Many years ago, Thomas Szasz largely convinced me that mental illness is radically different from ordinary physical illness. In economic terms: People with physical illness have unfavorable constraints; people with mental illness have socially disapproved preferences. Physical illness is about what you’re able to do; mental illness is about what you want to do.
Yes, it’s generally bad manners to loudly call attention to this distinction. Even though “I can’t come to your party” usually means, “I would rather do something else with my time,” it’s impolite to say so. The same goes for “I can’t stop drinking” or “I just can’t manage to show up for work on time.”
But what about really weird cases? Perhaps 95% of all alcoholics simply value their favorite beverage more than they value their families. But every now and then, you read a compelling first-hand account of someone who persuasively insists, “I just can’t help myself.” What about multiple personalities? Severe delusions? Can Szasz explain those?
Maybe not. But Alex Tabarrok’s post on the statistics of rare events got me thinking.
The CDC asked 12,870 individuals about defensive gun use over the
three samples.That’s a relatively large sample but note that this means
that just 117 people reported a defensive gun use, i.e. ~1%. In
comparison, 12,656 people (98.33%) reported no use, 11 people (0.09%)
said they didn’t know and 86 people (0.67%) refused to answer. People
answering surveys can be mistaken and some lie and the reasons go both
ways…The deep problem, however, is not miscodings per se but that
miscodings of rare events are likely to be asymmetric. Since defensive
gun use is relatively uncommon under any reasonable scenario there are
many more opportunities to miscode in a way that inflates defensive gun
use than there are ways to miscode in a way that deflates defensive gun
use.Imagine, for example, that the true rate of defensive gun use is not
1% but .1%. At the same time, imagine that 1% of all people are liars.
Thus, in a survey of 10,000 people, there will be 100 liars… Adding it up, the survey will find a defensive gun
use rate of approximately (100+10)/10000=1.1%, i.e. more than ten times
higher than the actual rate of .1%!
Notice that Alex’s point generalizes readily from defensive gun use to extreme mental illness. Suppose, for example, that you study the prevalence of multiple personalities (now called Dissociative Identity Disorder). In a group of 10,000 people, ten insist they have it. Taken individually, each of the ten seems credible. But if .1% of respondents would energetically lie, the discovery of ten believable stories is perfectly consistent with the complete non-existence of the disorder.
Why oh why though would anyone tell such a lie? Perhaps to be the center of attention – one of the most ubiquitous of all human motives. As Szasz puts it:
[W]hen a grisly, unsolved crime is reported by the press and the police look for the person who did it, innocent people often come forward and confess to the crime. Such a confession is never accepted on its face value as true; on the contrary, it is treated with the utmost skepticism. On the other hand, when a person lodges a psychiatric complaint against himself, it is not investigated at all.
Do the statistics of rare events prove Szasz right? No, but they do tip the evidentiary scales further in his favor. If X almost never happens, basic numeracy urges us to question whether the few purported cases of X are genuine – especially if many of us feel a temptation to claim X regardless of the truth.
Isn’t it desperate, though, to use Tabarrok’s insights to treat admittedly rare events as absolutely non-existent? Perhaps. But then again, isn’t that just what the great David Hume did in his “Of Miracles“?
When anyone tells me, that he saw a dead man restored to life, I
immediately consider with myself, whether it be more probable, that this
person should either deceive or be deceived, or that the fact, which he
relates, should really have happened. I weigh the one miracle against
the other; and according to the superiority, which I discover, I
pronounce my decision, and always reject the greater miracle.
To my mind, a person who genuinely “can’t stop drinking” is almost as miraculous as a dead man restored to life. If you dismiss the latter, you should at least be open to dismissing the former as well.
READER COMMENTS
JFA
Jun 4 2018 at 2:51pm
Take someone with depression. They tend to be visibly miserable. They say they are miserable. They say they don’t want to feel how they feel. Now you could say, “Nah, you just have a preference for being really miserable.” Or you could say, “Most people (myself included) want to be happy. When my preferences are satisfied, I don’t appear miserable. When my preferences are satisfied, I don’t say that I am miserable or that I don’t want my preferences satisfied. So if someone has visible signs of distress and misery and verbally expresses that they are distressed and miserable, perhaps I should consider that they are suffering from some kind of ailment that takes the form of depression.”
