people who actually change genders, versus people who identify as a gender without adapting that gender role, and really want to destroy the concept of gender. They want to stigmatize the gender performance and personality she had worked so hard to internalize and embody.

And I wonder how highly correlated these two dichotomies are.

Expand full comment

Loved this one! Thank you

Expand full comment
May 26, 2022·edited May 26, 2022

This is relevant to a few comment chains above, but it's also relevant to the main post and it would be a bit obnoxious of me to post it 5 times, so I'll put it in a top-level comment.

I'm ex-trans, and in the full sense of "had gender dysphoria, full phantom-limb, and it has gradually but almost completely abated".

So I'd go further than Scott's steelman and say "it is possible to be gender-dysphoric and honestly want to transition, and yet for transition to be a bad idea that won't help".

EDIT: If there's one thing that would really clear up the mess, it's a full RCT of transition therapy. That is, you take 5,000 people who say they want to transition, transition 2,500 of them, tell the other 2,500 they're just confused and should get over themselves, then follow up in 20 years and check life outcomes and happiness. Good luck doing that these days, but RCTs are the only way to avoid Aslan's old dictum that "no-one is ever told what would have happened". You'd probably want a bunch of pre-registered subgroups so that you could verify, after the study, that X criterion is actually relevant to whether transition is warranted.

Expand full comment

This post is bad.

People should not be put on risperidone for having spiritual experiences and wanting to tell people about them. At all. I don't know why you thought that was a reasonable thing to say. Please do not put people on risperidone for having positive experiences that are meaningful to them.

If any other crazy people are reading this, please know that Scott, although better than average at respecting the humanity and self-determination of people who seem crazy to him, still will throw you under the bus like this.

Also, antipsychotics are known to cause significant decreases in brain volume and cognitive function, even after the meds are discontinued. Citation: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7758211/

Expand full comment

The NYT article which started this off reminds me of one I read in 2011: https://www.nytimes.com/2011/11/26/health/man-uses-his-schizophrenia-to-gather-clues-for-daily-living.html

I hadn't noticed it was part of a series back then: 'Lives Restored: This is the fourth article in a series of profiles about people who are functioning normally despite severe mental illness and have chosen to speak out about their struggles.'

Expand full comment

I kinda assumed that as it becomes more mainstream more people will "catch" being trans but that doesn't seem so bad. Yes, gender dysphoria seems bad, but I figure that as it becomes more common and appealing it will start to simply blend into a general kind of non-conformist sexual and gender expression. I mean, when I first started running into people who were trans they were almost all fully medically transitioned. Now, I seem to run into far more people for whom being trans seems to mostly be about hiding their breasts or otherwise refusing to conform to gender stereotypes in a way that's frankly pretty mild but for the name.

And I'm hoping that this will moderate out the whole thing. I can't prove it, but my hope is that not only does this create greater acceptance for those that would feel deeply out of place in their birth gender regardless, but, also, by making it less of a big deal with basically make being trans kinda like being goth/punk/whatever (while also reducing the focus on medically transitioning).


I'm much more worried about the rhetoric about how it's innate and the implications that they have the other gender brain. Not because I even disagree (I'm skeptical it's that simple but don't know), but, rather because it creates an excuse that's the one special reason we have to be compassionate to people who are different in this one way but don't have to do so for all the other weird people.

Expand full comment

This Hearing Voices movement sounds like the start of a bad positive feedback loop.

Contrast with AA's firm negative feedback loop.

Expand full comment

I understand the idea behind maximum compassion and all that, but I am looking at this picure and I can't shake a feeling it makes no sense:

1. If you feel that your neighbor have been replaced with a hostile alien robot, you get medicated and maybe compulsory hospitalized

2. If you feel your left hand has been replaced with alien computer that serves as a beacon for alien invasion, you get medicated and doctors try to do their best to dissuade you from cutting your hand off and throwing it into a volcano (how else would you destroy an alien computer?!)

3. If you hear voices that instruct you to do things, you are medicated (or at least told to get medicated). Unless you either hide it or proclaim you are a member of an official religion and the voices are voices of God, in which case you are lauded and considered blessed.

4. If you feel your body is of a wrong shape and you need to stop eating until it is shaped correctly, you're anorexic and need to get medical help to start eating again.

