I feel pretty defensive reading and responding to this comment, given a previous conversation with Scott Alexander where he said his professional opinion would be that people who have had a psychotic break should be on antipsychotics for the rest of their life (to minimize risks of future psychotic breaks). This has known severe side effects like cognitive impairment and brain shrinkage and lacks evidence of causing long-term improvement. When I was on antipsychotics, my mental functioning was much lower (noted by my friends) and I gained weight rapidly. (I don’t think short-term use of antipsychotics was bad, in my case)
It is in this context that I’m reading that someone talking about the possibility of mental subprocess implantation (“demons”) should be “treated as a psychological emergency”, when the Eric Bryulant case had already happened, and talking about the psychological processes was necessary for making sense of the situation. I feared involuntary institutionalization at the time, quite a lot, for reasons like this.
If someone expresses opinions like this, and I have reason to believe they would act on them, then I can’t believe myself to have freedom of speech. That might be better than them not sharing the opinions at all, but the social structural constraints this puts me under are obvious to anyone trying to see them.
Given what happened, I don’t think talking to a normal therapist would have been all that bad in 2017, in retrospect; it might have reduced the overall amount of psychiatric treatment needed during that year. I’m still really opposed to the coercive “you need professional help” framing in response to sharing weird thoughts that might be true, instead of actually considering them, like a Bayesian.
I don’t remember the exact words in our last conversation. If I said that, I was wrong and I apologize.
My position is that in schizophrenia (which is a specific condition and not just the same thing as psychosis), lifetime antipsychotics might be appropriate. EG this paper suggests continuing for twelve months after a first schizophrenic episode and then stopping and seeing how things go, which seems reasonable to me. It also says that if every time you take someone off antipsychotics they become fully and dangerous psychotic again, then lifetime antipsychotics are probably their best bet. In a case like that, I would want the patient’s buy-in, ie if they were medicated after a psychotic episode I would advise them of the reasons why continued antipsychotic use was recommended in their case, if they said they didn’t want it we would explore why given the very high risk level, and if they still said they didn’t want it then I would follow their direction.
I didn’t get a chance to talk to you during your episode, so I don’t know exactly what was going on. I do think that psychosis should be thought of differently than just “weird thoughts that might be true”, as more of a whole-body nerve-and-brain dysregulation of which weird thoughts are just one symptom. I think in mild psychosis it’s possible to snap someone back to reality where they agree their weird thoughts aren’t true, but in severe psychosis it isn’t (I remember when I was a student I tried so hard to convince someone that they weren’t royalty, hours of passionate debate, and it just did nothing). I think if someone has mild psychosis and you can guide them back to reality-based thoughts for a second, that is compassionate and a good thing to do in the sense that it will make them feel better, but also kind of useless because the psychosis still has the same chance of progressing into severe psychosis anyway—you’re treating a symptom. Analogy to eg someone having chest pain from a heart attack, and you give them painkillers for the pain but don’t treat the heart attack.
(although there’s a separate point where it would be wrong and objectifying to falsely claim someone who’s just thinking differently is psychotic or pre-psychotic, given that you did end up psychotic it doesn’t sound like the people involved were making that mistake)
My impression is that some medium percent of psychotic episodes end in permanent reduced functioning, and some other medium percent end in suicide or jail or some other really negative consequence, and this is scary enough that treating it is always an emergency, and just treating the symptom but leaving the underlying condition is really risky.
I agree many psychiatrists are terrible and that wanting to avoid them is a really sympathetic desire, but when it’s something really serious like psychosis I think of this as like wanting to avoid surgeons (another medical profession with more than its share of jerks!) when you need an emergency surgery.
I don’t remember the exact words in our last conversation. If I said that, I was wrong and I apologize.
Ok, the opinions you’ve described here seem much more reasonable than what I remember, thanks for clarifying.
I do think that psychosis should be thought of differently than just “weird thoughts that might be true”, since it’s a whole-body nerve-and-brain dysregulation of which weird thoughts are just one symptom.
I agree, yes. I think what I was afraid of at the time was being called crazy and possibly institutionalized for thinking somewhat weird thoughts that people would refuse to engage with, and showing some signs of anxiety/distress that were in some ways a reaction to my actual situation. By the time I was losing sleep etc, things were quite different at a physiological level and it made sense to treat the situation as a psychiatric emergency.