There is certainly the possibility that those people who suffer from depression are engaged in self-delusion, but that tends to be an easy way of justifying why you are right and everyone else is wrong.
James Phillips
Jun 4 2018 at 3:02pm
It was seemingly a good argument right up until it assumed that the Resurrection is the prototype of an event that just is too improbable to believe. Many have investigated and found the evidence convincing.
A more neutral and defensible summary of Hume’s principle would be “extraordinary claims require extraordinary evidence.” Admittedly this was not Hume’s approach, but it should have been.
JFA
Jun 4 2018 at 3:11pm
As a follow-up (perhaps you could do a post on this): I assume you, as an intellectually curious person, have read various critiques of Szasz. What is the most convincing critique, and why do you not find it convincing enough?
CZ
Jun 4 2018 at 3:24pm
It’s hard to draw a line between constraints and preferences when it comes to mental illness. Low intelligence seems like it’s clearly a constraint and not a preference even though it is mental. So couldn’t anxiety be the constraint of low stress tolerance, OCD be the constraint of low willpower, psychopathy be the constraint of low empathy, etc.? People who suffer from anxiety generally would prefer to not be anxious, but something in their unconscious mind prevents them from realizing that preference, just like a person with low intelligence or physical strength might prefer to be smarter and stronger but be unable to achieve that.
I lean towards thinking of most mental illnesses as constraints for that reason. The conscious mind does not necessarily have any more control over unconscious background processes like intelligence or stress tolerance than it does over the body’s physical abilities. So if someone believes they are mentally ill because their unconscious mind is putting limitations on what their conscious mind wants to accomplish, I can accept that as an illness.
DDD
Jun 4 2018 at 3:29pm
Bryan,
Scott Alexander from Slate Star Codex published a critique of your preference/constraint views on mental illness a while ago. I found it pretty convincing. I would like to read your response on that.
Kevin Dick
Jun 4 2018 at 4:23pm
Huge Caplan fan, but I also found Scott Alexander’s argument more convincing than Bryan’s.
http://slatestarcodex.com/2015/10/07/contra-caplan-on-mental-illness/
robc
Jun 4 2018 at 5:08pm
JFA,
For many people with depression, you can test to find the root cause (for example, an imbalance in seratonin).
That moves it from “mental illness” to “physical illness”.
Joseph E Hertzlinger
Jun 4 2018 at 5:56pm
I’m reminded of the Flake Equation in XKCD.
Martin
Jun 4 2018 at 6:03pm
Psychiatrist here —
While some mental distress may certainly fit into the Szaszian framework you describe, I suggest you speak to someone with schizophrenia who is in a psychotic episode, or someone with bipolar disorder in the midst of a manic episode. You will see that these are not merely cases of different preferences, but are truly severe illnesses.
Something to consider: do patient’s who suffer a stroke have a preference not to move their affected body parts? Do patient’s with epilepsy have a preference for shaking around and losing consciousness? Do patient’s with steroid-induced psychosis merely have different preferences? If you would acknowledge that these cases are genuine illness, how can you argue that something like schizophrenia, which is a brain disorder, is not?
Mark Z
Jun 4 2018 at 6:34pm
Bryan, you might be interested in the research of Yochelson and Samenow on psychoanalysis and sociopathy. Their work was sort of popularized by the Sopranos, but the gist of it was that sociopaths or people with ‘criminal personalities’ tended to co-opt the language of psychoanalysis both to rationalize their behavior and to manipulate others, such as to obtain more permissive circumstances. Diagnosis of psychological illness may in some cases be a rationalization rather than an explanation for certain behavior.
JFA
Jun 4 2018 at 8:18pm
Robc, I agree with you. From what I understand, the Szaszian point is that mental illness is not real because it needs physical manifestations to be real. But all “mental” illness will have something to do with brain chemistry and/or architecture/wiring. Chances are the compulsions that Bryan is critiquing will have some root cause in the brain. I just found his “common sense” approach to most things (e.g. education signaling, parenting) to be absent in his views about mental illness.