5. If you feel your genitalia are of a wrong shape and need to be cut off or reshaped, you are stunning and brave and any doctor that is not rushing to help you to cut them off or heavily medicate you to "affirm" your feelings - even if you're a pre-pubescent kid whose opinion has zero value in any other case but this one - is a nazi bigot who should lose their medical license as soon as their bigotry became known. Also, anything less than enthusiastically embracing the fact you already *are* of the gender you feel like means the non-believer is a violent nazi who should be shunned, shamed, fired, and probably physically beaten or shot if one can get away with it.

Did I get any of it wrong? If not, should it make sense to me?

I mean, in none of these cases people are "faking" it - they may be genuinely believing it, even if the environment, as Scott pointed out, may have triggred the specific form of expression. But in some cases we think it's a medical issue which has to be dealt by professionals - with maximum care and attention to the patient, of course, and all that Scott mentioned - but as medical issue. And in other cases it's a public civil rights issue where holding a wrong opinion about it gets you physically attacked and societally destroyed. How does this work?

Expand full comment

Next they're going to tell us that furries should get to use the same water fountains as the fur-less.

Expand full comment
May 26, 2022·edited May 26, 2022

"a maximally compassionate policy would involve both trying to support people who are already transgender, and trying to prevent the switch from being flipped in people who aren’t transgender"

*endless screaming*

This is not a middle way, compromise position. This is an extreme transphobic position. Women who express beliefs far less extreme than this one are constantly threatened with rape or death.

That you could be a TERF without realising it is odd; that you are to TERFs as Pol Pot is to communists, while still considering yourself a reasonable centrist, is bizarre.


I should clarify that I'm using TERF and transphobic as descriptors rather than insults; I don't think the first is an insult, and I'm increasingly unsure about the second.

And I'm sure you don't need advice from me, but as a therapist you have to be really, really careful about this stuff. This quote, plus one session with an activist determined to misrepresent you, and you could be accused of attempted trans conversion. Your last experience with the media was unpleasant, but your next one could be much, much worse.

Expand full comment

This reminds me of a bizarre conversation I had with my doctor and the student shadowing him last week.

We were discussing the annual testing required after my weight loss surgery ten years ago (I lost 100 pounds) and a recent return of the polycystic ovarian syndrome that went away after my surgery. I asked if it had potentially been triggered by the 20-ish pounds I'd put on over COVID, and my doctor said, "Yes, probably. Losing even just five or ten pounds would probably resolve it."

He went on to add that there was a medication that might help, although it had some potentially nasty gastrointestinal side effects.

I said something like, "I'd rather not do medication if lifestyle change is enough. I'll get back to being more disciplined about my eating. That'll be easy now since my boyfriend dumped me and I'm not frequently going out to yummy restaurants with him anymore."

And then my super-yoked, super-fit doctor, who looks like a Men's Health Magazine cover model for living your best life after 55, said (I'm guessing for the benefit of the student?):

"You know, there's been a movement saying that we should be thinking differently about weight. A lot of doctors offices aren't weighing patients at appointments anymore, or discussing weight at all. Weight loss surgery, especially, is increasingly being frowned upon as an unnecessary intervention. Any thoughts on that?"

And I replied:

"That's really horrible. The extra 100 pounds I was carrying caused a ton of physical issues, including PCOS and a total lack of libido. My life is so much better post-surgery. And I never would have managed the weight loss with diet and exercise alone; I simply didn't have the willpower to consistently stay on a healthy diet, because I could always indulge 'now' and diet 'later.' Only the threat of immediate consequences, like having a bad surgical outcome, or feeling really sick after eating too much, were ever going to motivate me to make the right choices. I'm so much happier today. I feel so much healthier, have so much more energy. Those advocates are idiots."

And my doctor exchanged a look with the (similarly fit, athletic-looking) student and said, "Now isn't that an interesting perspective?"

Hearing Voices, transgenderism, Healthy at Every Weight...these feel like orthodoxy competitions filling the void left by the abandonment of organized religion.

Expand full comment

"I still remember a patient who asked me if I could cure his anxiety within a week. I told him absolutely not - medications take a few weeks to even kick in, and managing anxiety can be a lifelong process - and why did he need a cure in a week anyway? He said he was an inspirational speaker on the topic “How I Overcame My Anxiety”, and he had a speech scheduled next week, but was too anxious to work on it."