If you can show someone that they’re making errors that correspond to symptoms of mild psychosis, then telling them that and suggesting corresponding therapies to help with the underlying problem seems pretty reasonable.
Thanks, if you meant that, when someone is at a very early stage of thinking strange things, you should talk to them about it and try to come to a mutual agreement on how worrying this is and what the criteria would be for psych treatment, instead of immediately dehumanizing them and demanding the treatment right away, then I 100% agree.
I think if someone has mild psychosis and you can guide them back to reality-based thoughts for a second, that is compassionate and a good thing to do in the sense that it will make them feel better, but also kind of useless because the psychosis still has the same chance of progressing into severe psychosis anyway—you’re treating a symptom.
If psychosis is caused by an underlying physiological/biochemical process, wouldn’t that suggest that e.g. exposure to Leverage Research wouldn’t be a cause of it?
If being part of Leverage is causing less reality-based thoughts and nudging someone into mild psychosis, I would expect that being part of some other group could cause more reality-based thoughts and nudge someone away from mild psychosis. Why would causation be possible in one direction but not the other?
I guess another hypothesis here is that some cases are caused by social/environmental factors and others are caused by biochemical factors. If that’s true, I’d expect changing someone’s environment to be more helpful for the former sort of case.
[probably old-hat [ETA: or false], but I’m still curious what you think] My (background unexamined) model of psychosis-> schizophrenia is that something, call it the “triggers”, sets a person on a trajectory of less coherence / grounding; if the trajectory isn’t corrected, they just go further and further. The “triggers” might be multifarious; there might be “organic” psychosis and “psychic” psychosis, where the former is like what happens from lead poisoning, and the latter is, maybe, what happens when you begin to become aware of some horrible facts. If your brain can rearrange itself quickly enough to cope with the newly known reality, your trajectory points back to the ground. If it can’t, you might have a chain reaction where (1) horrible facts you were previously carefully ignoring, are revealed because you no longer have the superstructure that was ignore-coping with them; (2) your ungroundedness opens the way to unepistemic beliefs, some of which might be additionally horrifying if true; (3) you’re generally stressed out because things are going wronger and wronger, which reinforces everything.
If this is true, then your statement:
. I think if someone has mild psychosis and you can guide them back to reality-based thoughts for a second, that’s kind of useless because the psychosis still has the same chance of progressing into severe psychosis anyway—you’re treating a symptom
is only true for some values of “guide them back to reality-based thoughts”. If you’re trying to help them go back to ignore-coping, you might partly succeed, but not in a stable way, because you only pushed the ball partway back up the hill, to mix metaphors—the ball is still on a slope and will roll back down when you stop pushing, the horrible fact is still revealed and will keeping being horrifying. But there’s other things you could do, like helping them find a non-ignore-cope for the fact; or show them enough that they become convinced that the belief isn’t true.
There is this basic idea (I think from an old blogpost that Eliezer wrote) that if someone says there are goblins in the closet, dismissing them outright is confusing rationality with trust in commonly held claims, whereas the truly rational thing is to just open the closet and look.
I think this is correct in principle but not applicable in many real-world cases. The real reason why even rational people routinely dismiss many weird explanations for things isn’t that they have sufficient evidence against them, it’s that the weird explanation is inconsistent with a large set of high confidence beliefs that they currently hold. If someone tells me that they can talk to their deceased parents, I’m probably not going to invest the time to test whether they can obtain novel information this way; I’m just going to assume they’re delusional because I’m confident spirits don’t exist.
That said, if that someone helped write the logical induction paper, I personally would probably hear them out regardless of how weird the thing sounds. Nonetheless, I think it remains true that dismissing beliefs without considering the evidence is often necessary in practice.
If someone tells me that they can talk to their deceased parents, I’m probably not going to invest the time to test whether they can obtain novel information this way; I’m just going to assume they’re delusional because I’m confident spirits don’t exist.
This is failing to track ambiguity in what’s being refered to. If there’s something confusing happening—something that seems important or interesting, but that you don’t yet have words to well-articulate it—then you try to say what you can (e.g. by talking about “demons”). In your scenario, you don’t know exactly what you’re dismissing. You can confidently dismiss, in the absence of extraordinary evidence, that (1) their parents’s brains have been rotting in the ground, and (2) they are talking with their parents, in the same way you talk to a present friend; you can’t confidently dismiss, for example, that they are, from their conscious perspective, gaining information by conversing with an entity that’s naturally thought of as their parents (which we might later describe as, they have separate structure in them, not integrated with their “self”, that encoded thought patterns from their parents, blah blah blah etc.). You can say “oh well yes of course if it’s *just a metaphor* maybe I don’t want to dismiss them”, but the point is that from a partially pre-theoretic confusion, it’s not clear what’s a metaphor and it requires further work to disambiguate what’s a metaphor.