Mark Bahner
Jun 4 2018 at 8:37pm
Non-psychiatrist here. Bryan’s position on this matter causes me to think far less of him as an objective researcher and careful thinker.
BTW…here’s a great “This American Life” piece on a person lost in a bipolar manic episode who ended up with a bullet in his chest…delivered in a hospital:
When your hospital-borne infection is a bullet
Ray
Jun 4 2018 at 9:07pm
Another psychiatrist here…
Bryan, you often take as your examples people who are trying to excuse their behavior – the “alcoholic” who says he cannot stop drinking, the child who says he cannot focus on his studies.
But that’s not the majority of cases of mental illness. Most people with depression are not trying to excuse a behavior. Same with most non-violent schizophrenics (and most schizophrenics are non violent). Most people with ADHD who come to my office are not trying to get extra accommodations – they genuinely want to focus and do better in school. How do you explain this?
David S
Jun 4 2018 at 9:44pm
Perhaps the issue is not that preferences are undesirable, but that they change from moment to moment. An addict immediately prior to a fix prefers drugs enough to risk their life. An addict immediately after a fix dislikes drugs so much that they want to die to stop consuming them.
The same person can therefor be unable to stop themselves from drinking, and yet also value their family more than drinking – just at different times.
As you say, if they simply preferred drinking all the time then they wouldn’t actually have a problem. Society would have the problem with them!
Mark Z
Jun 4 2018 at 9:59pm
I think, in fairness to Bryan, he isn’t necessarily (indeed I doubt he is) describing all mental illnesses, such as schizophrenia.
He appears to more have in mind things like drug or alcohol addiction, or obsessive compulsive disorder. On these, I think he has a point; not so much that the diseases “don’t exist”, but that, since such diseases are essentially on a far end of a continuum of normal human behavior, there is a measure of choice involved both in self-diagnosis (and in seeking out clinical diagnosis) and perhaps even severity. All people are compulsive to a minor degree. Everyone gets “addicted”, to a moderate degree, to certain things. Everyone gets anxious and depressed. Now, some people do have chronic acute depression; and some people do have a strong genetic predisposition to alcoholism, but I think it’s fair to contend that many people (especially with difficult to define conditions) are enabled by their diagnoses. Some people may view a diagnosis of depression as license to be more lethargic and less active, which will likely exacerbate the depression; or they may perceive a diagnosis of a disorder as an immutable illness and view their situation as hopeless, discouraging them from changing their behavior in a positive way. For some alcoholics or addicts, the diagnosis may be a self-fulfilling prophecy: the notion that they are less capable of exercising self-control may lead them (consciously or unconsciously) to abdicate what self-control they can exercise.
This would be a fairly simple hypothesis to test (though would perhaps fail to meet ethical standards): take two groups of people, one group that doesn’t present symptoms of a given disorder (say, alcoholism or depression or OCD) and another that does; then within each group, randomly assign subjects to be either diagnosed as having the disorder, or not diagnosed, regardless of whether they present any symptoms of it; then observe whether the diagnosis itself influences behavior.
Vohu Manah
Jun 4 2018 at 10:01pm
I think Caplan is being far less rigorous here than he should be, but an interesting point: what is the difference between ‘constraint’ and ‘preference’ in a deterministic world? That is, free will couldn’t reasonably exist without subscribing to mind-body dualism, and even conscious choices are predetermined by prior material causation. So what makes the difference between an individual being ‘constrained’ or ‘preferring’ to do something?
The Original CC
Jun 4 2018 at 10:14pm
Bryan, you’re picking some pretty low-hanging fruit here. DID is probably not a real thing; you don’t need mental illness skeptic to argue this. A mainstream psychiatrist will probably do.
And your insistence that mental illness isn’t a real thing (yes, I know you’ll claim that I’m mischaracterizing your position, but I’ve read a lot of your posts and I do think this is what you’re arguing) is a bit embarrassing. Like another commenter said, just go hang out with a schizophrenic person and then report back to us. It’s eye-opening.
