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Melatonin: Much More Than You Wanted To Know

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Van Geiklswijk et al describe supplemental melatonin as “a chronobiotic drug with hypnotic properties”. Using it as a pure hypnotic – a sleeping pill – is like using an AK-47 as a club to bash your enemies’ heads in. It might work, but you’re failing to appreciate the full power and subtlety available to you.

Melatonin is a neurohormone produced by the pineal gland. In a normal circadian cycle, it’s lowest (undetectable, less than 1 pg/ml of blood) around the time you wake up, and stays low throughout the day. Around fifteen hours after waking, your melatonin suddenly shoots up to 10 pg/ml – a process called “dim light melatonin onset”. For the next few hours, melatonin continues to increase, maybe as high as 60 or 70 pg/ml, making you sleepier and sleepier, and presumably at some point you go to bed. Melatonin peaks around 3 AM, then declines until it’s undetectably low again around early morning.

Is this what makes you sleepy? Yes and no. Sleepiness is a combination of the circadian cycle and the so-called “Process S”. This is an unnecessarily sinister-sounding name for the fact that the longer you’ve been awake, the sleepier you’ll be. It seems to be partly regulated by a molecule called adenosine. While you’re awake, the body produces adenosine, which makes you tired; as you sleep, the body clears adenosine away, making you feel well-rested again.

In healthy people these processes work together. Circadian rhythm tells you to feel sleepy at night and awake during the day. Process S tells you to feel awake when you’ve just risen from sleep (naturally the morning), and tired when you haven’t slept in a long time (naturally the night). Both processes agree that you should feel awake during the day and tired at night, so you do.

When these processes disagree for some reason – night shifts, jet lag, drugs, genetics, playing Civilization until 5 AM – the system fails. One process tells you to go to sleep, the other to wake up. You’re never quite awake enough to feel energized, or quite tired enough to get restful sleep. You find yourself lying in bed tossing and turning, or waking up while it’s still dark and not being able to get back to sleep.

Melatonin works on both systems. It has a weak “hypnotic” effect on Process S, making you immediately sleepier when you take it. It also has a stronger “chronobiotic” effect on the circadian rhythm, shifting what time of day your body considers sleep to be a good idea. Effective use of melatonin comes from understanding both these effects and using each where appropriate.

1. Is melatonin an effective hypnotic?

Yes.

That is, taking melatonin just before you want to get to sleep, does help you get to sleep. The evidence on this is pretty unanimous. For primary insomnia, two meta-analyses – one by Brzezinski in 2005 and another by Ferracioli-Oda in 2013 – both find it safe and effective. For jet lag, a meta-analysis by the usually-skeptical Cochrane Collaboration pronounces melatonin “remarkably effective”. For a wide range of primary and secondary sleep disorders including, Buscemi et al say in their abstract that it doesn’t work, but a quick glance at the study shows it absolutely does and they are incorrectly under-reporting their own results. The Psychiatric Times agrees with me on this: “Results from another study reported as negative actually demonstrated a statistically significant positive result of a decrease in sleep latency by an average of 7.2 minutes for melatonin”.

Expert consensus generally follows the meta-analyses: melatonin works. I find cautious endorsements by the Mayo Clinic and John Hopkins less impressive than its less-than-completely-negative review on Science-Based Medicine, a blog I can usually count on for a hit job on any dietary supplement.

The consensus stresses that melatonin is a very weak hypnotic. The Buscemi meta-analysis cites this as their reason for declaring negative results despite a statistically significant effect – the supplement only made people get to sleep about ten minutes faster. “Ten minutes” sounds pretty pathetic, but we need to think of this in context. Even the strongest sleep medications, like Ambien, only show up in studies as getting you to sleep ten or twenty minutes faster; this New York Times article says that “viewed as a group, [newer sleeping pills like Ambien, Lunesta, and Sonata] reduced the average time to go to sleep 12.8 minutes compared with fake pills, and increased total sleep time 11.4 minutes.” I don’t know of any statistically-principled comparison between melatonin and Ambien, but the difference is hardly (pun not intended) day and night.

Rather than say “melatonin is crap”, I would argue that all sleeping pills have measurable effects that vastly underperform their subjective effects. The linked article speculates on one reason this might be: people have low awareness around the time they get to sleep, and a lot of people’s perception of whether they’re insomniac or not is more anxiety (or sometimes literally dream) than reality. This is possible, but I also think of this in terms of antidepressant studies, which find similarly weak objective effects despite patients (and doctors) who swear by them and say they changed their lives. If I had to guess, I would say that the studies include an awkward combination of sick and less-sick people and confuse responders and non-responders. Maybe this is special pleading. I don’t know. But if you think any sleeping pill works well, melatonin doesn’t necessarily work much worse than that.

Sleep latency statistics are hard to compare to one another because they’re so dependent on the study population. If your subjects take an hour to fall asleep, perhaps melatonin could shave off thirty-four minutes. But if your subjects take twenty minutes to fall asleep, then no sleeping pill will ever take off thirty-four minutes, and even an amazing sleeping pill might struggle to make fifteen. I cannot directly compare the people who say melatonin gives back ten minutes to the people who say melatonin gives back thirty-four minutes to the people who say Ambien gives back twelve, but my totally unprincipled guess is that melatonin is about a third as strong as Ambien. It also has about a hundred times fewer side effects, so there’s definitely a place for it in sleep medicine.

2. What is the right dose of melatonin?

0.3 mg.

“But my local drugstore sells 10 mg pills! When I asked if they had anything lower, they looked through their stockroom and were eventually able to find 3 mg pills! And you’re saying the correct dose is a third of a milligram?!”

Yes. Most existing melatonin tablets are around ten to thirty times the correct dose.

Many early studies were done on elderly people, who produce less endogenous melatonin than young people and so are considered especially responsive to the drug. Several lines of evidence determined that 0.3 mg was the best dose for this population. Elderly people given doses around 0.3 mg slept better than those given 3 mg or more and had fewer side effects (Zhdanova et al 2001). A meta-analysis of dose-response relationships concurred, finding a plateau effect around 0.3 mg, with doses after that having no more efficacy, but worse side effects (Brzezinski et al, 2005). And doses around 0.3 mg cause blood melatonin spikes most similar in magnitude and duration to the spikes seen in healthy young people with normal sleep (Vural et al, 2014).

Other studies were done on blind people, who are especially sensitive to melatonin since they lack light cues to entrain their circadian rhythms. This is a little bit of a different indication, since it’s being used more as a chronobiotic than a sleeping pill, but the results were very similar: lower doses worked better than higher doses. For example, in Lewy et al 2002), nightly doses of 0.5 mg worked to get a blind subject sleeping normally at night; doses of 20 mg didn’t. They reasonably conclude that the 20 mg is such a high dose that it stays in their body all day, defeating the point of a hormone whose job is to signal nighttime. Other studies on the blind have generally confirmed that doses of around 0.3 to 0.5 mg are optimal.

There have been disappointingly few studies on sighted young people. One such, Attenburrow et al 1996 finds that 1 mg works but 0.3 mg doesn’t, suggesting these people may need slightly higher doses, but this study is a bit of an outlier. Another Zhdanova study on 25 year olds found both to work equally. And Pires et al studying 22-24 year olds found that 0.3 mg worked better than 1.0. I am less interested in judging the 0.3 mg vs. 1.0 mg debate than in pointing out that both numbers are much lower than the 3 – 10 mg doses found in the melatonin tablets sold in drugstores.

UpToDate, the gold standard research database used by doctors, agrees with these low doses. “We suggest the use of low, physiologic doses (0.1 to 0.5 mg) for insomnia or jet lag (Grade 2B). High-dose preparations raise plasma melatonin concentrations to a supraphysiologic level and alter normal day/night melatonin rhythms.” Mayo Clinic makes a similar recommendation: they recommend 0.5 mg. John Hopkins’ experts almost agree: they say “less is more” but end up chickening out and recommending 1 to 3 mg, which is well above what the studies would suggest.

Based on a bunch of studies that either favor the lower dose or show no difference between doses, plus clear evidence that 0.3 mg produces an effect closest to natural melatonin spikes in healthy people, plus UpToDate usually having the best recommendations, I’m in favor of the 0.3 mg number. I think you could make an argument for anything up to 1 mg. Anything beyond that and you’re definitely too high. Excess melatonin isn’t grossly dangerous, but tends to produce tolerance and might mess up your chronobiology in other ways. Based on anecdotal reports and the implausibility of becoming tolerant to a natural hormone at the dose you naturally have it, I would guess sufficiently low doses are safe and effective long term, but this is just a guess, and most guidelines are cautious in saying anything after three months or so.

3. What are circadian rhythm disorders? How do I use melatonin for them?

Circadian rhythm disorders are when your circadian rhythm doesn’t match the normal cycle where you want to sleep at night and wake up in the morning.

The most popular circadian rhythm disorder is “being a teenager”. Teenagers’ melatonin cycle is naturally shifted later, so that they don’t want to go to bed until midnight or later, and don’t want to wake up until eight or later. This is an obvious mismatch with school starting times, leading to teenagers either not getting enough sleep, or getting their sleep at times their body doesn’t want to be asleep and isn’t able to use it properly. This is why every reputable sleep scientist and relevant scientific body keeps telling the public school system to start later.

When a this kind of late sleep schedule persists into adulthood or becomes too distressing, we call it Delayed Phase Sleep Disorder. People with DSPD don’t get tired until very late, and will naturally sleep late if given the chance. The weak version of this is “being a night owl” or “not being a morning person”. The strong version just looks like insomnia: you go to bed at 11 PM, toss and turn until 2 AM, wake up when your alarm goes off at 7, and complain you “can’t sleep”. But if you can sleep at 2 AM, consistently, regardless of when you wake up, and you would fall asleep as soon as your head hit the pillow if you first got into bed at 2, then this isn’t insomnia – it’s DSPD.

The opposite of this pattern is Advanced Phase Sleep Disorder. This is most common in the elderly, and I remember my grandfather having this. He would get tired around 6 PM, go to bed by 7, wake around 1 or 2 AM, and start his day feeling fresh and alert. But the weak version of this is the person who wakes up at 5 each morning even though their alarm doesn’t go off until 8 and they could really use the extra two hours’ sleep. These people would probably do fine if they just went to bed at 8 or 9, but the demands of work and a social life make them feel like they “ought” to stay up as late as everyone else. So they go to bed at 11, wake up at 5, and complain of “terminal insomnia”.

Finally, there’s Non-24-Hour-Sleep Disorder, where somehow your biological clock ended up deeply and unshakeably convinced that days on Earth are twenty-five (or whatever) hours long, and decides this is the hill it wants to die on. So if you naturally sleep 11 – 7 one night, you’ll naturally sleep 12 – 8 the next night, 1 to 9 the night after that, and so on until either you make a complete 24-hour cycle or (more likely) you get so tired and confused that you stay up 24+ hours and break the cycle. This is most common in blind people, who don’t have the visual cues they need to remind themselves of the 24 hour day, but it happens in a few sighted people also; Eliezer Yudkowsky has written about his struggles with this condition.

Melatonin effectively treats these conditions, but you’ve got to use it right.

The general heuristic is that melatonin drags your sleep time towards the direction of when you take the melatonin.

So if you want to go to sleep (and wake up) earlier, you want to take melatonin early in the day. How early? Van Geijlswijk et al sums up the research as saying it is most effective “5 hours prior to both the traditionally determined [dim light melatonin onset] (circadian time 9)”. If you don’t know your own melatonin cycle, your best bet is to take it 9 hours after you wake up (which is presumably about seven hours before you go to sleep).

What if you want to go to sleep (and wake up) later? Our understanding of the melatonin cycle strongly suggests melatonin taken first thing upon waking up would work for this, but as far as I know this has never been formally investigated. The best I can find is researchers saying that they think it would happen and being confused why no other researcher has investigated this.