I feel pretty defensive reading and responding to this comment, given a previous conversation with Scott Alexander where he said his professional opinion would be that people who have had a psychotic break should be on antipsychotics for the rest of their life (to minimize risks of future psychotic breaks). This has known severe side effects like cognitive impairment and brain shrinkage and lacks evidence of causing long-term improvement. When I was on antipsychotics, my mental functioning was much lower (noted by my friends) and I gained weight rapidly. (I don’t think short-term use of antipsychotics was bad, in my case)
It is in this context that I’m reading that someone talking about the possibility of mental subprocess implantation (“demons”) should be “treated as a psychological emergency”, when the Eric Bryulant case had already happened, and talking about the psychological processes was necessary for making sense of the situation. I feared involuntary institutionalization at the time, quite a lot, for reasons like this.
If someone expresses opinions like this, and I have reason to believe they would act on them, then I can’t believe myself to have freedom of speech. That might be better than them not sharing the opinions at all, but the social structural constraints this puts me under are obvious to anyone trying to see them.
Given what happened, I don’t think talking to a normal therapist would have been all that bad in 2017, in retrospect; it might have reduced the overall amount of psychiatric treatment needed during that year. I’m still really opposed to the coercive “you need professional help” framing in response to sharing weird thoughts that might be true, instead of actually considering them, like a Bayesian.
I don’t remember the exact words in our last conversation. If I said that, I was wrong and I apologize.
My position is that in schizophrenia (which is a specific condition and not just the same thing as psychosis), lifetime antipsychotics might be appropriate. EG this paper suggests continuing for twelve months after a first schizophrenic episode and then stopping and seeing how things go, which seems reasonable to me. It also says that if every time you take someone off antipsychotics they become fully and dangerous psychotic again, then lifetime antipsychotics are probably their best bet. In a case like that, I would want the patient’s buy-in, ie if they were medicated after a psychotic episode I would advise them of the reasons why continued antipsychotic use was recommended in their case, if they said they didn’t want it we would explore why given the very high risk level, and if they still said they didn’t want it then I would follow their direction.
I didn’t get a chance to talk to you during your episode, so I don’t know exactly what was going on. I do think that psychosis should be thought of differently than just “weird thoughts that might be true”, as more of a whole-body nerve-and-brain dysregulation of which weird thoughts are just one symptom. I think in mild psychosis it’s possible to snap someone back to reality where they agree their weird thoughts aren’t true, but in severe psychosis it isn’t (I remember when I was a student I tried so hard to convince someone that they weren’t royalty, hours of passionate debate, and it just did nothing). I think if someone has mild psychosis and you can guide them back to reality-based thoughts for a second, that is compassionate and a good thing to do in the sense that it will make them feel better, but also kind of useless because the psychosis still has the same chance of progressing into severe psychosis anyway—you’re treating a symptom. Analogy to eg someone having chest pain from a heart attack, and you give them painkillers for the pain but don’t treat the heart attack.
(although there’s a separate point where it would be wrong and objectifying to falsely claim someone who’s just thinking differently is psychotic or pre-psychotic, given that you did end up psychotic it doesn’t sound like the people involved were making that mistake)
My impression is that some medium percent of psychotic episodes end in permanent reduced functioning, and some other medium percent end in suicide or jail or some other really negative consequence, and this is scary enough that treating it is always an emergency, and just treating the symptom but leaving the underlying condition is really risky.
I agree many psychiatrists are terrible and that wanting to avoid them is a really sympathetic desire, but when it’s something really serious like psychosis I think of this as like wanting to avoid surgeons (another medical profession with more than its share of jerks!) when you need an emergency surgery.
Ok, the opinions you’ve described here seem much more reasonable than what I remember, thanks for clarifying.
I agree, yes. I think what I was afraid of at the time was being called crazy and possibly institutionalized for thinking somewhat weird thoughts that people would refuse to engage with, and showing some signs of anxiety/distress that were in some ways a reaction to my actual situation. By the time I was losing sleep etc, things were quite different at a physiological level and it made sense to treat the situation as a psychiatric emergency.