Expand full comment

Just a quick personal anecdote on IFS: my current therapist, who considers himself primarily a CBT/Rationality therapist, dabbles in IFS. When he first described it to me, he prefaced it with "I don't really understand why this works or how it works and it seems a bit crazy and unconventional to me, but this does seem to really work for some of my patients. Wanna give it a try?" My initial thought was that it would definitely not work for me, but that since we didn't completely understand why many medications work, why not give it a try and humor him.

The issue was personal and I won't go into details here, but basically, I found myself talking (internally) to a younger, more confident version of myself. It was arrogant and full of BDE (Big Dick Energy!) and I had gradually put this side of myself away as I grew older, got married, had kids, and ran a small business. But that part had never gone away and was actually mad about the second-class status it had developed. It wanted more time on center stage and wanted to help me with the issue I was having. With my therapist's help, I integrated this now mostly dormant part and it basically solved a long-standing issue.

I'm throwing this out there, primarily for Scott, but potentially for others in the therapy space: you and your patient can both be skeptical of how IFS works and it can still work. I've since used it both with my therapist and by myself with lots of success. It can be really helpful to see the different parts of yourself as having needs and roles and once you understand where they came from and what they are doing (a basic tenet is that there are no Bad Parts - just unintegrated ones), I was able to feel like a more whole person.

Expand full comment

I think that you are absolutely right about people with "mild" cases being in denial about just how problematic it can be - and also that some of these people are not, in fact, mild cases, and in fact, are hurting other people by pulling them into unhealthy psychosis.

I do agree that there's people who can probably hear voices and be fine. But I also suspect that it is really not so good for you, as you are on the edge of a serious psychiatric condition.

The trans movement feels much the same way in some ways, though to be honest, the thing that concerns me the most about gender dysphoria is the fact that none of the treatments for it have undergone proper clinical trials for the treatment of gender dysphoria.

And I am deeply suspicious of this fact.

Pharma companies are pretty infamous for evergreening patents and "reinventing" medications to make more money. On top of that, if you can have the Only Clinically Proven Drug for the treatment of gender dysphoria, you can potentially corner insurance markets and government support by saying that you are the only medication proven to help these people. There is a lot of money to be made there.

The fact that these companies aren't pushing clinical trials for their drugs so that they can be approved and corner this market makes me suspicious that they don't actually think that hormonal therapy actually works at all.

There's also the whole trans movement that is basically a nasty religious sect that attacks anyone who dares to contradict their core doctrine, but that's not really a problem with trans people but a group of them that are, frankly, pretty gross. The degree to which they've hijacked the gay movement is also not great, because gay people struggle to get equal rights in many parts of the world, and I think this particular sect is detrimental to that goal.

I worry about the same thing with all of these groups. The "pro-autism" groups seem to think that autism is a good thing, when it is pretty obvious that these people have a lot of problems. This group feels like it falls into much the same domain. All of them claim the mantle of human rights but what they want often denies rights to other people, and leads to worse outcomes. for them.

Expand full comment

"at least some large subset of transgender people aren’t consciously faking it."

Find me someone who believes that the 15 year old girl who just got her breasts removed is consciously faking it. To a second approximation, nobody believes this.

"Once the switch is flipped, you’re transgender in some pretty real way: you’re not faking it, and you’ll be miserable until you’re allowed to gender transition."

But this doesn't follow: that poor girl would have been fine if she'd just been forced to wait a while, or maybe she would have gone for they/them pronouns and left it at that (a vastly better outcome, imo).

"a maximally compassionate policy would involve both trying to support people who are already transgender, and trying to prevent the switch from being flipped in people who aren’t transgender yet."

I mean, duh? Most elected Republicans hold this position. That is, most don't want to take away Buck Angel's testosterone, or Blair White's estrogen. My guess is that most elected Democrats probably don't want the 15 year old's breasts removed either. So Scott is acting like this is some impossible compromise, but if we can just tamp down a few crazies we're already there.

Signed: a bog-standard Republican.