And what about non-24-hour sleep disorders? I think the goal in treatment here is to advance your phase each day by taking melatonin at the same time, so that your sleep schedule is more dependent on your own supplemental melatonin than your (screwed up) natural melatonin. I see conflicting advice about how to do this, with some people saying to use melatonin as a hypnotic (ie just before you go to bed) and others saying to use it on a typical phase advance schedule (ie nine hours after waking and seven before sleeping, plausibly about 5 PM). I think this one might be complicated, and a qualified sleep doctor who understands your personal rhythm might be able to tell you which schedule is best for you. Eliezer says the latter regimen had very impressive effects for him (search “Last but not least” here). I’m interested in hearing from the MetaMed researcher who gave him that recommendation on how they knew he needed a phase advance schedule.

Does melatonin used this way cause drowsiness (eg at 5 PM)? I think it might, but probably such a minimal amount compared to the non-sleep-conduciveness of the hour that it doesn’t register.

Melatonin isn’t the only way to advance or delay sleep phase. Here is a handy cheat sheet of research findings and theoretical predictions:

TO TREAT DELAYED PHASE SLEEP DISORDER (ie you go to bed too late and wake up too late, and you want it to be earlier)
– Take melatonin 9 hours after wake and 7 before sleep, eg 5 PM
– Block blue light (eg with blue-blocker sunglasses or f.lux) after sunset
– Expose yourself to bright blue light (sunlight if possible, dawn simulator or light boxes if not) immediately after waking up in the morning
– Get early morning exercise
– Beta-blockers early in the morning (not generally recommended, but if you’re taking beta-blockers, take them in the morning)

TO TREAT ADVANCED PHASE SLEEP DISORDER (ie you go to bed too early and wake up too early, and you want it to be later)
– Take melatonin immediately after waking
– Block blue light (eg with blue-blocker sunglasses or f.lux) early in the morning
– Expose yourself to bright blue light (sunlight if possible, light boxes if not) in the evening.
– Get late evening exercise
– Beta-blockers in the evening (not generally recommended, but if you’re taking beta-blockers, take them in the evening)

These don’t “cure” the condition permanently; your have to keep doing them every day, or your circadian rhythm will snap back to its natural pattern.

What is the correct dose for these indications? Here there is a lot more controversy than the hypnotic dose. Of the nine studies van Geijlswijk describes, seven have doses of 5 mg, which suggests this is something of a standard for this purpose. But the only study to compare different doses directly (Mundey et al 2005) found no difference between a 0.3 and 3.0 mg dose. The Cochrane Review on jet lag, which we’ll see is the same process, similarly finds no difference between 0.5 and 5.0.

Van Geijlswijk makes the important point that if you take 0.3 mg seven hours before bedtime, none of it is going to be remaining in your system at bedtime, so it’s unclear how this even works. But – well, it is pretty unclear how this works. In particular, I don’t think there’s a great well-understood physiological explanation for how taking melatonin early in the day shifts your circadian rhythm seven hours later.

So I think the evidence points to 0.3 mg being a pretty good dose here too, but I wouldn’t blame you if you wanted to try taking more.

4. How do I use melatonin for jet lag?

Most studies say to take a dose of 0.3 mg just before (your new time zone’s) bedtime.

This doesn’t make a lot of sense to me. It seems like you should be able to model jet lag as a circadian rhythm disorder. That is, if you move to a time zone that’s five hours earlier, you’re in the exact same position as a teenager whose circadian rhythm is set five hours later than the rest of the world’s. This suggests you should use DSPD protocol of taking melatonin nine hours after waking / five hours before DLMO / seven hours before sleep.

My guess is for most people, their new time zone bedtime is a couple of hours before their old bedtime, so you’re getting most of the effect, plus the hypnotic effect. But I’m not sure. Maybe taking it earlier would work better. But given that the new light schedule is already working in your favor, I think most people find that taking it at bedtime is more than good enough for them.

5. I try to use melatonin for sleep, but it just gives me weird dreams and makes me wake up very early

This is my experience too. When I use melatonin, I find I wake the next morning with a jolt of energy. Although I usually have to grudgingly pull myself out of bed, melatonin makes me wake up bright-eyed, smiling, and ready to face the day ahead of me…

…at 4 AM, invariably. This is why despite my interest in this substance I never take melatonin myself anymore.

There are many people like me. What’s going on with us, and can we find a way to make melatonin work for us?

This bro-science site has an uncited theory. Melatonin is known to suppress cortisol production. And cortisol is inversely correlated with adrenaline. So if you’re naturally very low cortisol, melatonin spikes your adrenaline too high, producing the “wake with a jolt” phenomenon that I and some other people experience. I like the way these people think. They understand individual variability, their model is biologically plausible, and it makes sense. It’s also probably wrong; it has too many steps, and nothing in biology is ever this elegant or sensible.

I think a more parsimonious theory would have to involve circadian rhythm in some way. Even an 0.3 mg dose of melatonin gives your body the absolute maximum amount of melatonin it would ever have during a natural circadian cycle. So suppose I want to go to bed at 11, and take 0.3 mg melatonin. Now my body has a melatonin peak (usually associated with the very middle of the night, like 3 AM) at 11. If it assumes that means it’s really 3 AM, then it might decide to wake up 5 hours later, at what it thinks is 8 AM, but which is actually 4.

I think I have a much weaker circadian rhythm than most people – at least, I take a lot of naps during the day, and fall asleep about equally well whenever. If that’s true, maybe melatonin acts as a superstimulus for me. The normal tendency to wake up feeling refreshed and alert gets exaggerated into a sudden irresistable jolt of awakeness.

I don’t know if this is any closer to the truth than the adrenaline theory, but it at least fits what we know about circadian rhythms. I’m going to try to put some questions about melatonin response on the SSC survey this year, so start trying melatonin now so you can provide useful data.

What about the weird dreams?

From a HuffPo article:

Dr. Rafael Pelayo, a Stanford University professor of sleep medicine, said he doesn’t think melatonin causes vivid dreams on its own. “Who takes melatonin? Someone who’s having trouble sleeping. And once you take anything for your sleep, once you start sleeping more or better, you have what’s called ‘REM rebound,’” he said.

This means your body “catches up” on the sleep phase known as rapid eye movement, which is characterized by high levels of brain-wave activity.

Normal subjects who take melatonin supplements in the controlled setting of a sleep lab do not spend more time dreaming or in REM sleep, Pelayo added. This suggests that there is no inherent property of melatonin that leads to more or weirder dreams.

Okay, but I usually have normal sleep. I take melatonin sometimes because I like experimenting with psychotropic substances. And I still get some really weird dreams. A Slate journalist says he’s been taking melatonin for nine years and still gets crazy dreams.

We know that REM sleep is most common towards the end of sleep in the early morning. And we know that some parts of sleep structure are responsive to melatonin directly. There’s a lot of debate over exactly what melatonin does to REM sleep, but given all the reports of altered dreaming, I think you could pull together a case that it has some role in sleep architecture that promotes or intensifies REM.

6. Does this relate to any other psychiatric conditions?

Probably, but this is all still speculative.

Seasonal affective disorder is the clearest suspect. We know that the seasonal mood changes don’t have anything to do with temperature; they seem to be based entirely on winter having shorter (vs. summer having longer) days.

There’s some evidence that there are two separate kinds of winter depression. In one, the late sunrises train people to a late circadian rhythm and they end up phase-delayed. In the other, the early sunsets train people to an early circadian rhythm and they end up phase-advanced. Plausibly SAD also involves some combination of the two where the circadian rhythm doesn’t know what it’s doing. In either case, this can make sleep non-circadian-rhythm-congruent and so less effective at doing whatever it is sleep does, which causes mood problems.

How does sunrise time affect the average person, who is rarely awake for the sunrise anyway and usually sleeps in a dark room? I think your brain subconsciously “notices” the time of the dawn even if you are asleep. There are some weird pathways leading from the eyes to the nucleus governing circadian rhythm that seem independent of any other kind of vision; these might be keeping tabs on the sunrise if even a little outside light is able to leak into your room. I’m basing this also on the claim that dawn simulators work even if you sleep through them. I don’t know if people get seasonal affective disorder if they sleep in a completely enclosed spot (eg underground) where there’s no conceivable way for them to monitor sunrise times.

Bright light is the standard treatment for SAD for the same reason it’s the standard treatment for any other circadian phase delay, but shouldn’t melatonin work also? Yes, and there are some preliminary studies (paper, article) showing it does. You have to be a bit careful, because some people are phase-delayed and others phase-advanced, and if you use melatonin the wrong way it will make things work. But for the standard phase-delay type of SAD, normal phase advancing melatonin protocol seems to go well with bright light as an additional treatment.

This model also explains the otherwise confusing tendency of some SAD sufferers to get depressed in the summer. The problem isn’t amount of light, it’s circadian rhythm disruption – which summer can do just as well as winter can.

I’m also very suspicious there’s a strong circadian component to depression, based on a few lines of evidence.

First, one of the most classic symptoms of depression is awakening in the very early morning and not being able to get back to sleep. This is confusing for depressed people, who usually think of themselves as very tired and needing to sleep more, but it definitely happens. This fits the profile for a circadian rhythm issue.

Second, agomelatine, a melatonin analogue, is an effective (ish) antidepressant.

Third, for some reason staying awake for 24+ hours is a very effective depression treatment (albeit temporary; you’ll go back to normal after sleeping). This seems to sort of be a way of telling your circadian rhythm “You can’t fire me, I quit”, and there are some complicated sleep deprivation / circadian shift protocols that try to leverage it into a longer-lasting cure. I don’t know anything about this, but it seems pretty interesting.

Fourth, we checked and depressed people definitely have weird circadian rhythms.

Last of all, bipolar has a very strong circadian component. There aren’t a whole lot of lifestyle changes that really work for preventing bipolar mood episodes, but one of the big ones is keeping a steady bed and wake time. Social rhythms therapy, a rare effective psychotherapy for bipolar disorder, revolves around training bipolar people to control their circadian rhythms.

Theories of why circadian rhythms matter so much revolve either around the idea of pro-circadian sleep – that sleep is more restorative and effective when it matches the circadian cycle – or the idea of multiple circadian rhythms, with the body functioning better when all of them are in sync.

7. How can I know what the best melatonin supplement is?

Labdoor has done purity tests on various brands and has ranked them for you. All the ones they highlight are still ten to thirty times the appropriate dose (also, stop calling them things like “Triple Strength!” You don’t want your medications to be too strong!). As usual, I trust NootropicsDepot for things like this – and sure enough their melatonin (available on Amazon) is exactly 0.3 mg. God bless them.

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Book Review: Twelve Rules For Life

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I.

I got Jordan Peterson’s Twelve Rules For Life for the same reason as the other 210,000 people: to make fun of the lobster thing. Or if not the lobster thing, then the neo-Marxism thing, or the transgender thing, or the thing where the neo-Marxist transgender lobsters want to steal your precious bodily fluids.

But, uh…I’m really embarrassed to say this. And I totally understand if you want to stop reading me after this, or revoke my book-reviewing license, or whatever. But guys, Jordan Peterson is actually good.

The best analogy I can think of is C.S. Lewis. Lewis was a believer in the Old Religion, which at this point has been reduced to cliche. What could be less interesting than hearing that Jesus loves you, or being harangued about sin, or getting promised Heaven, or threatened with Hell? But for some reason, when Lewis writes, the cliches suddenly work. Jesus’ love becomes a palpable force. Sin becomes so revolting you want to take a shower just for having ever engaged in it. When Lewis writes about Heaven you can hear harp music; when he writes about Hell you can smell brimstone. He didn’t make me convert to Christianity, but he made me understand why some people would.

Jordan Peterson is a believer in the New Religion, the one where God is the force for good inside each of us, and all religions are equal paths to wisdom, and the Bible stories are just guides on how to live our lives. This is the only thing even more cliched than the Old Religion. But for some reason, when Peterson writes about it, it works. When he says that God is the force for good inside each of us, you can feel that force pulsing through your veins. When he says the Bible stories are guides to how to live, you feel tempted to change your life goal to fighting Philistines.

The politics in this book lean a bit right, but if you think of Peterson as a political commentator you’re missing the point. The science in this book leans a bit Malcolm Gladwell, but if you think of him as a scientist you’re missing the point. Philosopher, missing the point. Public intellectual, missing the point. Mythographer, missing the point. So what’s the point?