If you can show someone that they’re making errors that correspond to symptoms of mild psychosis, then telling them that and suggesting corresponding therapies to help with the underlying problem seems pretty reasonable.
Thanks, if you meant that, when someone is at a very early stage of thinking strange things, you should talk to them about it and try to come to a mutual agreement on how worrying this is and what the criteria would be for psych treatment, instead of immediately dehumanizing them and demanding the treatment right away, then I 100% agree.
If psychosis is caused by an underlying physiological/biochemical process, wouldn’t that suggest that e.g. exposure to Leverage Research wouldn’t be a cause of it?
If being part of Leverage is causing less reality-based thoughts and nudging someone into mild psychosis, I would expect that being part of some other group could cause more reality-based thoughts and nudge someone away from mild psychosis. Why would causation be possible in one direction but not the other?
I guess another hypothesis here is that some cases are caused by social/environmental factors and others are caused by biochemical factors. If that’s true, I’d expect changing someone’s environment to be more helpful for the former sort of case.
[probably old-hat [ETA: or false], but I’m still curious what you think] My (background unexamined) model of psychosis-> schizophrenia is that something, call it the “triggers”, sets a person on a trajectory of less coherence / grounding; if the trajectory isn’t corrected, they just go further and further. The “triggers” might be multifarious; there might be “organic” psychosis and “psychic” psychosis, where the former is like what happens from lead poisoning, and the latter is, maybe, what happens when you begin to become aware of some horrible facts. If your brain can rearrange itself quickly enough to cope with the newly known reality, your trajectory points back to the ground. If it can’t, you might have a chain reaction where (1) horrible facts you were previously carefully ignoring, are revealed because you no longer have the superstructure that was ignore-coping with them; (2) your ungroundedness opens the way to unepistemic beliefs, some of which might be additionally horrifying if true; (3) you’re generally stressed out because things are going wronger and wronger, which reinforces everything.
If this is true, then your statement:
is only true for some values of “guide them back to reality-based thoughts”. If you’re trying to help them go back to ignore-coping, you might partly succeed, but not in a stable way, because you only pushed the ball partway back up the hill, to mix metaphors—the ball is still on a slope and will roll back down when you stop pushing, the horrible fact is still revealed and will keeping being horrifying. But there’s other things you could do, like helping them find a non-ignore-cope for the fact; or show them enough that they become convinced that the belief isn’t true.
There is this basic idea (I think from an old blogpost that Eliezer wrote) that if someone says there are goblins in the closet, dismissing them outright is confusing rationality with trust in commonly held claims, whereas the truly rational thing is to just open the closet and look.
I think this is correct in principle but not applicable in many real-world cases. The real reason why even rational people routinely dismiss many weird explanations for things isn’t that they have sufficient evidence against them, it’s that the weird explanation is inconsistent with a large set of high confidence beliefs that they currently hold. If someone tells me that they can talk to their deceased parents, I’m probably not going to invest the time to test whether they can obtain novel information this way; I’m just going to assume they’re delusional because I’m confident spirits don’t exist.
That said, if that someone helped write the logical induction paper, I personally would probably hear them out regardless of how weird the thing sounds. Nonetheless, I think it remains true that dismissing beliefs without considering the evidence is often necessary in practice.
This is failing to track ambiguity in what’s being refered to. If there’s something confusing happening—something that seems important or interesting, but that you don’t yet have words to well-articulate it—then you try to say what you can (e.g. by talking about “demons”). In your scenario, you don’t know exactly what you’re dismissing. You can confidently dismiss, in the absence of extraordinary evidence, that (1) their parents’s brains have been rotting in the ground, and (2) they are talking with their parents, in the same way you talk to a present friend; you can’t confidently dismiss, for example, that they are, from their conscious perspective, gaining information by conversing with an entity that’s naturally thought of as their parents (which we might later describe as, they have separate structure in them, not integrated with their “self”, that encoded thought patterns from their parents, blah blah blah etc.). You can say “oh well yes of course if it’s *just a metaphor* maybe I don’t want to dismiss them”, but the point is that from a partially pre-theoretic confusion, it’s not clear what’s a metaphor and it requires further work to disambiguate what’s a metaphor.
As the joke goes, there’s nothing crazy about talking to dead people. When dead people respond, then you start worrying.