Nathan
Jun 4 2018 at 10:15pm
I agree with several of the previous posters that this is a major blind spot for Bryan. I know he’s been called on numerous times to rebut the Scott Alexander article, and has never attempted to do so.
I am not a psychiatrist, but I am an attorney who has handled civil commitment cases for severely mentally ill people. I’d love Bryan to explain how my client who was practically catatonic–to the point where all she was doing was standing and nodding rhythmically, unable to even take my business card in her hand–really just had a preference for nodding and being unresponsive.
Or the client of mine who was highly intelligent, but when he testified on his own behalf, spoke for 45 minutes straight without coming up for air, exhibiting exactly the sort of tangential speech Scott describes in his article? This man was intelligent, did not want to be civilly committed, and all he needed to do was convince the judge that he wasn’t crazy. Why couldn’t he stop talking in a way that was precisely consistent with a formal thought disorder typically associated with schizophrenia? I guess he just preferred to be locked up against his will, despite all the evidence to the contrary.
Or how about Andre Thomas, the Texas death row inmate who gouged his own eye out, and then several years later, gouged out his other eye–and ate it! No doubt he just has a preference for being blind and eating his own eyeballs.
I could go on, but why bother? Maybe it’d be easier to bet Bryan $50 that he’ll write a response to Scott’s critique within the next year…
Martin
Jun 4 2018 at 10:44pm
To the extent Bryan hold’s Szasz’s position, then he would have to hold that nearly all mental illness is in fact not true illness, and the compromise position you are describing is, from a Szaszian point of view, untenable.
The history of the antipsychiatry movement is relevant here. It arose as a response to both real and imagined abuses by the psychiatrists in the early 20th century and held that psychiatry was used primarily as a means of social control. While there are legitimate instances of this in the US (and far more in repressive regimes like the USSR), their claims were broadened to the claim that all mental illness was essentially a fiction.
A certain flavor of libertarian finds this explanation appealing and seems to have adopted it as a faith (I would argue that the noble anti-war sentiments of many libertarians that grows into total pacifism and the “US shouldn’t have gotten involved in WW2” arguments is a similar intellectual blind spot).
These arguments are over 50 years old, developed during a time when knowledge of the physical aspects of mental illness, such as brain changes, endocrine changes, etc, were virtually unknown. This movement could never have arisen much later, when knowledge of the brain has increased (although not as much as we’d like).
I’m afraid that Bryan is suffering from a major bias in this thinking here. I recently treated a man with schizophrenia who was stable for years on medicine. When his insurance changed and he was unable to obtain a refill, he became psychotic again and stabbed himself in the abdomen and nearly died. Once he was medically stabilized we asked him why he did it. He told us that he needed to remove the implants that aliens had placed inside of him. Another patient burned his genitals off because he was convinced they didn’t belong to him. These are not people simply with different preferences (as if “different preferences” really was explanatory at all anyway). Mental illness is brain illness is physical illness.
Mark Bahner
Jun 4 2018 at 11:26pm
Yes, in the link I provided (spoiler alert!), the guy:
1) Jumped off a third floor balcony,
2) Totaled his car at the entrance to the hospital, and
3) Didn’t even trust that his mother and father were his mother and father at the hospital.
Explaining those actions as some sort of revealed “preference” is…insane.
Alex
Jun 5 2018 at 2:30am
“people with mental illness have socially disapproved preferences”
Yes, socially disapproved preferences like suicide, the second cause of death for people 15-34
https://www.cdc.gov/injury/wisqars/LeadingCauses.html
In the US alone there are 120 suicides per day. Suicide is commonly caused by depression, a horrendous mental illness that also leads to alcoholism and drug addiction.
Laurie Carver
Jun 5 2018 at 5:04am
What a weird post. “People with physical illnesses face constraints” – yes, parts of their bodies aren’t working how they should, for one reason or another. This may shock you, but there’s this organ called “the brain”, and the current scientific consensus is that it is where and how humans make decisions. It’s a very complex organ, and we don’t have as good an understanding of it as we do, say, the liver, but there’s no reason why it should not also sometimes not work how it should. A malfunctioning brain is just as much a “constraint” as, say, a broken leg, so “mental” illness is actually a subset of physical.