About once per news cycle, we get a thinkpiece about how Modern Life Lacks Meaning. These all go through the same series of tropes. The decline of Religion. The rise of Science. The limitless material abundance of modern society. The fact that in the end all these material goods do not make us happy. If written from the left, something about people trying to use consumer capitalism to fill the gap; if written from the right, something about people trying to use drugs and casual sex. The vague plea that we get something better than this.

Twelve Rules isn’t another such thinkpiece. The thinkpieces are people pointing out a gap. Twelve Rules is an attempt to fill it. This isn’t unprecedented – there are always a handful of cult leaders and ideologues making vague promises. But if you join the cult leaders you become a cultist, and if you join the ideologues you become the kind of person Eric Hoffer warned you about. Twelve Rules is something that could, in theory, work for intact human beings. It’s really impressive.

The non-point-missing description of Jordan Peterson is that he’s a prophet.

Cult leaders tell you something new, like “there’s a UFO hidden inside that comet”. Self-help gurus do the same: “All you need to do is get the right amount of medium-chain-triglycerides in your diet”. Ideologues tell you something controversial, like “we should rearrange society”. But prophets are neither new nor controversial. To a first approximation, they only ever say three things:

First, good and evil are definitely real. You know they’re real. You can talk in philosophy class about how subtle and complicated they are, but this is bullshit and you know it. Good and evil are the realest and most obvious things you will ever see, and you recognize them on sight.

Second, you are kind of crap. You know what good is, but you don’t do it. You know what evil is, but you do it anyway. You avoid the straight and narrow path in favor of the easy and comfortable one. You make excuses for yourself and you blame your problems on other people. You can say otherwise, and maybe other people will believe you, but you and I both know you’re lying.

Third, it’s not too late to change. You say you’re too far gone, but that’s another lie you tell yourself. If you repented, you would be forgiven. If you take one step towards God, He will take twenty toward you. Though your sins be like scarlet, they shall be white as snow.

This is the General Prophetic Method. It’s easy, it’s old as dirt, and it works.

So how come not everyone can be a prophet? The Bible tells us why people who wouldn’t listen to the Pharisees listened to Jesus: “He spoke as one who had confidence”. You become a prophet by saying things that you would have to either be a prophet or the most pompous windbag in the Universe to say, then looking a little too wild-eyed for anyone to be comfortable calling you the most pompous windbag in the universe. You say the old cliches with such power and gravity that it wouldn’t even make sense for someone who wasn’t a prophet to say them that way.

“He, uh, told us that we should do good, and not do evil, and now he’s looking at us like we should fall to our knees.”

“Weird. Must be a prophet. Better kneel.”

Maybe it’s just that everyone else is such crap at it. Maybe it’s just that the alternatives are mostly either god-hates-fags fundamentalists or more-inclusive-than-thou milquetoasts. Maybe if anyone else was any good at this, it would be easy to recognize Jordan Peterson as what he is – a mildly competent purveyor of pseudo-religious platitudes. But I actually acted as a slightly better person during the week or so I read Jordan Peterson’s book. I feel properly ashamed about this. If you ask me whether I was using dragon-related metaphors, I will vociferously deny it. But I tried a little harder at work. I was a little bit nicer to people I interacted with at home. It was very subtle. It certainly wasn’t because of anything new or non-cliched in his writing. But God help me, for some reason the cliches worked.

II.

Twelve Rules is twelve chapters centered around twelve cutesy-sounding rules that are supposed to guide your life. The meat of the chapters never has anything to do with the cutesy-sounding rules. “Treat yourself like someone you are responsible for helping” is about slaying dragons. “Pet a cat when you encounter one on the street” is about a heart-wrenchingly honest investigation of the Problem of Evil. “Do not bother children when they are skateboarding” is about neo-Marxist transgender lobsters stealing your precious bodily fluids. All of them turn out to be the General Prophetic Method applied in slightly different ways.

And a lot of them – especially the second – center around Peterson’s idea of Order vs. Chaos. Order is the comfortable habit-filled world of everyday existence, symbolized by the Shire or any of a thousand other Shire-equivalent locations in other fantasies or fairy tales. Chaos is scary things you don’t understand pushing you out of your comfort zone, symbolized by dragons or the Underworld or [approximately 30% of mythological objects, characters, and locations]. Humans are living their best lives when they’re always balanced on the edge of Order and Chaos, converting the Chaos into new Order. Lean too far toward Order, and you get boredom and tyranny and stagnation. Lean too far toward Chaos, and you get utterly discombobulated and have a total breakdown. Balance them correctly, and you’re always encountering new things, grappling with them, and using them to enrich your life and the lives of those you care about.

So far, so cliched – but again, when Peterson says cliches, they work. And at the risk of becoming a cliche myself, I couldn’t help connecting this to the uncertainty-reduction drives we’ve been talking about recently. These run into a pair of paradoxes: if your goal is to minimize prediction error, you should sit quietly in a dark room with earplugs on, doing nothing. But if your goal is to minimize model uncertainty, you should be infinitely curious, spending your entire life having crazier and crazier experiences in a way that doesn’t match the behavior of real humans. Peterson’s claim – that our goal is to balance these two – seems more true to life, albeit not as mathematically grounded as any of the actual neuroscience theories. But it would be really interesting if one day we could determine that this universal overused metaphor actually reflects something important about the structure of our brains.

Failing to balance these (Peterson continues) retards our growth as people. If we lack courage, we might stick with Order, refusing to believe anything that would disrupt our cozy view of life, and letting our problems gradually grow larger and larger. This is the person who sticks with a job they hate because they fear the unknown of starting a new career, or the political ideologue who tries to fit everything into one bucket so he doesn’t have to admit he was wrong. Or we might fall into Chaos, always being too timid to make a choice, “keeping our options open” in a way that makes us never become anyone at all.

This is where Peterson is at his most Lewisian. Lewis believes that Hell is a choice. On the literal level, it’s a choice not to accept God. But on a more metaphorical level, it’s a choice to avoid facing a difficult reality by ensconcing yourself in narratives of victimhood and pride. You start with some problem – maybe your career is stuck. You could try to figure out what your weaknesses are and how to improve – but that would require an admission of failure and a difficult commitment. You could change companies or change fields until you found a position that better suited your talents – but that would require a difficult leap into the unknown. So instead you complain to yourself about your sucky boss, who is too dull and self-absorbed to realize how much potential you have. You think “I’m too good for this company anyway”. You think “Why would I want to go into a better job, that’s just the rat race, good thing I’m not the sort of scumbag who’s obsessed with financial success.” When your friends and family members try to point out that you’re getting really bitter and sabotaging your own prospects, you dismiss them as tools of the corrupt system. Finally you reach the point where you hate everybody – and also, if someone handed you a promotion on a silver platter, you would knock it aside just to spite them.

…except a thousand times more subtle than this, and reaching into every corner of life, and so omnipresent that avoiding it may be the key life skill. Maybe I’m not good at explaining it; read The Great Divorce (online copy, my review).

Part of me feels guilty about all the Lewis comparisons. One reason is that maybe Peterson isn’t that much like Lewis. Maybe they’re just the two representatives I’m really familiar with from the vast humanistic self-cultivation tradition. Is Peterson really more like Lewis than he is like, let’s say, Marcus Aurelius? I’m not sure, except insofar as Lewis and Peterson are both moderns and so more immediately-readable than Meditations.

Peterson is very conscious of his role as just another backwater stop on the railroad line of Western Culture. His favorite citations are Jung and Nietzsche, but he also likes name-dropping Dostoevsky, Plato, Solzhenitsyn, Milton, and Goethe. He interprets all of them as part of this grand project of determining how to live well, how to deal with the misery of existence and transmute it into something holy.

And on the one hand, of course they are. This is what every humanities scholar has been saying for centuries when asked to defend their intellectual turf. “The arts and humanities are there to teach you the meaning of life and how to live.” On the other hand, I’ve been in humanities classes. Dozens of them, really. They were never about that. They were about “explain how the depiction of whaling in Moby Dick sheds light on the economic transformations of the 19th century, giving three examples from the text. Ten pages, single spaced.” And maybe this isn’t totally disconnected from the question of how to live. Maybe being able to understand this kind of thing is a necessary part of being able to get anything out of the books at all.

But just like all the other cliches, somehow Peterson does this better than anyone else. When he talks about the Great Works, you understand, on a deep level, that they really are about how to live. You feel grateful and even humbled to be the recipient of several thousand years of brilliant minds working on this problem and writing down their results. You understand why this is all such a Big Deal.

You can almost believe that there really is this Science-Of-How-To-Live-Well, separate from all the other sciences, barely-communicable by normal means but expressible through art and prophecy. And that this connects with the question on everyone’s lips, the one about how we find a meaning for ourselves beyond just consumerism and casual sex.

III.

But the other reason I feel guilty about the Lewis comparison is that C.S. Lewis would probably have hated Jordan Peterson.

Lewis has his demon character Screwtape tell a fellow demon:

Once you have made the World an end, and faith a means, you have almost won your man [for Hell], and it makes very little difference what kind of worldly end he is pursuing. Provided that meetings, pamphlets, policies, movements, causes, and crusades, matter more to him than prayers and sacraments and charity, he is ours — and the more “religious” (on those terms) the more securely ours.

I’m not confident in my interpretation of either Lewis or Peterson, but I think Lewis would think Peterson does this. He makes the world an end and faith a means. His Heaven is a metaphorical Heaven. If you sort yourself out and trust in metaphorical God, you can live a wholesome self-respecting life, make your parents proud, and make the world a better place. Even though Peterson claims “nobody is really an atheist” and mentions Jesus about three times per page, I think C.S. Lewis would consider him every bit as atheist as Richard Dawkins, and the worst sort of false prophet.

That forces the question – how does Peterson ground his system? If you’re not doing all this difficult self-cultivation work because there’s an objective morality handed down from on high, why is it so important? “C’mon, we both know good and evil exist” takes you pretty far, but it might not entirely bridge the Abyss on its own. You come of age, you become a man (offer valid for boys only, otherwise the neo-Marxist lobsters will get our bodily fluids), you act as a pillar of your community, you balance order and chaos – why is this so much better than the other person who smokes pot their whole life?

On one level, Peterson knocks this one out of the park:

I [was] tormented by the fact of the Cold War. It obsessed me. It gave me nightmares. It drove me into the desert, into the long night of the human soul. I could not understand how it had come to pass that the world’s two great factions aimed mutual assured destruction at each other. Was one system just as arbitrary and corrupt as the other? Was it a mere matter of opinion? Were all value structures merely the clothing of power?

Was everyone crazy?

Just exactly what happened in the twentieth century, anyway? How was it that so many tens of millions had to die, sacrificed to the new dogmas and ideologies? How was it that we discovered something worse, much worse, than the aristocracy and corrupt religious beliefs that communism and fascism sought so rationally to supplant? No one had answered those questions, as far as I could tell. Like Descartes, I was plagued with doubt. I searched for one thing— anything— I could regard as indisputable. I wanted a rock upon which to build my house. It was doubt that led me to it […]

What can I not doubt? The reality of suffering. It brooks no arguments. Nihilists cannot undermine it with skepticism. Totalitarians cannot banish it. Cynics cannot escape from its reality. Suffering is real, and the artful infliction of suffering on another, for its own sake, is wrong. That became the cornerstone of my belief. Searching through the lowest reaches of human thought and action, understanding my own capacity to act like a Nazi prison guard or gulag archipelago trustee or a torturer of children in a dunegon, I grasped what it means to “take the sins of the world onto oneself.” Each human being has an immense capacity for evil. Each human being understands, a priori, perhaps not what is good, but certainly what is not. And if there is something that is not good, then there is something that is good. If the worst sin is the torment of others, merely for the sake of the suffering produced – then the good is whatever is diametrically opposite to that. The good is whatever stops such things from happening.

It was from this that I drew my fundamental moral conclusions. Aim up. Pay attention. Fix what you can fix. Don’t be arrogant in your knowledge. Strive for humility, because totalitarian pride manifests itself in intolerance, oppression, torture and death. Become aware of your own insufficiency— your cowardice, malevolence, resentment and hatred. Consider the murderousness of your own spirit before you dare accuse others, and before you attempt to repair the fabric of the world. Maybe it’s not the world that’s at fault. Maybe it’s you. You’ve failed to make the mark. You’ve missed the target. You’ve fallen short of the glory of God. You’ve sinned. And all of that is your contribution to the insufficiency and evil of the world. And, above all, don’t lie. Don’t lie about anything, ever. Lying leads to Hell. It was the great and the small lies of the Nazi and Communist states that produced the deaths of millions of people.

