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Comment by sillysaurusx | Hacker News Reader

At this point I think maintaining anonymity is a losing battle. So I am gradually reworking my life to be compatible with the sort of publicity that circumstances seem to be forcing on me. I had a talk with my employer and we came to a mutual agreement that I would gradually transition away from working there.

Wait, what? Why?

What'd he write that's so incompatible with employment as a psychiatrist?

I don't get it. Why is it a risk for any employer anywhere to keep him on payroll? What's the worst possible outcome for the employer?

This post is putting on a tough front, but I'd be terrified if I were him. Imagine being forced to start your own business or go bankrupt.

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Background: https://slatestarcodex.com/2020/06/22/nyt-is-threatening-my-...

> First, I’m a psychiatrist, and psychiatrists are kind of obsessive about preventing their patients from knowing anything about who they are outside of work. You can read more about this in this Scientific American article – and remember that the last psychiatrist blogger to get doxxed abandoned his blog too. I am not one of the big sticklers on this, but I’m more of a stickler than “let the New York Times tell my patients where they can find my personal blog”.

I think this doesn't really answer the question, though. Psychiatrists like to do X - is that because they follow a cargo cult of other psychiatrists who do X, or because there's empirical evidence that not-X is bad for patient outcomes (or bad for doctor outcomes - he has repeatedly mentioned concerns over his physical security)?

This is exactly the kind of question I'd expect SSC to tackle thoughtfully on his blog if it wasn't so close to home. But without clear evidence against it, it's hard to criticise him for taking the conservative approach.

Further, I'd expect he'd admit these days that using (most of) his real name for his blog was a mistake. He shouldn't be expected to further overreach professional standards of anonymity just because he previously made that misstep.

Consider therapists who have you lie on a couch vs those who have you sit in the same style chair, as an equal.

Some therapists position themselves as an authority figure for their patients. If they were to open up about themselves, the patient might think they're incapable after seeing the therapist has doubts in their own life.

This has advantages and drawbacks. It may be more efficient in earning trust, thus helping some patients heal faster. OTOH, some patients may never really accept this kind of therapist.

In my experience, psychiatrists more often position themselves as authorities, and among psychologists/therapists/counselors there is a mix.

It's really hard IMO to get communicable science out of talk therapy because there are so many variables and it is extremely subjective and personal. The whole point is to help a patient navigate their own issues.

I draw the above opinion on therapy from reading a few books about the history of psychoanalysis and the various branches it has taken.

> Consider therapists who have you lie on a couch vs those who have you sit in the same style chair, as an equal.

> Some therapists position themselves as an authority figure for their patients.

It is not obvious that the person who gets to recline while the other person must sit is the one with lower status or authority.

Sure it is. You're in a more vulnerable position while reclining.

What about the common trope of a person with wealth and/or power reclining while a servant or slave feeds them grapes or fans them with palm fronds [1]? Is Djambi actually higher status than Hedonism bot [2]?

[1] https://tvtropes.org/pmwiki/pmwiki.php/Main/GrapesOfLuxury

[2] https://www.youtube.com/watch?v=AFYMzQ3Vfq0

Haha IMO we are all equally capable of thinking for ourselves, and therefore it is not necessary to have the patient recline in order to subjugate them and/or induce openness.

Isn't that done also to break eye contact? In (some) analytical therapy face-to-face discussion is discouraged as far as I know.

Therapists usually try to encourage social skills that increase eye contact.

>It's really hard IMO to get communicable science out of talk therapy because there are so many variables and it is extremely subjective and personal. The whole point is to help a patient navigate their own issues.

Eliza did this for some people decades ago. An app with GTP-3 could do a lot if it could navigate the legal and ethical issues.

No, just no. Not even close.

> I’m a psychiatrist, and psychiatrists are kind of obsessive about preventing their patients from knowing anything about who they are outside of work.

Maybe that's true in the US. In the UK I follow a bunch of psychiatrists on twitter and they all use their real name. And they're strongly encouraged to use their real name by their regulator (the GMC) if they're making claims as a doctor on social media.

But that doesn't mesh with "start my own private practice." Either those concerns apply to his original job and his new practice, or neither. Something doesn't seem to add up...