How this fits with moral agency is an interesting subject, because some decisions the brain makes are not conscious, deliberate ones – eg breathing, or flinching at a loud noise. If in the act of flinching we somehow caused harm to someone, we probably wouldn’t be held morally responsible, because of its involuntary nature as far as our conscious selves are concerned. The question then becomes: how much is a given set of behaviours, such as alcoholism, like this? Again, basically we don’t know because the brain is so complex, but some neuroscientists think very old parts of the brain associated with the fight or flight mechanism learn that alcohol is the solution to the bad physiological symptoms that alcohol stimulates. These parts of the brain can cause very strong urges, up to the point of overriding the conscious parts, because otherwise our ancestors would’ve been eaten by lions or whatever. And while they can learn, they are very short term focused, for the same reason, and in particular not aware that they are part of a brain in a complex causal world that they can affect. When drinkers reach for the bottle for consolation, or as “hair of the dog that bit them”, they are teaching it that drink is a solution. In the extreme, a hungover alcoholic might effectively be feeling (nb not consciously “thinking”) that there is a lion after them, and that drinking will allow them to escape. But of course that just makes the lion bigger and scarier, so they go into this spiral of drinking more and more. Obviously their moral culpability then depends on just how strong this urge is – ie how restrictive the constraint is. It certainly seems plausible that some people might be experiencing something like this, because they don’t seem happy about their drinking, happily jaunting off to the pub; some force the booze down themselves, puking and crying. That seems weird for the preferences theory. Maybe it’s wrong, but it’s not really reasonable just to dismiss it out of hand.
JFA
Jun 5 2018 at 7:01am
“Maybe it’d be easier to bet Bryan $50 that he’ll write a response to Scott’s critique within the next year…”
Hahaha. Yes.
Tom West
Jun 5 2018 at 9:06am
I’ll admit I find the difficulty of distinguishing between “can’t” and “won’t” is a troublesome aspect of mental illness. The reality is that one blurs into another and the vast majority are not decisively one or the other.
But insisting there’s even a slightly bright line is choosing philosophy over reality.
I’ll admit I’m surprised to see Bryan dip into this particular well again.
Robert EV
Jun 5 2018 at 10:22am
You do realize that a lot of physical constraints can be overcome with targeted exercise?
So how is this not a preference?
Joshua Woods
Jun 5 2018 at 10:35am
I think the post is a very good one and Bryan deserves credit for tackling an area where people are so sensitive and quick to resort to personal attacks – even if you ultimately disagree.
I note that all those using the “spend some time with the mentally ill and you’ll see how foolish you are” line of attack do not mention Thomas Szasz at all – a qualified Psychiatric practitioner who originally made many of these observations and certainly spent more than his fair share of time with the people in question.
In fact the accusation can be turned around – I would ask those using that argument to spend some time with people with dementia or other recognised brain diseases and observe how different they are to the “mental illnesses”.
The fundamental Szaszian point as I see it is that grouping undesirable personality traits and behaviours into the disease category with measles and flu is a category error. This point holds even if the traits cause problems in life, (so does being ugly) and even if the traits respond to treatment (so does being ugly!)
Ari
Jun 5 2018 at 12:44pm
I used to think like Caplan 10 years ago but not anymore. I just thought people who had mental illness were lazy. Many are but not everyone.
Bryan does not know what mental illness is. I hope Bryan gets a real mental illness one day and he can say it yourself.
Actually I think this kind of thinking is a bit dangerous because sometimes leaving mental illnesses untreated can be dangerous to humans. Especially in case of extreme illnesses like schizophrenia or PTSD.
How many people here who comment on this issue have *had* to use anti-depressants in order to get through work day. While exercise helps, its not everything.
Also while Szasz was a psychiatrist, he did not have mental illness himself.
Ari
Jun 5 2018 at 12:57pm
Also panic attacks are a very real thing. I didn’t know they even existed before I had one (some years ago). Not fun, although like hyperventilation, just passing.