Consider then that the alleviation of unnecessary pain and suffering is a good. Make that an axiom: to the best of my ability I will act in a manner that leads to the alleviation of unnecessary pain and suffering. You have now placed at the pinnacle of your moral hierarchy a set of presuppositions and actions aimed at the betterment of Being. Why? Because we know the alternative. The alternative was the twentieth century. The alternative was so close to Hell that the difference is not worth discussing. And the opposite of Hell is Heaven. To place the alleviation of unnecessary pain and suffering at the pinnacle of your hierarchy of value is to work to bring about the Kingdom of God on Earth.

I think he’s saying – suffering is bad. This is so obvious as to require no justification. If you want to be the sort of person who doesn’t cause suffering, you need to be strong. If you want to be the sort of person who can fight back against it, you need to be even stronger. To strengthen yourself, you’ll need to deploy useful concepts like “God”, “faith”, and “Heaven”. Then you can dive into the whole Western tradition of self-cultivation which will help you take it from there. This is a better philosophical system-grounding than I expect from a random psychology-professor-turned-prophet.

But on another level, something about it seems a bit off. Taken literally, wouldn’t this turn you into a negative utilitarian? (I’m not fixated on the “negative” part, maybe Peterson would admit positive utility into his calculus). One person donating a few hundred bucks to the Against Malaria Foundation will prevent suffering more effectively than a hundred people cleaning their rooms and becoming slightly psychologically stronger. I think Peterson is very against utilitarianism, but I’m not really sure why.

Also, later he goes on and says that suffering is an important part of life, and that attempting to banish suffering will destroy your ability to be a complete human. I think he’s still kind of working along a consequentialist framework, where if you banish suffering now by hiding your head in the sand, you won’t become stronger and you won’t be ready for some other worse form of suffering you can’t banish. But if you ask him “Is it okay to banish suffering if you’re pretty sure it won’t cause more problems down the line?” I cannot possibly imagine him responding with anything except beautifully crafted prose on the importance of suffering in the forging of the human spirit or something. I worry he’s pretending to ground his system in “against suffering” when it suits him, but going back to “vague traditionalist platitudes” once we stop bothering him about the grounding question.

In a widely-followed debate with Sam Harris, Peterson defended a pragmatic notion of Truth: things are True if they help in this project of sorting yourself out and becoming a better person. So God is True, the Bible is True, etc. This awkwardly jars with book-Peterson’s obsessive demand that people tell the truth at all times, which seems to use a definition of Truth which is more reality-focused. If Truth is what helps societies survive and people become better, can’t a devoted Communist say that believing the slogans of the Party will help society and make you a better person?

Peterson has a bad habit of saying he supports pragmatism when he really supports very specific values for their own sake. This is hardly the worst habit to have, but it means all of his supposed pragmatic justifications don’t actually justify the things he says, and a lot of his system is left hanging.

I said before that thinking of Peterson as a philosopher was missing the point. Am I missing the point here? Surely some lapses in philosophical groundwork are excusable if he’s trying to add meaning to the lives of millions of disillusioned young people.

But that’s exactly the problem. I worry Peterson wakes up in the morning and thinks “How can I help add meaning to people’s lives?” and then he says really meaningful-sounding stuff, and then people think their lives are meaningful. But at some point, things actually have to mean a specific other thing. They can’t just mean meaning. “Mean” is a transitive verb. It needs some direct object.

Peterson has a paper on how he defines “meaning”, but it’s not super comprehensible. I think it boils down to his “creating order out of chaos” thing again. But unless you use a purely mathematical definition of “order” where you comb through random bit streams and make them more compressible, that’s not enough. Somebody who strove to kill all blue-eyed people would be acting against entropy, in a sense, but if they felt their life was meaningful it would at best be a sort of artificial wireheaded meaning. What is it that makes you wake up in the morning and reduce a specific patch of chaos into a specific kind of order?

What about the most classic case of someone seeking meaning – the person who wants meaning for their suffering? Why do bad things happen to good people? Peterson talks about this question a lot, but his answers are partial and unsatisfying. Why do bad things happen to good people? “If you work really hard on cultivating yourself, you can have fewer bad things happen to you.” Granted, but why do bad things happen to good people? “If you tried to ignore all bad things and shelter yourself from them, you would be weak and contemptible.” Sure, but why do bad things happen to good people? “Suffering makes us stronger, and then we can use that strength to help others.” But, on the broader scale, why do bad things happen to good people? “The mindset that demands no bad thing ever happen will inevitably lead to totalitarianism.” Okay, but why do bad things happen to good people? “Uh, look, a neo-Marxist transgender lobster! Quick, catch it before it gets away!”

C.S. Lewis sort of has an answer: it’s all part of a mysterious divine plan. And atheists also sort of have an answer: it’s the random sputtering of a purposeless universe. What about Peterson?

I think – and I’m really uncertain here – that he doesn’t think of meaning this way. He thinks of meaning as some function mapping goals (which you already have) to motivation (which you need). Part of you already wants to be successful and happy and virtuous, but you’re not currently doing any of those things. If you understand your role in the great cosmic drama, which is as a hero-figure transforming chaos into order, then you’ll do the things you know are right, be at one with yourself, and be happier, more productive, and less susceptible to totalitarianism.

If that’s what you’re going for, then that’s what you’re going for. But a lot of the great Western intellectuals Peterson idolizes spent their lives grappling with the fact that you can’t do exactly the thing Peterson is trying to do. Peterson has no answer to them except to turn the inspiringness up to 11. A commenter writes:

I think Nietzsche was right – you can’t just take God out of the narrative and pretend the whole moral metastructure still holds. It doesn’t. JP himself somehow manages to say Nietzsche was right, lament the collapse, then proceed to try to salvage the situation with a metaphorical fluff God.

So despite the similarities between Peterson and C.S. Lewis, if the great man himself were to read Twelve Rules, I think he would say – in some kind of impeccably polite Christian English gentleman way – fuck that shit.

IV.

Peterson works as a clinical psychologist. Many of the examples in the book come from his patients; a lot of the things he thinks about comes from their stories. Much of what I think I got from this book was psychotherapy advice; I would have killed to have Peterson as a teacher during residency.

C.S. Lewis might have hated Peterson, but we already know he loathed Freud. Yet Peterson does interesting work connecting the Lewisian idea of the person trapped in their victimization and pride narratives to Freud’s idea of the defense mechanism. In both cases, somebody who can’t tolerate reality diverts their emotions into a protective psychic self-defense system; in both cases, the defense system outlives its usefulness and leads to further problems down the line. Noticing the similarity helped me understand both Freud and Lewis better, and helped me push through Freud’s scientific veneer and Lewis’ Christian veneer to find the ordinary everyday concept underneath both. I notice I wrote about this several years ago in my review of The Great Divorce, but I guess I forgot. Peterson reminded me, and it’s worth being reminded of.

But Peterson is not really a Freudian. Like many great therapists, he’s a minimalist. He discusses his philosophy of therapy in the context of a particularly difficult client, writing:

Miss S knew nothing about herself. She knew nothing about other individuals. She knew nothing about the world. She was a movie played out of focus. And she was desperately waiting for a story about herself to make it all make sense.

If you add some sugar to cold water, and stir it, the sugar will dissolve. If you heat up that water, you can dissolve more. If you heat the water to boiling, you an add a lot more sugar and get that to dissolve too. Then, if you take that boiling sugar water, and slowly cool it, and don’t bump it or jar it, you can trick it (I don’t know how else to phrase this) into holding a lot more dissolved sugar than it would have if it had remained cool all along. That’s called a super-saturated solution. If you drop a single crystal of sugar into that super-saturated solution, all the excess sugar will suddenly and dramatically crystallize. It’s as if it were crying out for order.

That was my client. People like her are the reason that the many forms of psychotherapy currently practised all work. People can be so confused that their psyches will be ordered and their lives improved by the adoption of any reasonably orderly system of interpretation.

This is the bringing together of the disparate elements of their lives in a disciplined manner – any disciplined manner. So, if you have come apart at the seams (or you have never been together at all) you can restructure your life on Freudian, Jungian, Adlerian, Rogerian, or behavioral principles. At least then you make sense. At least then you’re coherent. At least then you might be good for something, if not yet good for everything.

I have to admit, I read the therapy parts of this book with a little more desperation than might be considered proper. Psychotherapy is really hard, maybe impossible. Your patient comes in, says their twelve-year old kid just died in some tragic accident. Didn’t even get to say good-bye. They’re past their childbearing age now, so they’ll never have any more children. And then they ask you for help. What do you say? “It’s not as bad as all that”? But it’s exactly as bad as all that. All you’ve got are cliches. “Give yourself time to grieve”. “You know that she wouldn’t have wanted you to be unhappy”. “At some point you have to move on with your life”.

Jordan Peterson’s superpower is saying cliches and having them sound meaningful. There are times – like when I have a desperate and grieving patient in front of me – that I would give almost anything for this talent. “You know that she wouldn’t have wanted you to be unhappy.” “Oh my God, you’re right! I’m wasting my life grieving when I could be helping others and making her proud of me, let me go out and do this right now!” If only.

So how does Jordan Peterson, the only person in the world who can say our social truisms and get a genuine reaction with them, do psychotherapy?

He mostly just listens:

The people I listen to need to talk, because that’s how people think. People need to think…True thinking is complex and demanding. It requires you to be articulate speaker and careful, judicious listener at the same time. It involves conflict. So you have to tolerate conflict. Conflict involves negotiation and compromise. So, you have to learn to give and take and to modify your premises and adjust your thoughts – even your perceptions of the world…Thinking is emotionally painful and physiologically demanding, more so than anything else – exept not thinking. But you have to be very articulate and sophisticated to have all this thinking occur inside your own head. What are you to do, then, if you aren’t very good at thinking, at being two people at one time? That’s easy. You talk. But you need someone to listen. A listening person is your collaborator and your opponent […]

The fact is important enough to bear repeating: people organize their brains through conversation. If they don’t have anyone to tell their story to, they lose their minds. Like hoarders, they cannot unclutter themselves. The input of the community is required for the integrity of the individual psyche. To put it another way: it takes a village to build a mind.

And:

A client of mine might say, “I hate my wife”. It’s out there, once sdaid. It’s hanging in the air. It has emerged from the underworld, materialized from chaos, and manifested itself. It is perceptible and concrete and no longer easily ignored. It’s become real. The speaker has even startled himself. He sees the same thing reflected in my eyes. He notes that, and continues on the road to sanity. “Hold it,” he says. “Back up That’s too harsh. Sometimes I hate my wife. I hate her when she won’t tell me what she wants. My mom did that all the time, too. It drove Dad crazy. It drove all of us crazy, to tell you the truth. It even drove Mom crazy! She was a nice person, but she was very resentful. Well, at least my wife isn’t as bad as my mother. Not at all. Wait! I guess my wife is atually pretty good at telling me what she wants, but I get really bothered when she doesn’t, because Mom tortured us all half to death being a martyr. That really affected me. Maybe I overreact now when it happens even a bit. Hey! I’m acting just like Dad did when Mom upset him! That isn’t me. That doesn’t have anthing to do with my wife! I better let her know.” I observe from all this that my client had failed previously to properly distinguish his wife from his mother. And I see that he was possessed, unconsciously, by the spirit of his father. He sees all of that too. Now he is a bit more differentiated, a bit less of an uncarved block, a bit less hidden in the fog. He has sewed up a small tear in the fabric of his culture. He says “That was a good session, Dr. Peterson.” I nod.

This is what all the textbooks say too. But it was helpful hearing Jordan Peterson say it. Everybody – at least every therapist, but probably every human being – has this desperate desire to do something to help the people in front of them who are in pain, right now. And you always think – if I were just a deeper, more eloquent person, I could say something that would solve this right now. Part of the therapeutic skillset is realizing that this isn’t true, and that you’ll do more harm than good if you try. But you still feel inadequate. And so learning that Jordan Peterson, who in his off-hours injects pharmaceutical-grade meaning into thousands of disillusioned young people – learning that even he doesn’t have much he can do except listen and try to help people organize their narrative – is really calming and helpful.