The full quote is

> At some point, I may start my own private practice, where I’m my own boss and where I can focus on medication management – and not the kinds of psychotherapy that I’m most worried are ethically incompatible with being a public figure

It seems believable to me that "medication management" (you've been diagnosed with a mental illness, we have an idea how to treat this chemically, but it's a really complex balance that needs constant professional intervention) is less sensitive to being a public figure than other aspects of psychiatry (lie on the couch and open up to me with your personal secrets).

I'm sure this is a ridiculous simplification and as I said in another post here I'd like to hear SSC's take on it (but don't expect to). But it's uncharitable to say "something doesn't add up".

my original thesis was, and I got quite a lot of flack for it at the time, that it's going to mightily piss his patients off if they ever figure out that he's blogging about them, if only in anonymized form.

I think this really is the issue here with his employer, and I honestly always found it extremely weird, maybe unethical that he wants to avoid his patients figuring out that their stories may appear on a public blog.

Ah. Thank you! That’s an entirely reasonable theory that fits the data. I didn’t realize he blogged about his patients.

Do you happen to know of any examples of articles he published along those lines? Now I’m curious what he said...

https://slatestarcodex.com/2016/07/12/34/

here's one, I don't know if he put that preface on all of them, apparently he fictionalises them and mixes them up.

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

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

Oh man, I have noticed this same behaviour with doctors.

I think how we portray doctors and hospitals as isn't aligned with practice. People really lack the skills to express their issues succinctly to doctors and expect them to figure out everything when they couldn't in months or years. The idea that a 30 min conversation is enough for doctors to know your entire life and medical history to prescribe you relevant medicine and diagnosis is flawed. Many people omit details out of fear and shame. Not that doctors are better at communicating that as a message. It's really like an interview.

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

Um, yes, burying your emotions is unhealthy! I'm surprised to see this coming from anyone in the realm of mental health. It is much more surprising coming from a supposed mental health professional who created a decently sized discussion forum via his blog. He continues,

> My relationship strategy is the same. Date really low-conflict, low-drama, agreeable people. If we have a conflict anyway, then agree to disagree and wait for the problem to go away. Apparently this is terrible

Yes... Yes it is. When you are motivated to be your best and you still fail, such as when people have kids, you realize you're better off dealing with your emotions rather than ignoring them. Some people realize this earlier than others. I hope the number of people practicing in mental health while maintaining this blogger's attitude is small.

Just for clarity: In England that would be professional misconduct and something for his employer, and his professional regulator, to look at.

https://slatestarcodex.com/2014/08/31/radicalizing-the-roman... is another.

I think your theory is spot on.

His new practice will be medication management, not psychotherapy.

When people go this route, do they still see or talk to another therapist?

I always figured people's chemical imbalances were influenced by behavior. If you just treat the chemical imbalance without addressing the behavior, isn't that rather risky?

They do. Psychotherapists cannot prescribe medication but are licensed to deliver psychotherapy. Psychiatrists, who are MDs, can prescribe medication but also can do psychotherapy if they choose to do so. I even know psychiatrists that only do psychotherapy and won't do medication management. To complicate further, non-psychiatrist MDs can also prescribe certain classes of psychotropic medication.

Either way, pharmacotherapy is rarely administered alone, usually psychotherapists refer patients to psychiatrists if they believe pharmacotherapy can be beneficial, and with patient's consent they can share notes. He will be that therapist.

> pharmacotherapy is rarely administered alone, usually psychotherapists refer patients to psychiatrists if they believe pharmacotherapy can be beneficial, and with patient's consent they can share notes. He will be that therapist.

I see, thank you for your reply.

It is really a case by case thing. I have ADD but with chemical treatment I'm basically fine and don't need other intervention. I go in to see someone a few times a year to get another prescription but I didn't really need any cognitive psych stuff.

All the "behavioral" problems I may have had were largely caused by the underlying imbalance and just stopped once I was on it. Or at least, stopped enough that they are no longer a problem for me, and I think really once a behavior isn't causing issues in your life it is probably hard to classify it as a "problem"

This post has better background on what the source of all of this trouble is https://slatestarcodex.com/2019/02/22/rip-culture-war-thread...

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