Expand full comment

I must say that switch flipping theory sounds very improbable. Why would it work only in one way but not the other? Why can you make presumably cis people trans by some groups of people being openly supportive to transness but can't make trans people cis even by full blown conversional therapy?

But even if we accept it as equally possible, wouldn't the obvious and much easier solution be to just let trans identities be normalised as fast as possible? If being trans isn't a forbidden cool thing but just a regular way of being there is no pressure to "flip the switch". No need to develop a sofisticated policies when to encorage transition and when to discorage it, no need for high accuracy tests for real transness. Let's just stop waging a culture war over it and there will be much less casualties.

Expand full comment

Nice Diderot reference in there.

Expand full comment

This style of free wheeling switching between topics is fun and entertaining. Kind of like a discussion between old friends around a campfire where topic come and go based on input from individuals with shared similar experiences.

But, I think that the Hearing Voices and Gender Dysphoria are such important and serious issues that it might have been better to treat them in separate essays.

The Special Snowflake issue seems a lot less important but it is interesting and could have served as the topic of its own fun but less serious post.

Expand full comment

I enjoyed this a lot, a great article.

But just throwing out one thing, the level of nytimes bashing felt a little jarring, especially in light of the "because I’m balanced and reasonable empathetic to both sides" description. I get there are personal reasons for this, and I agree there are a lot of articles with odd framing and questionable decisions, but I also thing the times is a valuable american institution doing work non else can or will. Maybe it's worth an attempt at empathy even for the nytimes.

Expand full comment
May 26, 2022·edited May 26, 2022

Jumping on the trans wagon, I read Scott's post and the other comments carefully, and I feel there is a hidden assumption that exists here that requires naming: What is so socially bad about gender transitioning that we require people to be miserable before we allow them to make that choice?

It seems that people hold the view that staying in one's assigned gender is somehow morally better, and to transition requires special circumstances of misery such as gender dysphoria before it becomes socially legitimate. This is comparable to the pro-LGBT argument that because people were born that way and cannot change their sexual orientation, then we as a society must begrudgingly accept them (rather than simply allow people to be attracted to whoever they desire at the moment, without needing any predefined neurological justification for that desire to be accepted by society). Yes, many gender affirming surgeries are painful and dangerous, but so are cosmetic surgeries, and we don't require people to suffer before we make those socially acceptable. Why do we require misery for breast removal but not for breast enlargement? Shouldn't we allow everyone to change their body, gender, and pronouns as they see fit, similar to how we allow them to change their appearance?

I find this assumption and the subsequent requirement problematic for the cause of trans acceptance. While they do help some people accept gender transition and same-sex sexual orientation, they also prevent the same people from accepting those who don't fit the special criteria: people who are fluid about their sexuality, or people who have a slight, non-painful preference to be of another gender (or not to conform to gender at all, while also changing their body in the process). I want to challenge this view, and believe it will some day disappear like the "born this way" view also all-too-slowly disappears, allowing people to be who they want to be without need for neurological justification.

Expand full comment

Some meta-commentary: apparently, even if only a small part of a post discusses "trans" issues, the majority of the comments will be on the topic. Or at least a majority of the vitriol in the comments.

Expand full comment

I say this often, but this might be my favorite post from Scott ever.

Expand full comment

Regarding people who here voices. I’m still thinking of the rank and file of the Abrahamic big 3 - Judaism, Christianity and Islam - that are fine with prophets receiving messages from God as long as it occurred in some hazy past, but regard direct experience of the divine in their own time as a mark of insanity.

Saul had an experience on the way to Damascus that made him a key player in establishing the largest religion in history. If you accept this at face value why would you be skeptical of a 21st century update?

Or one from the 19th century. More traditional Christians are pretty skeptical of Mormonism, but why? Because the revelations came after the invention of the printing press?

Cardinal on the phone to the Pope: “Jesus has just returned…. In Salt Lake City. Your Holiness, you still there?”

How do you know the guy on the corner delivering his direct revelation of the word of god is just crazy?

Why believe that because it comes down from an ancient oral tradition that was eventually transcribed into a very old language it’s ‘The Truth?’

Expand full comment

This is one of the best blog posts I've ever read, and not just on here.

And not just because this line made me literally LOL: "And on one level it’s definitely true that mankind will not be free until the last admissions officer is strangled with the entrails of the last New York Times journalist."