JFA
Jun 5 2018 at 1:13pm
@Ari
While I think Bryan’s (and Szasz’s) views on mental illness are wrong, I don’t think you have to have direct personal experience with mental illness to see that they are wrong. After seeing loved ones suffer with depression and having known people afflicted by schizophrenia, I would not wish that upon anyone. I wish you the best in your struggles.
@Joshua Woods, I think up until Ari’s comment, the discussion had been quite civil. I think the “spend time with someone with mental illness” arguments are a bit subjective, but they emulate Bryan’s frequent starting point of personal experience (be it direct or indirect). One thing that Szasz did well was calling attention to the involuntary confinement that resulted mental illness diagnoses. Szasz’s view that mental illness is not associate with morphological abnormality (and therefore not an illness) don’t seem to be informed by biochemistry or genetics. Szasz’s definition of mental illness seems to be informed more by his desire not to have some behaviors socially sanctioned rather than by the mental experiences of those who were socially sanctioned. Again, a fine goal he had but and incorrect solution.
tl;dr: Thomas Szasz didn’t want people locked up for a wide variety of behaviors that were labeled as symptoms of mental illness, so he decided to say mental illness didn’t exist.
Nathan
Jun 5 2018 at 1:15pm
>The fundamental Szaszian point as I see it is that grouping undesirable personality traits and behaviours into the disease category with measles and flu is a category error. This point holds even if the traits cause problems in life, (so does being ugly) and even if the traits respond to treatment (so does being ugly!)
If this were the extent of the Szaszian point, I’d agree. There are lots of undesirable personality traits that should not be considered mental illnesses. Some traits vary in their undesirability based upon societal norms–extreme religiosity might be considered a disorder in the Soviet Union, whereas atheism would be seen as such in modern day Iran or Afghanistan.
But Szasz and Caplan go far beyond that, arguing that schizophrenics who suffer delusions are really just “play-acting,” and that they could believe correct things if they wanted to or were properly incentivized, but choose not to because it’s more fun.
I think this *might* describe a very small percentage of diagnosed schizophrenics. In my career I’ve dealt with hundreds of mentally ill clients. I can think of exactly one who fit this description. He had grandiose beliefs about his interactions with various famous people, but he still managed to lead a pretty normal life. He also seemed to enjoy his delusions, and there were times where I thought he might just be saying crazier and crazier things to see how far he could push things.
But as I said, this was one person out of hundreds. The rest seemed to genuinely suffer from their delusions, and were unable to put them aside (or even pretend to put them aside) when it was clearly in their interest to do so.
>I note that all those using the “spend some time with the mentally ill and you’ll see how foolish you are” line of attack do not mention Thomas Szasz at all – a qualified Psychiatric practitioner who originally made many of these observations and certainly spent more than his fair share of time with the people in question.
Szasz was a prolific author and I don’t care to read everything he’s every written looking for the answer, so I’ll just ask it here: How did Szasz explain formal thought disorders?
Max Goedl
Jun 5 2018 at 1:31pm
It should be pointed out that Hume is making a mistake in probability theory in the passage quoted by Bryan.
He says one shouldn’t believe that miracle X occurred if the probability that X occurred is smaller than the probability that someone would claim X occurred even though X did not occur, i.e. if
Prob(X) / Prob(Y | not-X)
is smaller than 1, where Y is the event that someone claims that X occurred.
But that’s wrong. Hume forgets that we must also take into account the ratio of the probability of not-X to the probability that someone would claim X occurred when X really did occur. By Bayes’ theorem, we should conclude, after observing Y, that not-X is more probable than X if and only if
Prob(not-X) / Prob(Y | X) > Prob(X) / Prob(Y | not-X).
Clearly, it is very well possible that Prob(X) / Prob(Y | not-X) is smaller than one but greater than Prob(not-X) / Prob(Y | X).
A Country Farmer
Jun 5 2018 at 1:37pm
I read the Slate Star Codex piece, and the overwhelming feeling I had was that it seems to presume a lack of free will (whether through lack of causation, or lack of control). In other words, I think Scott’s analogy between the executive that has a flu and the person that’s depressed fails because the person that’s depressed may have chosen to cause the psychogenic symptoms.