And it makes me even more convinced that he’s good. Not just a good psychotherapist, but a good person. To be able to create narratives like Peterson does – but also to lay that talent aside because someone else needs to create their own without your interference – is a heck of a sacrifice.

I am not sure if Jordan Peterson is trying to found a religion. If he is, I’m not interested. I think if he had gotten to me at age 15, when I was young and miserable and confused about everything, I would be cleaning my room and calling people “bucko” and worshiping giant gold lobster idols just like all the other teens. But now I’m older, I’ve got my identity a little more screwed down, and I’ve long-since departed the burned-over district of the soul for the Utah of respectability-within-a-mature-cult.

But if Peterson forms a religion, I think it will be a force for good. Or if not, it will be one of those religions that at least started off with a good message before later generations perverted the original teachings and ruined everything. I see the r/jordanpeterson subreddit is already two-thirds culture wars, so they’re off to a good start. Why can’t we stick to the purity of the original teachings, with their giant gold lobster idols?

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avilad
116 days ago
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Navigating And/Or Avoiding The Inpatient Mental Health System

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Apology and disclaimer

This is in response to questions I get about how to interact (or not interact) with the inpatient mental health system and involuntary commitment. The table of contents is:

1. How can I get outpatient mental health care without much risk of being involuntarily committed to a hospital?
2: How can I get mental health care at a hospital ER without much risk of being involuntarily committed?
3. I would like to get voluntarily committed to a hospital. How can I do that?
4. I am seeking inpatient treatment. How can I make sure that everyone knows I am there voluntarily, and that I don’t get shifted to involuntary status?
5. How can I decide which psychiatric hospital to go to?
6. I am in a psychiatric hospital. How can I make this experience as comfortable as possible?
7. I am in a psychiatric hospital and not happy about it and I want to get out as quickly as possible. What should I do?
8. I am in the psychiatric hospital and I think I am being mistreated. What can I do?
9. I think my friend/family member is in the psychiatric hospital, but nobody will tell me anything.
10. My friend/family member is in the psychiatric hospital and wants to get out as quickly as possible. How can I help them?
11. How will I pay for all of this?
12. I have a friend/family member who really needs psychiatric treatment, but refuses to get it. What can I do?

I am a psychiatrist, which both means I have some useful experience here, and makes it hard for people trying to avoid the system to trust me. Anything written with too much honesty risks degenerating into “here’s how to cheat the system so nobody will know you’re about to commit suicide”. But anything written with too little honesty risks degenerating into some variation of “trust the wise benevolent doctors to do what is best for you”. This is an impossible edge to balance on, and I am sure I fail at one point or another.

But my first excuse is that if somebody doesn’t understand how the commitment system works, they’re not going to innocently blunder into spilling their guts. They’re just going to never go to the psychiatrist at all. If someone wants to avoid ending up in the hospital but doesn’t know how, it’s not like they’re stuck doing everything we want. They can just lie about everything. Or they can just never go to the psychiatrist at all. If they understand a little bit about how the system works, they can at least lie strategically, in the one place where they have to lie, while cooperating 99% of the way.

And my second excuse is that in the end, this is not an adversarial enterprise. Psychiatrists commit people because they’re scared. They’re scared because they can’t predict what the patient is going to do – and on another level, they’re scared because they might get sued if they don’t follow the rules. If patients who aren’t going to hurt themselves know how to explain that they aren’t going to hurt themselves in a way that reassures their psychiatrist, and in a way that doesn’t leave their psychiatrist legally liable for not committing them, then everybody can be more comfortable and get on with the hard work of actual treatment.

This guide applies to adult mental health care only. Child/adolescent mental health care is totally different and I don’t know anything about it. I have only worked in two states, it might be a bit different in other states, and it is definitely a lot different outside the US. Nothing in here is official medical advice. Follow it at your own risk. Please don’t use this to avoid psychiatric care which you actually need. All of this will be wrong in certain situations; when in doubt, trust your intuition.

1: How can I get outpatient mental health care without much risk of being involuntarily committed to a hospital?

Mental health care is divided into inpatient and outpatient settings. Inpatient care means it’s in a hospital, voluntary or otherwise. Outpatient care is your local doctor’s office, or psychiatrist’s office, or therapist’s office.

If you go to a hospital for mental health reasons, your risk of getting involuntarily committed is relatively high – see below for more. If you go to an outpatient provider, your risk is much lower.

In theory, the outpatient system is supposed to provide voluntary treatment, with risk of involuntary commitment only in certain very clearly delineated situations that you can understand and avoid. Each state’s laws are slightly different (and I can’t say anything about non-US countries), but they tend to allow involuntary commitment only in cases of immediate risk of hurting yourself, hurting someone else, or being so psychotic that you could plausibly hurt someone by accident (eg you jump out of a window because you think you can fly).

The key word is “immediate”. If you just have occasional thoughts about suicide, or you have some limited hallucinations but remain grounded in reality, according to the law this is not enough to involuntarily commit you.

In practice, not every mental health professional knows the laws or interprets them the same way, so they can just commit you anyway. The check on this is supposed to be that you can sue them when you get out of the hospital, but almost nobody bothers to do this, and judges and juries usually find in favor of the mental health professional.

So the law isn’t as much protection as it probably should be. In reality your best protection is to only open up to competent people whom you trust, and to frame what’s going on in a way that doesn’t scare them unnecessarily.

Don’t joke about committing suicide. Don’t bring up occasional stray suicidal thoughts if they don’t matter. Don’t say something like “I think about suicide sometimes, but doesn’t everyone?”, because your psychiatrist will have heard the last ten people answer “No, of course I never think about suicide”, and they will not be impressed with your claim about the human condition. Assume that any time you mention suicide, there’s a tiny but real chance of getting committed. If you are actually suicidal, take that chance in order to get help. Otherwise, this is really not the time to bring it up. If you wouldn’t offhandedly chat about terrorism with an airport security guard, don’t offhandedly chat about suicide with a psychiatrist.

(none of this applies to competent psychiatrists whom you trust, but award this status only after many positive experiences over a long-term relationship)

If your psychiatrist asks you outright if you ever have suicidal thoughts, well, tough call. If you don’t, then say you don’t. If you mostly don’t but you are some sort of chronically indecisive person who has trouble giving a straight answer to a question, now is the time to suppress that tendency and just say that you don’t. If you do, but you would never commit suicide and it’s not a big part of why you’re seeing them and you don’t mind lying, you can probably just say you don’t. If you do, and it’s important, and you don’t want to lie about it, then make sure to be very specific about how limited your thoughts are (eg: “I only thought that way once, three years ago) and to add as many of these as are true:

1. “Of course I would never go through with it, but sometimes I think about…”
2. “I love my friend/family member/partner/pet too much to ever go through with it.”
3. “I don’t have any plans for how I would do it.”
4. “I’m [religion], and we believe that God doesn’t want us to commit suicide.”
5. “I’ve been thinking about it for [long time], but the thoughts haven’t gotten any worse lately.”

The same applies to hallucinations and other signs of psychosis. Most people have very minor random hallucinations as they are going to sleep. Most people hear their own thoughts as silent “voices” in their head at least some of the time. Most people who take hallucinogenic drugs will hallucinate. You don’t need to bring these up when someone asks you about hallucinations. If you actually have some troubling psychotic symptoms, then mention them, but add as many of these as are true:

1. “Of course, I know these aren’t really real.”
2. “These have been going on for a while and aren’t any worse lately.”
3. “I would never listen to anything the voices say.”
4. “I only get that way when I’m on drugs / really tired / under a lot of stress.”

If you do all of these things, your chance of getting involuntarily committed to a psychiatric hospital by an outpatient provider is probably one percent or less, unless you’re really really sick.

Notice the words “by an outpatient provider” here. None of this applies if you are in a hospital (eg with pneumonia). If you are in a hospital, be extra careful about this to the point of paranoia. Tell them you don’t have any psychiatric problems, get your pneumonia or whatever treated, and then go out of the hospital, find a competent outpatient psychiatrist whom you trust, and open up about your issues to them. If you decide to open up to the nurse-assistant giving you a three question psychiatric screen in the pneumonia ward, you may end up on a psychiatric unit regardless of how careful you are, because hospitals don’t take chances.

2: How can I get mental health care at a hospital ER without much risk of being involuntarily committed?

Hospital ERs are not set up to provide psychiatric help to random people. They are set up to evaluate people and decide if it’s a real emergency. If it is, you will be committed to an inpatient unit. If it isn’t, they will tell you to see an outpatient psychiatrist, and you will be back at the beginning except with an extra $5000 bill to pay.

This is not true 100% of the time, and you can take your chances if you want. In particular, if you have extreme anxiety, sometimes they can give you enough fast-acting anti-anxiety medication to calm you down and last you until you can see an outpatient psychiatrist. But going to a hospital ER for any mental-health-related reason other than expecting to get admitted to a hospital psychiatric unit should be a last resort.

3. I would voluntarily like to get committed to a hospital. How can I do that?

If you have a competent outpatient psychiatrist whom you trust, call them up and tell them what’s going on. If they have connections at a local hospital, they may be able to get you directly admitted, which will save you a lot of time and suffering.

Otherwise, you will have to go to a hospital ER. Be prepared for this to be extremely unpleasant. It may take up to 24 hours of sitting in the ER before a psychiatrist can see you. You will probably get examined by nurses, medical students, non-psychiatrist doctors, etc, and each time you will think “Finally! I am getting evaluated and I can get out of this ER!” but you will be wrong. Although there will probably be some crappy food and drink available, there may not be much in the way of entertainment, quiet, or privacy. Do yourself a favor and bring a book or game or something. You may not be allowed to keep your cell phone or laptop or other metal object (more on this later). If family or friends are willing to help, have them come along – if only so they can go out and bring you back real food when you get hungry.

Once you set foot in an ER and mention the word “psychiatry”, you should be prepared for someone to tell you that you’re not allowed to leave until the evaluation is complete. Maybe no one will tell you this, and you can try to leave, and it’ll be fine. But you should be prepared for it not to work.

After many trials and tribulations, you will be examined by a psychiatrist, who will decide whether or not to accept you to the psychiatric unit. You are not guaranteed admission to the unit just because you want it. You might be turned down if the psychiatrist thinks you aren’t sick enough to need it, or if your insurance refuses to pay for it. Insurance companies are very reluctant to pay for hospitalizations unless there is a clear risk involved, so explain what the risk is.

The only thing that (almost) always works is mentioning suicide. If you say you’re suicidal, you will get admitted. If you want to be sure, do the opposite of everything above. Stress that you are suicidal. Stress that it’s not just the occasional fleeting thought, but actually something that you might really go ahead with. If you have a plan, share it.

If you’re not suicidal, expect to have to argue. Talk about what you’ve already tried and why it didn’t work. Talk about all the damage your mental illness has caused in your life. If there’s any chance you might snap and do something horrible – hurt someone, hurt yourself, have some kind of spectacular breakdown – play it up. If you have to, say something vague like “I don’t know what I would do if I couldn’t get help”. Be ready for this not to work, and for the psychiatrist evaluating you to recommend you go to an outpatient psychiatrist.

If you really want help beyond the level of outpatient treatment, but your insurance company won’t budge, ask about a partial hospital program. This is something where you go to a hospital-like environment from 9 to 5 for a few weeks, seeing doctors and getting therapy and classes, but you’re not involuntarily committed and you go home at night. Sometimes insurance companies will be willing to do this as a compromise if you are not suicidal.

4. I am seeking inpatient treatment. How can I make sure that everyone knows I am there voluntarily, and that I don’t get shifted to involuntary status?

I want to be really clear on this: in your head, there might be a huge difference between voluntary and involuntary hospitalization. In your doctor’s head, and in the legal system, these are two very slightly different sets of paperwork with tiny differences between them.

It works like this, with slight variation from state to state: involuntary patients are usually in the hospital for a few days while the doctors evaluate them. If at the end of those few days the doctors decide the patient is safe, they’ll discharge them. If, at the end of those few days, the doctors decide the patient is dangerous, the doctors will file for a hearing before a judge, which will take about a week. The patient will stay in the hospital for that week. 99% of the time the judge will side with the doctors, and the patient will stay until the doctors decide they are safe, usually another week or two.