(I've viewed the Gray Lady that way since long before you ran afoul of them; am in fact a recovered NYT subscriber.)

Expand full comment

Progressives always say that detrans people are rare. I suspect they're not that rare, and that the studies showing they are are bad science in some way. Remember, scientists and the scientific institutions are utterly and unreservedly devoted to saying that all the things that trans rights activists want to be true are true. The world would look the same as it does now whether detrans people are rare or common.

Something like 41% of trans people attempt suicide. 1 in 3 trans youth have attempted suicide in the last year. (Veale et al 2015) Maybe it's society's fault for not accepting them. But alternatively, we should seriously consider that some trans suicides could be prevented by treating some people with mental health care that doesn't affirm their wish to be the opposite sex.




Expand full comment
May 26, 2022·edited May 26, 2022

> whether there’s something to be gained from picking over experiences like these

On what axis is the baseline state of consciousness better than the hippie tripping balls? The obvious metric of "ability to safely operate heavy machinery" etc is unfair as the hippie just took the chemical equivalent of blunt trauma to several key pieces of his brain. This tells us nothing about the validity of the resulting mindset.

I've recently compared thoughts I think on psilocybin and thoughts I think without, and I'm hestitant to consider the sober ones saner or more productive. I don't want to get all postmodern here, jumping out of the window because you don't believe in gravity is still a bad idea. Still, a majority of consensus social reality is complete bullshit, even if (or especially if!) you aim to achieve goals considered valuable in that consensus.

EDIT: Actually the post itself provides an excellent example.

> “I am a guy who works a McJob and is bad at it, and that is all I am”

How dysfunctional a mental/spiritual framework has to be, to reduce a person to a sentence like this? And yet this is how a large part of the population looks at the world, and at each other.

Expand full comment

I enjoyed the write up and I appreciate the sentiments, but as a "too interesting" person (yes, with a couple of psychotic breaks under my belt) I feel a little self conscious now, lol.

I read "The Spiritual Gift of Madness" years ago and it resonated with me, but I felt at the time like it was only about 75% applicable, and the rest was agenda-driven ranting. A good thing to read, especially if you have a history of mental instability and have chosen not to medicate daily, but the "Mad Pride" movement imo goes a little too far sometimes...

I just don't see how mental health can ever be anything other than case by case. In my case, no meds every really helped me feel better or heal from the atrocious childhood that destabilized me in the first place. I've had to do, yes, woo-woo IFS and other trauma-release modalities to start to get a handle on it.

But I'm not going around telling people never to take meds. What I WILL say is, if you take them, PAY ATTENTION. People may not need meds forever and ever, but only for about 6 months or so, but they just "default" to forever and ever. I'm very thankful for the Zoloft that got me through my father dying for 6 months when I was 20, but once the crisis was past it wasn't doing me any favors so I quit. If I quit and I turned out to need it, I'd have gone back on, but I didn't, so I didn't.

I don't hear voices, but I do have to make sure I can functionally blend my "non default" reality into the rest of the consensus, and I do it very well. Mad Pride helped me understand that this is a valid way to live. I have a personal motto that serves me daily - "It doesn't matter what's real, it matters what's functional." It really doesn't matter what I believe to be true, as long as I'm feeding myself, paying the mortgage, walking the dogs, being friendly to my neighbors etc. It doesn't matter what my neighbors believe to be true, as long as they're able to do the same.

Expand full comment

Shion's law:

Psychiatry is going to turn out to be at least as complicated as we already know humans are.

Expand full comment

I asked God for help the other day. He sent an angel down to help me, who spent the entire session complaining about his own problems.

Expand full comment

Hearing Voices is also an immensely useful modality for all the folks with dissociative disorders who are routinely missed in diagnosis. Because anti-psychotics do not work for that, while making friends and working with the voices does. And the many of the symptoms of dissociative disorders, as described in Dell's subjective/phenomenological model, look more like psychosis than dissociation to most un- or under-trained eyes.

Expand full comment

The Hippie Movement created the greatest art of the 20th century in the form of music. I don't blame Scott for being blind or deaf to this; it's not his field.