KevinDC
Jun 5 2018 at 4:00pm
I used to agree with Caplan and Szasz. Or, more accurately, I found their case superficially plausible, though I hadn’t given the topic significant thought. However, like a few of the people above, I found Scott Alexander’s case against those views to be utterly convincing. But instead of referencing that post again, I wanted to point to Scott’s description of a patient in an entirely different post of his [edited for length]:
Scott goes on to talk about how doctors disagreed with whether or not this was the right kind of approach, but lets take a moment to consider what this looks like through Caplan’s lens. If Caplan and Szasz are right, we’re supposed to believe that this woman just has a preference for believing her hair dryer was going to burn her place down. She preferred to believe it so much that she was willing to severely damage her career and friendships to preserve this belief. If she claimed she just “couldn’t help” feeling this way and feeling compelled to act on it – well, that is just her Social Desirability Bias preventing her from admitting she really just prefers to believe this, plus perhaps a desire to be the center of attention. Presumably her attempts to get help for this condition are further reflections of Social Desirability Bias. And when someone found a simple and effective way to help her stop acting the way she preferred to act, and presumably no longer be the center of attention, she gratefully went along with it because something something something.
To my mind, that story is far more miraculous than the standard scholarship on OCD.
Roderick T. Long
Jun 5 2018 at 4:00pm
I think the crucial question to address is what one’s account of free will and moral responsibility is. Is it compatibilist or incompatibilist? If it’s incompatibilist (but not hard determinist), then we have a clear criterion for at least some cases in which people meaningfully “can’t help it,” and Szasz will be wrong about those cases. If it’s compatibilist, still most compatibilist theories have criteria for causation in “the right way” vs. “the wrong way.” So we’d have to look at what those criteria are in the different compatibilist theories, and what reasons are offered on their behalf. Without a definition of the property in question, the debate seems pointless.
Roderick T. Long
Jun 5 2018 at 4:12pm
One point I’d want to add, though, is that I think the category of “mental illness” is broader than the category “displaying actions one can’t help.” Suppose every time I see a pigeon I’m driven into a state of panic, because of that traumatic incident in my childhood when I was bullied by a snarky pigeon in debate society. Now maybe that fear is so strong that I literally can’t prevent myself from running away (where “can’t” is to be cashed out in terms of the best available theory of free will). But maybe it isn’t; maybe I possess enough willpower that I could, if I chose, maintain an external demeanour of calm and walk normally past the pigeon. Yet I don’t choose to; I run away instead. In that case I might count as having some kind of mental illness without being unable to control my actions.
To put it another way, the medical concept of mental illness is broader than the legal concept of insanity. That’s one reason why the call to ban gun sales to the “mentally ill” is so obnoxious.
Roderick T. Long
Jun 5 2018 at 4:18pm
I guess I should add to that that the reason mental illness is regarded as an excusing factor is sometimes a) the fact that the person literally cannot make herself not do the action, and sometimes b) that perhaps she could but it would be unreasonable to demand it of her given her pigeon phobia (just as actions under duress may be technically free). The borderline may be fuzzy; the ability to overcome one’s fear might be a matter of training rather than a direct act of will, for example.
I_read_the_SSC_piece_too!
Jun 5 2018 at 4:26pm
It is hard to think of 2 sentences that would be more painful to read if you have lost someone to alcoholism, say a parent. Or if you are an alcoholic, recovering or not, who has hurt people you love.
I know Bryan thinks something along the lines of “of all the true things in the world, it is important for the good of mankind that I say this particular true thing, and that I say it this way.” I…disagree. This seems not true, and even if he believes it, there would be much better ways to make the point. Say, “after high profile cases of a particular mental illness do diagnoses of that disorder go up? And is the increase (if any) at the expense of closely related mental illnesses where differential diagnosis is hard, or do they represent genuine new cases?”
Interesting to ask why Bryan (and Robin) end up expressing their ideas in forms that are more controversial than necessary. I doubt they, even subconsciously, care about book sales or fame all that much. I would guess the backlash strengthens their self-identities as contrarian thinkers. If I’m right, consider this backlash, and you’re welcome.
nl7
Jun 5 2018 at 5:53pm
Re Dissociative Identity Disorder and multiple personalities:
There is a large contingent of experts who believe it is primarily or exclusively caused by treatment, rather than caused directly by mental trauma.