Voluntary patients are technically allowed to leave whenever, but they have to do this by filing a form saying they want to. Once they file that form, their doctors may keep them in the hospital for a few more days while they decide whether they want to accept the form or challenge it. If they want to challenge it, they will file for a hearing before a judge, which will take about a week. The patient will stay in the hospital for that week. 99% of the time the judge will side with the doctors, and the patient will stay until the doctors decide they are safe, usually another week or two.

You may notice that in both cases, the doctors can keep the patient for a few days, plus however long it takes to have a hearing, plus however long the judge gives them after a hearing. So what’s the difference between voluntary and involuntary hospitalization? Pride, I guess, plus a small percent of cases where the doctors just shrug and say “whatever” when the voluntary patient tries to leave.

Some decent fraction of the time, patients who intended to get voluntarily hospitalized end up involuntarily hospitalized for inscrutable bureaucratic reasons. The one I’m most familiar with is the ambulance ride: suppose the hospital you’re in doesn’t have any psychiatric beds available and wants to send you to the hospital down the road. For inscrutable bureaucratic reasons, they have to send you by ambulance. And for inscrutable bureaucratic reasons, any psychiatric patient transferred by ambulance has to be involuntary. Your doctors don’t care about this, because they know that there is no practical difference between voluntary and involuntary – but if you are still trying to maintain your pride, this might come as kind of a shock.

Some other decent fraction of the time, patients who ought to be involuntarily hospitalized end up voluntarily hospitalized for inscrutable bureaucratic reasons. The one I’m most familiar with is doctors asking patients whom they are committing against their will to sign a voluntary form, ie “Agree to come voluntarily, or else I will commit you involuntarily”. This sounds super Orwellian, but it really is done with the patient’s best interest at heart. Involuntary commitments usually leave some kind of court record, which people can find if they’re searching your name for eg a background check. Voluntary commitments usually don’t. Even though nobody feels very warmly to the psychiatrist telling them to sign voluntarily or else, that psychiatrist is right and you should suck it up and sign the voluntary form.

If given a choice, you should sign voluntary, if only for the background-check reason above. But don’t count on getting the choice, and don’t get too attached to the illusion that it really matters in some deep way.

5. How can I decide which psychiatric hospital to go to?

If it’s an emergency, the answer is “whichever one is closest” or even “whichever one the ambulance you should call right now takes you to.”

If you have a little more leeway, and you have a competent outpatient psychiatrist whom you trust, ask them which one to go to. They will probably be familiar with the local terrain and be able to give you good advice.

If you live in a big city with wealthier and poorer areas, and it’s all the same to your insurance company, try to go to a hospital in the wealthier area. Not only do wealthier people always get nicer things, but – and sorry if this is politically incorrect – you would rather be locked up for a week with the sorts of people who end up in wealthy-area psychiatric hospitals than with the sorts of people who end up in poor-area psychiatric hospitals.

US News & World Report ranks the best psychiatric hospitals. They’re mostly looking at doctor prestige, but I would guess this correlates with other factors patients want in a hospital. If you’re really prestigious you have a lot of money and a lot of eyes watching you, and that probably helps. I suspect teaching hospitals are also good, for the same reason. But these are just guesses.

If you have no other way of figuring this out, you can try looking at Psych Ward Reviews. This site is underused and suffers from the expected bias – you only write about somewhere if you don’t like it – but it’s better than nothing.

Keep in mind that sometimes hospitals will be full, and they will send you to a different hospital instead, and you will not have any say in this.

6. I am in a psychiatric hospital. How can I make this experience as comfortable as possible?

When you go to the hospital ER to get admitted, bring a bag of stuff with you. This should include clothing, fun things to do like books, earplugs, snacks you like, and phone numbers for people you might want to contact.

Keep in mind that you will not be allowed to have anything that could be used as a weapon, for a definition of “could be used as a weapon” which is clearly aimed at MacGyver-level masterminds who can create a railgun out of three paperclips and a stick of gum. The same goes for anything that could be used as a suicide method. This means for example no laced shoes, pillowcases, scarves, and a bunch of other things you will not expect. Basically, bring stuff to the hospital, but expect a decent chance it won’t be allowed in.

Metal objects, including laptops, cell phones, mp3 players, etc, will never be allowed in. These will be taken from you and put in a locker during your stay. If for some reason you have to transfer hospitals during your stay, these things always somehow get lost. Your best bet is to bring a friend with you to the ER, and have them take your cell phone and other valuables.

If you forget to bring a bag of stuff, or if you were committed involuntarily and unexpectedly and didn’t get a chance, call a friend or family member and ask them to bring you your stuff.

7. I am in a psychiatric hospital and not happy about it and I want to get out as quickly as possible. What should I do?

Good news: average stays for psychiatric hospitals have been decreasing for decades, and are now usually a week or less. I did a study on the hospital I worked in and came up with an median stay of 5.9 days, and remember that there are a lot of really sick people bringing up those numbers.

(there are a few states that have laws centered around the number “three days”, but there are also a lot of states that don’t. For some reason the “three days” number has leaked into the general consciousness and everyone expects that to be how long they stay in the hospital. Don’t necessarily expect to get out of the hospital in exactly three days, but do expect it will be closer to 5.9 days than to weeks or months.)

Even better news: contrary to rumor, psychiatrists rarely have a financial incentive to keep people hospitalized. In fact, most hospitals and insurances now encourage quick “turnover” to “open up beds” for the next group of needy patients, and doctors can get bonuses for getting people out as quickly as possible. This should worry everyone else in the hospital who’s getting treated for pneumonia or whatever, but from the perspective of a psychiatric patient who wants to leave quickly it’s pretty good.

If you have a good doctor, you should trust their judgment and do what they say. But if you have a bad doctor, then the only thing you can count on is that they will respond to incentives. Their incentive to get you out quickly is the hospital administrators and insurance companies breathing down their neck. Their incentive to keep you longer is that if you get out of the hospital and ever do anything bad, they can get sued for “missing the signs”. So their goal is to do a token amount of work that proves they evaluated you properly so nothing that happens later is their fault.

That means they’ll keep you for some standard time interval, traditionally (though not always) three days, just so they can say they “monitored” you. If you seem unusually scary in some way, they might monitor you a little longer, up to a week or two. Your chances of successfully convincing them not to do this are essentially nil. Imagine you kill someone a few weeks after leaving the hospital, and during the trial the prosecutor says “The patient was taken to St. Elsewhere Hospital for evaluation of mental status, but discharged early, because he said he didn’t want to have to sit around and be evaluated for the usual amount of time, and his doctor thought this was a reasonable request.” Your doctor is definitely imagining this scenario.

Instead of pleading with your doctors to let you go early, just do everything right. Have meals at mealtime. Go to groups at group time. Groom yourself, not just because you look saner when you’re well-groomed, but because there will actually be nurses monitoring your grooming status and reporting it to the psychiatrists making release decisions. When people tell you things you should do after leaving the hospital, agree that you will definitely do them. If people ask you questions, give reassuring-sounding answers.

For this last one – don’t contradict evidence against you, don’t accuse other people of lying, just downplay whatever you can downplay, admit to what the doctors already believe, and make it sound like things have gotten better. For example, if you were found lying face-down with an empty bottle of pills next to you, don’t say “I didn’t attempt suicide, I just tripped and the pills fell into my mouth!” (I have seriously had patients try this one on me). Don’t say “It was my girlfriend’s fault, she drove me to do it!” Just say something like “That was a really bad night for me, and I don’t remember exactly what happened, but now I’m feeling a lot more hopeful, and I think that was a mistake.”

Don’t overdo it. Nothing is more annoying than the person who’s like “The twenty minutes I’ve been talking with you so far have turned my life around, and now I realize how wrong I was to reject God’s beautiful gift of existence, and am overflowing with abounding joy at the prospect of getting to go back into the world and truly confront my problems with the help of my loving family and…” Just be like “Yeah, things were rough, but I feel a little better now.”

Most important, take the damn drugs.

Yes, I know that some psychiatric drugs are unpleasant or addictive or dangerous or make you feel miserable. I’m not challenging your decision not to want to be on them. But take the damn drugs while you are in the hospital, for 5.9 days. Then, when they let you out, stop taking the drugs. I guarantee you this will be easier for you, for your psychiatrist, and for the various judges and lawyers involved. The alternative is that you refuse to take the drugs, somebody has to set up a court hearing to get an involuntary treatment order, you have to sit in the hospital for weeks while the legal system gets its act together, the psychiatrists finally get the order and drug you against your will, and then after however many weeks or months, you get released from the hospital and stop taking the drugs.

If you have a good doctor whom you trust, then talk to them about the drugs and make a decision together. Let them know if there are any side effects. If a drug isn’t working for you, tell them, so they can switch it. Be honest, and willing to stand up for yourself, but also open-minded and ready to listen.

But if you have a bad doctor, just take the damn drugs. Bring up side effects, mention anything that’s intolerable, but when – like bad doctors everywhere – they ignore you, just take the damn drugs. Then, when you get out of the hospital, go to a competent outpatient psychiatrist whom you trust, tell them the drugs aren’t right for you, and talk it over with them until you come up with a better plan.

This is a good general principle for everything: agree to whatever people ask you while you’re in the hospital, talk to a competent outpatient psychiatrist whom you trust once you get out, and decide which things to stick to. I remember working with a doctor who wanted to discharge his patient to some kind of outpatient drug rehab. The patient refused to go, so the doctor wouldn’t discharge her, and they were in a stalemate over it for weeks, and the whole time the patient was tearfully begging the doctor to release her. I cannot tell you how much willpower it took not to sneak into the patient’s room and yell at her “JUST AGREE TO GO TO THE REHAB AND THEN DON’T DO IT, YOU IDIOT”. I mean, I am as in favor of Truth as everyone else, but I don’t even think her doctor cared if she went to the rehab or not. He just wanted to be able to document “Patient agreed to go to rehab”, so that when she started taking drugs again, he would have ironclad court-admissable evidence that it wasn’t his fault.

Finally, your doctors will be very interested in “discharge planning”, ie making sure you have somewhere safe to be after you leave the hospital. They may not be willing to believe you about this. So get a family member (best) or friend (second-best) on your side. Have them agree to tell the doctors that they will watch over you after you leave, make sure you take your medication, make sure you get to your follow-up outpatient psychiatrist appointments, make sure you don’t take any illegal drugs. Your best bet for this is your mother – psychiatrists love mothers. Tell your doctors “I talked to my mother, she’s really concerned about my condition, she says that I can stay with her after I leave and she’s going to watch me really closely and make sure I’m okay”. Only say this if it’s true, because your doctors will call your mother and make sure of it. But if you can make this work, this is really helpful.

Even if all of this works, it’s just going to get you out of the hospital in a bit less than 5.9 days instead of a bit more than 5.9 days. There’s no good way to get out instantly. Sorry.

8. I am in the psychiatric hospital and I think I am being mistreated. What can I do?

Your best bet is to find someone with a position like “Recipient Rights Representative” or “Patient Rights Advocate”. Most states mandate that all psychiatric hospitals have a person like this. Their job is to listen to people’s concerns and investigate. Usually the doctors hate them, which I take as a pretty good sign that they are actually independent and do their job. If you haven’t already gotten a pamphlet about this person when you were admitted, ask the front desk or your nurse or someone else who seems to know what’s going on how to contact this person.

You may be able to switch doctors or nurses. Just go to the front desk or someone else official-looking and ask. I don’t think this is a legally codified right, but sometimes nobody cares enough to refuse. Keep in mind that if you switch doctors, you may have to stay longer so that the new doctor can do their three-day-or-so assessment of you, separate from the last doctor’s three-day-or-so assessment.

Threats don’t work. Everybody makes threats, and everyone at the hospital is used to them. Threatening to hire a lawyer is especially boring and overdone and will not even get anyone’s attention.