The Hippie Movement, which is too broad to break down into a few of names, brought to 20th century America the notions of tolerance and non-judgment. That seems important for the black civil rights movement, and ultimately if not immediately for feminism of the sensible sort and the gay acceptance movement. "Letting Your Freak Flag Fly" was a hippie ethic that seems to have resulted in more good than bad. Accepting weirdos is good. They are often the best among us.

Could be wrong but I think Scott still sees the hippie movement through the lens of his awful On the Road review (Love you Scott, but that one was awful). The hippie movement was anti-rational and gave us a lot of art and symbolism -- post Chirstian symbolism one could say -- in an attempt to make sense out of a post-Christian society. The attempt suffered many failures, but we needed those failures. We need more failures. We need to discover a post-Christian spirituality. The Beats and the Hippies tried to find it. They failed, but in a great American way. I love the Beats and Hippies like Scott likes all those CA gubernatorial candidates. I respect those who try passionately to be American, even if they are pathetic in the final analysis.

We need more Hippies!

Expand full comment

There was this study about communication, where autistic people played telephone games among themselves they scored as well as the none autistic people who also played telephone among themselves.

When the groups were mixed they did poorly.

So autism might be a disorder of communication with neurotypicals, rather than a disorder of communication. Functionally though that might not make a difference. --> prelim findings of study here.


I am pleased to hear that quirkiness is in! Now I suppose I should stop trying to downplay my quirkiness perhaps. (then again my hobbies are not that quirky).

I also think low-levels of hearing things seem much less bad than anti-psychotic side effect medications.

I mean I think its complicated; I think at times there can be a link between mental illness and positive traits, but thats the exeception not the rule.

Expand full comment
May 27, 2022·edited May 27, 2022

I think the element of “if the voice in my head isn’t agentic then it must be me” is crucial to the distress some people feel about the voices in their head, especially if they don’t like what the voice says.

If you believe the voice is some external force - a demon, angel, fey, whatever - then it doesn’t matter what it says; it’s a different person with a weird opinion. It doesn’t reflect badly on you that they have a weird opinion. In fact, it might reflect credit on you; you’re important enough for some big external force to be contacting you!

But if there’s no magic, if that voice is *you* and is advocating things *you* believe to be wrong … then doesn’t that mean that some deep part of *you* is evil? How is a person supposed to feel about that?

I don’t buy that the answer is “the voice is a demon, don’t worry about it bro”, because that carries a lot of dubious baggage. The way I think about it - and have suggested to others, with all the arrogance Scott predicts - is that we’re not fighter pilots, we’re the captains of a ship. Of course there are a lot of voices in our heads; our stomach, our love, our morbid curiosity, aspects of us even more esoteric; they all have a voice. But those voices aren’t the core you, they’re a part of your body but not your mind. *You* are the aggregator who hears those voices, sometimes with competing views and goals, and steers the ship with all that in mind. Sometimes those voices are flawed! That’s okay! Part of your job in life is to learn how your particular voices are flawed, and fuse them together into a working ship anyway, like some campy Hollywood found family movie. Rarely those voices are too persistent or have no upside, and you have to seek outside help, but even then you’re just being a responsible manager. It reflects credit on you for recognizing the situation and calling for backup, rather than shame for having been made “out of spec”.

I know for a fact that viewpoint has helped 2-3 people, but that is not a lot of people, so take it with however many grains of salt that merits.

Expand full comment

Re-Reading Scotts review of Jaynes (he linked it above) one thing that's really striking is that according to Jaynes not only was hearing voices much more common in the ancient world, but that the disappearance of the voices was considered a great loss for humanity. Even if you disagree with Jaynes on how common these voices used to be, I think that its true they became less common and that this was considered a bad thing.

Now you may say that that was just status-quo bias in a society accustomed to hearing voices, but then the reverse can be said about our culture.

Expand full comment

"""And most chronically mentally ill people have been traumatized by the psychiatric system in some way or another. Sometimes this is specific individuals behaving maliciously or callously. Other times it’s just the normal trauma of being shuffled from institution to institution by a system which isn’t optimizing for preventing you from being stuck on a gurney for twelve hours with nothing to do."""