Their argument is that most diagnoses come disproportionately from a small number of practitioners, and most symptoms are observed after treatment begins, and, they allege, that the number of distinct ‘personalities’ grows with the length of time under the care of a practitioner who treats DID.
It’s also interesting how cultural it is. Many countries do not have a meaningful number of diagnoses. And those that do see it vary based on media depictions. In India, multiple personalities are culturally depicted as switching after you sleep, so diagnosed patients generally do that. It is quite possible that DID is largely cultural and if people were not told it exists they might manifest their anxieties in entirely different ways, but they know it exists so they conform to the cultural expectations of the diagnosis.
RPLong
Jun 5 2018 at 5:56pm
I believe Caplan’s point is “true enough for economics.” That is, an alcoholic who is destroying his family is not making rational utility function decisions based on an alcoholism constraint; rather, he is making rational decisions where alcohol and family commitments are present within the same utility function, with one factor rated more highly than the other.
I don’t see any other way for an economist to model those decisions.
But of course, the thing to which we’re all objecting is that this model is wholly inadequate as a mental health model. That same alcoholic could find a way to make alcohol consumption prohibitively costly for himself to the benefit of his other commitments, and that would correct the unwanted behavior; but the question is left open as to whether that person has been cured of alcoholism, and psychologists themselves disagree on this point. (Hence the disagreement over the OCD woman with the hairdryer.)
The question is whether mental illness is problematic thinking or problematic behavior, and I suspect this plays into the point Dr. Long made above about free will and responsibility.
KevinDC
Jun 5 2018 at 6:19pm
Joshua Woods says:
It’s actually not true that Szasz “spent more than his fair share of time with the people in question.” As recounted by Clayton Cramer in his book My Brother Ron: A Personal and Social History of the Deinstitutionalization of the Mentally Ill:
The fact that Szasz deliberately went out of his way to avoid having any exposure to or experience with the sorts of patients he was writing about does not inspire a massive amount of confidence.
Robert EV
Jun 5 2018 at 10:16pm
No one has mentioned that the Rosenhan experiment showed that it takes one to know one, and neither Bryan nor Szasz are/were one.
Ricardo Cruz
Jun 6 2018 at 4:23am
Szasz makes an interesting point that ought be explored. But I think we should also be skeptical about the distinction itself between constraint and preference. I believe it’s a continuum. For example, I believe Lagrange multipliers (from Calculus 101) show you can replace explicit constraints by making it very difficult to move (gradients) to any result you don’t want.
robc
Jun 6 2018 at 9:40am
Wasn’t this the Szasz argument? There is no such thing as mental illness, there is only physical illness. If it doesn’t have an underlying physical cause then it isn’t an illness, it is a preference.
JFA
Jun 6 2018 at 11:56am
robc,
yes, but he just denied there were underlying physical causes for mental illness. He wanted some evidence of physical abnormality (e.g. a lesion on the brain) and wasn’t keen on symptomatic definitions. He kind of ignored genetics and biochemistry regarding causes of disease and physical ailments that are only presented symptomatically (such as headaches) that are regularly treated.
robc
Jun 6 2018 at 4:38pm
JFA,
I am not either, the symptom isn’t the disease.
Treating symptoms isn’t a cure (I am sure there are exceptions).
Personal example: my 2 year old daughter is autistic. It seems like a very symptomatic diagnosis. Her therapy is treating the symptoms (and doing a great job of it) but I would still like to know the actual cause (it is genetics – she is me only even more so – but I would like details).
Jay
Jun 9 2018 at 2:16pm
Bryan Caplan is a doctor of economics, and spends much of his time modeling the results of rational individuals acting on clearly-defined preferences. Scott Alexander is a doctor of psychiatry, and spends much of his time trying to help insane people put themselves together. With no disrespect to Dr. Caplan, he should probably defer to Dr. Alexander’s expertise on this matter.
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