Actually hiring a lawyer will definitely get people’s attention, but it’s a high-variance strategy. Remember that it’s very hard to get a doctor not to hold you for a three-day-or-so evaluation, and that most people are released before anything goes to court anyway (a court hearing can take weeks to set up). I have mostly seen this work in cases where I have no idea what the doctors are thinking and everybody seems sort of confused and just letting the patient sit in the hospital for no reason. Lawyers can be a very good incentive for people to un-confuse themselves. I am not a lawyer, I have tried to avoid the state of prolonged confusion where lawyers become necessary, and I don’t want to give any legal advice beyond saying it will definitely get people’s attention. But I would feel bad if someone read this, hired a lawyer, found them not to be genuinely helpful (as in fact they probably will not be), and then got a huge legal bill.

Some people wait until they get out, then comparison-shop from the outside world and hire a lawyer to sue the people who mistreated them in the past. If you’re going to do this, document everything. Your doctors are documenting everything, and if one side comes in with perfect documentation and the other side just has vague memories, the first side will win. By “document everything”, I mean have a piece of paper where you write down things like “2:41 PM on October 10: Nurse Roberts threw a pencil at me. Informed such-and-such a person and they refused to help. Informed such-and-such another person and they also refused to help.” Write down exactly where and when everything took place – the psychiatric hospital may have video surveillance, and if everybody knows which videos to get, it will make life much easier. Report everything to the Patient Rights Advocate, even if they’re useless, just so you can call them up and have them testify you reported it to them at the time. I am not a lawyer, this is not legal advice, and your lawyer will be able to tell you much more – but documentation never hurts.

If things are really bad, figure out if there are surveillance cameras, and hang out in front of them.

Once you leave the hospital, consider giving feedback. Most hospitals will have some kind of survey or hotline or something that lets you praise hospital staff whom you liked and report hospital staff whom you didn’t like. This won’t heal any wounds you suffered – and while in the hospital, threatening to report a doctor will be ignored just like all threats – but it might help somebody way down the line. You can also write a report on Psych Ward Reviews. In fact, do this anyway, whether you’re mistreated or not, so that other people can learn which hospitals don’t mistreat people.

9. I think my friend/family member is in the psychiatric hospital, but nobody will tell me anything.

Yes, this definitely sounds like the sort of thing that happens.

Because of medical privacy laws, it is illegal to tell a person’s friend or family that they are in the psychiatric hospital, or which psychiatric hospital they’re in, without their consent. If the person is too paranoid, angry, or confused to give consent, then their friends and family won’t have a good way to figure out what’s going on.

Your best bet is to call every psychiatric hospital that they could plausibly be in and ask “Is [PERSON’S NAME] there?” Sometimes, all except one of them will say “No”, and one of them will say “Due to medical privacy laws, we can’t tell you”. I know this sounds ridiculous, but it really works.

Once you have some idea which hospital your friend is in, call and ask to speak to them. They will say something like “Due to medical privacy laws, we can’t tell you if that person is here.” Say “I understand that, but could you please just ask them if they’re willing to speak to me right now?” If they are willing to speak to you, problem solved. Otherwise, you might still get some information based on whether the person leaves you on hold for a while in a way that suggests she’s going to your friend and asking them whether they want to talk to you.

You can also ask to speak to (or leave a message for) the doctor taking care of your friend. The receptionist will say “Due to medical privacy laws, we can’t tell you if that person is here.” Say “I understand that, but I have some important information about their case that I want the doctor to know. They don’t need to tell me whether my friend is there or not, just listen.” At this point, all but the most committed receptionists will either admit that your friend isn’t there, or actually get a doctor or take a message. There is no doctor in the world who is so committed to medical privacy that they will waste time listening to the history of a patient they don’t really have just to maintain a charade, so if you actually get a doctor this is a really strong sign.

Once you have a good idea where your friend is, you can ask the receptionist to pass a message along to them, like “Call me at [this phone number]”. If they still don’t respond – well, that’s their right.

Most hospitals will have visiting hours. Going to visit someone who refuses to let you know they’re at the hospital and refuses to give anyone consent to talk to you is a high-variance strategy, but you can always try.

10. My friend/family member is in the psychiatric hospital and wants to get out as quickly as possible. How can I help them?

First, make sure they actually want to get out as quickly as possible, and you’re not just assuming this. You would be surprised how many people miss this step.

Second, make sure they know everything in section 7 here.

Third, offer to talk to the doctors. Doctors often don’t trust mentally ill patients, but they usually trust family members. If your friend isn’t sick enough to need to be in the hospital, tell the doctors that. Describe the circumstances around their admission and why it’s not as bad as it looks. Mention how well you know the person, and how you’ve been with them through their illness, and how you know they would never do anything dangerous. Only say this if it’s true – if they’re in the hospital for stabbing a police officer, your “they would never do anything truly dangerous” claim is just going to make you look like an idiot.

Offer to help with discharge planning (see the end of section 6). Tell them that the patient will be staying with you after they leave the hospital, that you’re going to be watching them closely to make sure that they’re safe, that you’ll make sure they take their medications and go to followup appointments. Again, only say this if it’s true – or at the very least, coordinate with the patient, so you don’t say “My son will be staying with me under my close supervision.” and then your son ruins it all by saying “Haha, as if.”

If you have a sob story, tell it. If you are ninety-seven years old and your son is the only person who is able to take care of you and bring you to your doctors’ appointments, mention that. Sob stories from patients generally don’t work, but sob stories from family members might.

Offer to come to the hospital during visiting hours and meet with the doctors. This both underlines everything above – it shows you’re really invested in their care – and also gives you a good opportunity to pressure the doctors face to face. I don’t mean you should threaten them or be a jerk about it, but just ask “Why can’t Johnny come home? We really need Johnny at home to help with the chores. Everyone at home misses Johnny.” I don’t guarantee this will work, but it will work a little, on certain people.

If there are many people in your family who are willing to work on this, use whoever is closest to the patient (eg their mother) – and in case of a tie use the person who is the most upstanding high-status member of society. A promise to take care of someone sounds better coming from a family member who is a doctor themselves (or a lawyer, or a teacher) compared to from the patient’s unemployed stoner brother with a NO FEAR tattoo.

As somebody who is not in a psychiatric hospital, you are in a much better position to hire a lawyer if one needs to be hired. Again, in the majority of cases a patient won’t even stay long enough to have a court hearing. If you are poor and have limited resources, this is definitely not how I would recommend using them. But if you have money to burn, or your friend/family member is being held for an inexplicable amount of time (longer than a week or two) and you don’t know why, you are going to be in a much better position to take care of this than the patient themselves.

Even if all this works, it’s just going to make someone stay a bit less than 5.9 days instead of a bit more than 5.9 days. There’s no good way to get someone out instantly.

11. How will I pay for all of this?

If you don’t have health insurance, there is usually some kind of state/county mental health insurance program that is supposed to help with this kind of thing. You usually have to earn below a certain amount to qualify. Your social worker at the hospital can talk to you about this. I am not promising you such a program will exist – if you’re concerned about money, look into this before you go to the hospital.

If you do have health insurance, they may pay for your admission. The problem is that they have to decide if you are really ill enough to need psychiatric care, and they make this determination separately from the doctors who decide whether to commit you or not. In the worst case scenario, you can be involuntarily committed because your doctors decided you needed care, but your health insurance refuses to pay for it because they decided you didn’t need care. If this happens, you are stuck with the bill. This is horrifying and there should be some kind of law against it, but I’ve seen it happen and I think it’s legal.

Your best bet in these cases is to try to get the state/county mental health insurance mentioned above. Sometimes you can sign up for it after you leave the hospital, and then get your costs reimbursed.

If everything goes wrong, and you’re stuck with a bill and no insurance company willing to pay it, try to argue the hospital down. Hospitals know that the average random sick person can’t afford to pay $20,000 or whatever ridiculous amount they charge. They make these numbers up as part of a complicated plot to fool insurance companies into overpaying, which never works, and they expect patients to try to bargain. They are also usually willing to consider whatever payment plan you think you can make work. I don’t know very much about this, but there’s some more information here.

As far as I know, committing people involuntarily and leaving them with a huge bill is legal, and hiring a lawyer will not help with this. I don’t know much, so you may want to ask a lawyer’s opinion anyway, if you can afford it.

12. I have a friend/family member who really needs psychiatric treatment, but refuses to get it. What can I do?

If your family member is not a danger to themselves or others, your options are limited. You can try to convince them to voluntarily seek treatment, but if it doesn’t work, it doesn’t work.

If your family member is a danger to themselves or others, you have a good case for getting them involuntarily committed to the hospital. A good example of this would be them threatening to hurt you, or actually hurting you, or being so out of touch with reality that you are legitimately afraid they might hurt you or themselves. Them being paranoid (“people are out to get me”) or extremely confused about basic reality (“I am able to fly”) counts as legitimate reason to believe they might hurt you or themselves. If this describes your family member, document everything worrying that they say or do so you can present it to the doctors doing the assessment and (eventually) the courts.

Then, if your family member is cooperative/confused enough to let you drive them to the hospital, drive them to a hospital ER. If they’re not this cooperative, call the police and they will take things from there. Be prepared for the police to potentially put your family member in handcuffs and be really aggressive and police-y about it (and if you have a dog, arrange for it to be somewhere else at the time – like stuck in a bedroom with the door closed). The police will bring your family member to the hospital ER. You should go to the hospital ER too, so that you can tell the doctors what’s wrong and why you think they need treatment – ie why they are dangerous or potentially dangerous.

The most common way this ends is that your family member goes to the hospital, is started on some drugs, gets a little better, goes home, stops taking the drugs, and gets worse again. If the doctors at the hospital are not competent, they may not think about this. It may end up being your job to insist on some kind of longer-term solution.

If your family member is psychotic, then the gold standard for longer-term solutions is a long-acting injectable antipsychotic medication. This is a shot that a nurse can give them which will give them a few months’ worth of antipsychotics all at once, safely. This way they don’t have to remember/agree to take their medication at home. Then a few months later you can wrangle them back to a doctor’s office where someone can give them the shot again; repeat as needed. If your family member doesn’t agree to this, you’re going to need a judge’s order – but judges are really cooperative with this kind of thing and your psychiatrist can tell you more about how to make this happen. A partial hospital program can also help with this.

There is a kind of institution with different names everywhere, usually something like “Assertive Community Treatment”, which basically consists of some mental health professionals in a van who go around to people’s houses and make sure they’re okay / staying on medication after they’ve been discharged from the hospital. These are chronically underfunded and you have to fight to get into them, but if nothing else works you can see if there’s one of them in your area. These people are also good at wrangling patients to get their monthly dose of long-acting injectable antipsychotics.

If you need a quick way to deal with a family member’s psychosis, and they refuse to take antipsychotic medicine, and they don’t meet criteria for involuntary hospital admission – well, I can’t believe I’m saying this, and this is super not medical advice – but cannabidiol, a chemical in marijuana, is a weak but functional antipsychotic. Normal marijuana is awful for this situation and contains lots of other chemicals that make psychosis worse, but you can get special cannabidiol-only strains that act sort of like weak non-prescription antipsychotic medication. In a state like California where marijuana is legal, you can talk to a marijuana expert about which strains these are and how to use them. In a state where only medical marijuana is legal, you can take your family member to a random quack to get them a medical marijuana card, then follow the same process. Most psychotic people refuse to believe that they are psychotic, but most of them are very anxious. If you frame the marijuana as a way to help with their anxiety, they may go along with it. Then they might get non-psychotic enough to make them understand there’s a problem, after which they can go to a psychiatrist and get a longer-term solution. Again, this is definitely not medical advice and if you have any other options you should take those instead.

You can get a lot more (and much more responsible) advice from the Treatment Advocacy Center, a non-profit that helps people figure out how to get their friends and family members psychiatric treatment.

Postscript

All of this is to prepare you for worst-case scenarios. Many people seek inpatient mental health treatment, find it very helpful, and consider it a positive experience. According to a survey on Shrink Rap (heavily selected population, possibly brigaded, not to be taken too seriously) about 40% of people who were involuntarily committed to psychiatric hospitals eventually decided it was helpful for them. This fits my experience as well. Be careful, but don’t avoid getting treatment if you really need it.

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avilad
120 days ago
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francisga
120 days ago
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Lafayette, LA, USA
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16 things Catholic girls should know about consent

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How should Catholic parents teach their kids about consent?