I would become literally murderous. As in I would actively work to tear the throat out of the orderly who strapped me to it, and the doctor who ordered it. Not a metaphor. It would go on my todo, and stay there until it was done. If some court doctor wants to medicalize their understanding of this decision path, they may go on the todo list as well.

Expand full comment
May 28, 2022·edited May 28, 2022

"People hate admitting that some cases are mild, and others are severe. Especially the kind of people who work at the New York Times" - I think the reason for this is not the one that Scott cited, but rather due to the fact that if you admit that some cases are mild and other cases are severe then (a) there's no conflict, nothing to boldly declare, nothing to subvert, and consequently (b) the solution to the issue is in the hands of people who are able and willing to discuss the specifics of what makes a case mild enough or severe enough to need certain types of treatments.

If you treat having hallucinations as yet another "identity," yet another abstract-nation that you are either IN or OUT of, then the discussion stays non-specific and emotional. It stays compelling, it remains *broadly appealing,* it stays *fun*.

Expand full comment

People are harmed, and harm others, because of things they are wrong about. Although trying to forcefully enforce correct thinking in all situations would do much more harm than good, people should put effort into trying to believe the truth.

Expand full comment

Hey I'm one of those people who hear voices, (but from an outside observer, it would look like me saying the things myself, but from my perspective, I'm repeating what you guys would probably call "thoughts")

But who the hell knows where those comes from, so I choose not to take responsibility over them, I tell myself that I'm just saying this stuff out loud so that other people could see what's up with the voices too, (cause hey, isn't this just a teensy bit interesting?) which leads me to believe that there's a third observer-observing this dialectic that I'm coming up with in my head, which makes me immediately start thinking of various creation stories and myths or Me being Marlowe from The Heart of Darkness (but also kurtz and the congo river)

If you would like to see a demonstration of this, I write stuff (for your amusement, for whatever you take amusement in)

Expand full comment

This is very similar to my own take on experiences of egolessness and dissolution into a greater whole, which I wrote here: https://sevensecularsermons.org/why-atheists-need-ecstasy/ .

The more problematic case is the "Targeted Individuals" community, where paranoid people find each other and confirm each other's theories of persecution. They're much harder to find because duh, they're paranoid and hence secretive, but they definitely do exist in remote corners of the internet.

Expand full comment

>at least some large subset of transgender people aren’t consciously faking it.


>If I had to steelman their position it would be something like: there’s some switch that can be flipped by social pressure and wanting to look cool. Once the switch is flipped, you’re transgender in some pretty real way

The correct steelman is that "not consciously faking it" doesn't imply "is transgender". It is possible to have mistaken beliefs about oneself. This is especially so since you then add that someone may be pretty miserable without transition, with the implication that transition relieves their misery. How could they possibly know that, at least when they haven't yet transitioned? It's certainly possible to be mistaken about whether something will relieve your misery (and also about what the source of that misery is). Just because someone isn't faking it doesn't mean that they're right.

For that matter, how could they possibly know that they feel like a woman? They don't have any external examples of feeling-like-a-woman that they can compare it to, unless they're psychic.

Basically, you seem to be conflating "is sincere" with "is correct". You can be both sincere and incorrect, especially about things you have no way to really know.

Expand full comment

Very good read, thanks!

Expand full comment

Re: People not always appreciating that severity of mental health issues can exist on a continuum, I think it's worth remembering that people are much more likely to be exposed to people who fall on the mild end of global functioning impact. This can distort their perceptions of what more severe impacts might look like in terms of prevalence and presentation. Unless you are in a relevant field or have a direct personal connection, there's a good chance that severe outcomes are out of sight out of mind.

Expand full comment

I find the rationalist tendency to assume "makes decent money" equals "successful" to be sadly amusing.

Expand full comment

> This being the real world, many of those patients are right. So they look elsewhere.

As someone who has a number of psychiatric issues, I will just add my voice to the chorus stating that it is *extraordinarily* difficult to trust what is often effectively a complete stranger at first, with information which they could use to have you locked up without an actual trial that involves things like "standards of evidence" and "counsel" and sometimes even "the presence of the person whose fate is being decided".

And yes, **that** factor, more than any other, has been the primary thing which has on multiple occasions significantly delayed my seeking desperately needed care.

Expand full comment

The piece from Freddie echoed heavily with me.

Expand full comment