We don’t want to give the impression that we’ll wink at sexual misbehavior, as long as our kids reach adulthood without a police record, a pregnancy, or an STD. We want more for them than that. We utterly fail our children if we teach them only about consent, without any other understanding of what sexuality is for and why they are so valuable as human beings. Reducing sexual health to mere consent is just another form of degradation

At the same time, we don’t want our kids to get a police record, an STD, or a unwed pregnancy. Or a damaged psyche, or a broken heart, or a shattered sense of self-worth. An education in consent is not enough, but we must teach them about consent.

But too often, Catholic parents dig in, just telling kids to save sex for marriage, period. Perhaps they teach their kids to avoid the occasions of sin like the saints, but they’ve never taught them how. They’ve never taught their kids what to do if they have, like billions of teenagers before them, gotten carried away by desire, or what to do if they themselves have good intentions but their boyfriends do not. They’ve never taught them how to navigate that minefield of conscience, desire, and external pressure. They send their daughters out entirely unequipped.

And so girls who want to be good are left to piece together some kind of dreadful “least bad” course of action with almost no information about what they can and should do in actual relationships. Teenage girls often put their own best interests last, in hopes of minimizing damage or offense for everyone else. 

So here is what Catholic parents should teach their daughters about consent:

  1. It’s never too late to say “no” for any reason. You’ve done that thing before, with him or with another guy? You can still say “no.” You’ve done worse things already? You can still say “no.” You’ve done lots and lots of things, but not this particular thing? You can still say “no.” You’ve talked about this thing, even agreed to do this thing? You can still say “no.” You’re right in the middle of the thing and have changed your mind? You can still say “no.” It’s a little thing that no one could possibly object to, but you just don’t want to? You can still say “no.”

If you find yourself in the habit of encouraging sexual behavior over and over and over again, and then backing out over and over and over again, then maybe you’re being a jerk, and should think about how you’re spending your time, and how you’re treating your male friend. But that’s a separate issue that you can deal with later. Even jerks can say “no.”  You can say “no” at any time for any reason, because you have no obligation to turn your body over to your boyfriend. Why would you?

 

2. Yes, he can stop. Of course he can stop. What is he, a defective robot? If he’s all worked up, it may be very difficult to stop, and he may be mad or offended or disappointed, but he has free will and he can stop. If he doesn’t stop when you tell him to stop, that is sexual assault. He. Can. Stop.

You’re not genuinely injuring a guy by stopping after one or both of you are aroused. You don’t have to sacrifice yourself on the altar of blue balls. If he’s man enough to ask for sex, he’s man enough to deal with a little disappointment. 

 

3. There’s no such thing as being tricked into consenting. If you consent, you do it on purpose, consciously. If you didn’t realize you consented, or didn’t mean to consent, then you did not consent, and whoever tricked or coerced you is assaulting you, by definition.

 

4. A hymen is just a membrane. We hear a lot about protecting virginity, but sex is about so much more than vaginal penetration. There are non-PIV acts which feel important and powerful because they are — and they belong within marriage, just as much as intercourse does. You don’t have to let yourself be used for all kinds of absurd and degrading things just to protect that precious treasure of technical virginity. A hymen is just a membrane. You, on the other hand, are made in the image of God, and should not submit to degradation from anyone who professes to care about you.

 

5. Listen to your gut. If a situation feels weird or fishy, trust that God-given instinct and get the hell out. You don’t owe anyone an explanation. A firm “No, thank you, I’d prefer to do x” or “That won’t work for me, how about we do x instead?” is all you need. And if someone throws a tantrum over your alternative plans, you can be reasonably certain your good was not at the top of their list of priorities. A good man will value your comfort as well as your consent.

 

6. There is never any good reason for a guy to mention what his previous girlfriends were willing to do. Whether it’s a compliment (“I’m glad you’re not uptight like she was”) or a complaint (“All the other girls I’ve been with had no problem with such-and-such”), this is pure manipulation, meant to put you off balance, exert pressure, and make you feel like you have something to prove. It doesn’t matter if you’re different from every other girls in the entire universe. You are you, and if he can’t appreciate that, then he can go dangle.

 

7. Love doesn’t manipulate. It’s old school manipulative when he says “If you really loved me, you’d do such-and such.” It’s also manipulative if he turns it on its head by saying, “Let me show you how much I love you,” or “Why won’t you let me show my love for you by . . . ” Love isn’t about putting pressure on people. Love lets people be.

 

8. You never owe a guy sexual favors just because he does something nice for you. If a guy wants to spend time with you and you like him, be nice to him. But a date is not a contract. You’re not chattel, to be traded, no matter what he thinks he deserves.

And if you do hold the line and say no to “big” things, don’t feel like you then ought to compensate by agreeing to smaller things that also make you uncomfortable. Your comfort isn’t up for bargaining.

 

9. An adult man who wants sex or romance with you when you’re underage is a bad man. Full stop. You may be flattered, you may feel like you’re especially mature, and you may very much want what he’s asking for; but, by definition, this is assault. There’s a reason you cannot legally consent when you’re underage. An older man only wants an underage younger girl if there is something wrong with him. He’s very likely gone after other, maybe even younger girls, and will continue to do so. You should protect them by telling someone you trust.

 

10. If you’ve had sex, you’re not automatically in a relationship; you don’t owe him anything; and you’re not fated to be together. Sex makes you feel like there is a bond, but you have the power to break it at any time. It may hurt to disrupt that sensation of being in a relationship, but it may be the smartest thing you can do — the sooner, the better.

 

11. You don’t have to get married to someone just because of your sexual past together. Even if you’re pregnant. In fact, getting married because you “have to” could be grounds for a future annulment, if you got married because of pressure and a sense of obligation, rather than as a free choice. If you did something wrong, like choosing to have consensual sex with someone who’s not right for you, you can’t somehow redeem or erase that past sin by getting married. The past is the past. God wants you to have a good future.

 

12. It’s a bad mistake to have sex outside of marriage, but it’s not somehow more Catholic to refuse use a condom. Contraception is a sin, and so I cannot in good conscience say, “Yes, if you’re going to have sex, use a condom.” Even if your goal is to prevent the spread of disease and to prevent the conception of a potentially fatherless child, it’s not somehow less-bad to commit two mortal sins instead of one.

But some young Catholics will tell themselves that there is something noble or bracingly honest about having refusing to use a condom, even as they persist in seeking out unmarried sex. This is absurd. What are you doing? If you want to avoid sin, because it hurts you and your partner and cuts you off from God, then avoid sin. Don’t play games with telling yourself, “I’m sinning, but I’m doing it the Catholic way!” There is no such thing as sinning the Catholic way.

 

13. You’re not bad for wanting to have sex! Feeling strong sexual desire doesn’t prove that you’re a bad girl, or different from good Catholics. God has given us this desire for a reason. Sex is good, and the desire for sex is a normal, healthy desire. Your job is to figure out how to respond to your desire in a healthy and moral way. And no, it’s not easy. You will probably fail. Try again. But . . .

14. If you find that you cannot make yourself stop seeking out sex, then there’s probably something else wrong in your life, and you need help with identifying, addressing, and healing it. It’s normal and healthy to have a strong, hard-to-control libido when you’re young, but it’s neither normal nor healthy to feel driven and compelled to seek out sex with lots and lots of people. This is self-destructive behavior, likely with deep roots. It will be difficult to talk to someone  about this, but you really do need help — psychological help, not just confession.

 

Some girls will also agree to unprotected sex as a way of accepting some kind of built-in punishment for their promiscuity, not realizing that the promiscuity itself is a symptom of psychological distress. Confession is helpful. It is likely not sufficient by itself.

15. If something bad happens, whether it was consensual or not, you’re not alone. The people who truly love you will not love you less just because you did something you shouldn’t do, and they certainly won’t love you less if something happened to you that shouldn’t have happened. If you have someone who truly loves you, that person will talk to you, or find you someone to talk to, or take you to the doctor, or take you to confession, or take you to a therapist, or do whatever you need so you can be in a better place than you are right now. Having had sex does not make you an outcast. You are young. All is not lost.

 

16. You’re not ruined, no matter what you’ve done or what others have done to you. You cannot be “damaged goods,” because you are not goods. You are a person. Even if you feel worthless right now, and even if other people say you are worthless, you do not and existentially cannot exist for the consumption of any other human being. Not your future husband, not anybody. You are a child of the living God.

 

Yes, your past will affect you. Yes, you are changed by your choices and by the choices of others. But if you have regrets, they can be forgiven. If you have wounds, they can be healed. You are not ruined. You cannot be ruined. As long as you are alive, there is hope.

 

Here’s the kicker. Much of what I’ve said above goes for married relationships, too. You can go to extremes, of course. Some men behave as if their wives can never say “no” once they are married; and some women behave as if their husbands must gain explicit permission for every thought, word, and deed. It often takes couples many years to understand each other well enough to find the right balance. Spouses can reasonably expect to have sex with each other if possible. But there is also such a thing as violating consent in a marriage. Marriage does not give one spouse the right to use the other spouse, sexually or otherwise.

 

So, Catholics, let’s get over our aversion to the word “consent.” Our kids need to know about consent in dating, and they’ll need to know it when they’re ready for marriage, too. It’s one more way to learn to love each other better. 

 

***

Many thanks to my friends M.B., C.P., F.S., R.S., G.H., K.C., C.C., D.M., J.T., A.G., M.E., E.L., S.J., M.D., K.M., R.B., A.H., K.C., for helping me compile and refine this list.
Photo via Pexels (creative commons)

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173 days ago
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Ask Unclutterer: Where can I donate stuffed animals?

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Reader Darlene recently asked the following question in the comment section of the post What to do with those old toys:

I have bags of slightly used stuffed animals. I’ve found most places like hospitals and day care center don’t want them because of germ contamination. Where can I find a site that would welcome them? How about for the flood victims in Texas or hurricane victims in Florida or even … victims in California? Give me some ideas please.

Darlene, this is a common concern, so I’m very glad you asked the question. The following are a few suggestions that may help anyone with gently used stuffed animals looking for new homes.

Give them away directly to people who want them

I’ve successfully used my local freecycle group to give away stuffed animals. It doesn’t always work, but it sometimes does. Other similar possibilities are Facebook, Nextdoor, and the free section of Craigslist.

Give them to Goodwill or other thrift stores

While many thrift stores don’t accept donations of stuffed animals, a number of them do!

Each Goodwill chapter has its own policies regarding what it accepts — and some specify that they take stuffed animals, such as Goodwill of the Heartland in Iowa and Goodwill of San Francisco, Marin and San Mateo Counties in California.

The St. Vincent de Paul Society of Lane County in Oregon is another example of a charity that takes stuffed animals for its thrift stores. Again, each local organization will have its own policies, but you might find that yours will welcome your donation.

Note: These policies can change over time, so be sure to check before each donation.

Donate via SAFE: Stuffed Animals for Emergencies

SAFE is a 20-year-old non-profit organization that helps get gently used stuffed animals (as well as blankets, children’s clothes, and other items) to those who need them. You can donate through one of the chapters in Florida or South Carolina. Or you can send them to one of the urgent needs locations that SAFE has identified. Here’s just one of the places currently listed:

Edmund D. Edelman’s Children’s Court is the court that handles all the juvenile dependency cases in all of Los Angeles County. These cases usually deal with abuse and neglect issues. Annually they handle about 30,000 cases, and some of these cases require the children to speak. The courthouse has asked us if we could donate stuffed animals to help ease these children’s fears during a very stressful time in their lives.

SAFE also has good instructions for cleaning stuffed animals (PDF) before donating them.

Donate to police or fire departments

An 8-year-old girl in Colorado who had been in an auto accident donated her stuffed animal collection to the Denver police department to give to other children like herself. You could certainly ask if your local police or fire department would like your stuffed animals to hand out to children in similar traumatic circumstances.

Give them to animal shelters

As reader Monique mentioned in the comments, this is always an alternative to consider. And it will work for toys that have stains (even after washing) that would make them unsuitable for giving to children. Please check with the shelter you have in mind, as not all of them will want such donations. But some, such as Four Peaks Animal Rescue in Arizona, do include stuffed animals on their wish lists.

Post written by Jeri Dansky

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176 days ago
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