Back in 2015, Scott Alexander wrote this reply to my 2006 Rationality and Society piece on the economics of mental illness.  I never replied; to be honest, I never read it.  The reason, though, is not because I do not respect Scott, but because I respect him too much.  I didn’t read his critique because I knew that if I read it, I could easily spend a week reflecting – and composing a reply.  I knew, moreover, that until I wrote my reply, I would think of little else.

Over the years, many friends have asked me to respond, but I’ve always kicked the can down the road until I felt I had a week to spare.  Now I’m ready.  I’ve read Scott’s critique of my Szasz-inspired article carefully.  My overall reaction:

1. With a few exceptions, Scott fairly and accurately explains my original (and current) position.

2. Scott correctly identifies several gray areas in my position, but by my count I explicitly acknowledged all of them in my original article.

3. Scott then uses those gray areas to reject my whole position in favor of the conventional view.

4. The range of the gray areas isn’t actually that big, so he should have accepted most of my heterodoxies.

5. If the gray areas were as big as Scott says, he should reject the conventional view too and just be agnostic.

Now here’s my point-by-point analysis, with Scott (and occasionally my original article) in blockquotes.

[Caplan] compares this to the work of Thomas Szaszszszsz, who proposes that psychiatry is an inherently political enterprise that works to delegitimize people with unusual preferences. For example, until the 1970s homosexuality was considered a psychiatric disease, and now it is considered an uncommon but legitimate preference. In the past being transgender was considered a psychiatric disease, but now many people are moving toward considering it an uncommon but legitimate preference. In each case, when society thinks that a preference is gross, or anti-social, or so extreme that they can’t imagine themselves having it, they shout “Psychiatric disease!” and then they can stick anyone who offends them in mental hospitals; if the preference becomes more legitimate, they retreat and say “Guess those ones weren’t psychiatric diseases after all, but we’re still 100% sure all the other ones are”. Caplan says that instead of these constant mini-retreats we should just admit that all psychiatric diseases are unusual preferences.

Well-said, but the last sentence slightly overstates.  To quote my original piece, “This article argues that much if not all of the [“mental illness”] loophole should never have been opened in the first place. Most glaringly, a large fraction of what is called mental illness is nothing other than unusual preferences…”  Thus, while I’m open to the possibility that every single alleged mental illness is non-existent, I’m not convinced that this is so.

Caplan ends by noting that genetics and neurobiology cannot prove him wrong. Yes, weird preferences may be genetic, and they may be linked to weird neurobiology, but so are our normal preferences! There are genetic factors influencing schizophrenia, but there are also genetic factors influencing politics, religion, and extraversion. Yes, drugs can make you less schizophrenic, but they can also make you less extraverted.

I agree with Caplan’s last paragraph. We can’t prove him wrong with neurobiology alone. So let’s prove him wrong with philosophy, psychology, economics, and common sense.

Since I continue to hear logically irrelevant arguments about genetics and drugs, I would be delighted if Scott’s concession here were widely acknowledged.

So where do I go wrong, according to Scott?

First, the distinction between preferences and constraints is fuzzy:

Let’s start with preferences vs. budgetary constraints.

Alice has always had problems concentrating in school. Now she’s older and she hops between a couple of different part-time jobs. She frequently calls in sick because she feels like she doesn’t have enough energy to go into work that day, and when she does work her mind isn’t really on her projects. When she gets home, she mostly just lies in bed and sleeps. She goes to a psychiatrist who diagnoses her with ADHD and depression.

Bob is a high-powered corporate executive who rose to become Vice-President of his big Fortune 500 company. When he gets home after working 14 hour days, he trains toward his dream of running the Boston Marathon. Alas, this week Bob has the flu. He finds that he’s really tired all the time, and he usually feels exhausted at work and goes home after lunch; when he stays, he finds that his mind just can’t concentrate on what he’s doing. Yesterday he stayed home from work entirely because he didn’t feel like he had the energy. And when he gets home, instead of doing his customary 16 mile run he just lies in bed all day. His doctor tells him that he has the flu and is expected to recover soon.

At least for this week Alice and Bob are pretty similar. They’d both like to be able to work long hours, concentrate hard, and stay active after work. Instead they’re both working short hours, calling in sick, failing to concentrate, and lying in bed all day.

But for some reason, Bryan calls Alice’s problem “different preferences” and Bob’s problem “budgetary constraints”, even though they’re presenting exactly the same way! It doesn’t look like he’s “diagnosing” which side of the consumer theory dichotomy they’re on by their symptoms, but rather by his assumptions about the causes.

I’m unimpressed, because I not only anticipated such objections in my original paper, but even proposed a test to help clarify the fuzziness:

Admittedly, not all cases are easy to classify. I have some control over my heartbeat, but it is impossible for me to reduce it to 10 beats per minute. Is the number of times my heart beats per minute a constraint or a choice? The distinction between constraints and preferences suggests an illuminating test for ambiguous cases: Can we change a person’s behavior purely by changing his incentives? If we can, it follows that the person was able to act differently all along, but preferred not to; his condition is a matter of preference, not constraint. I will refer to this as the ‘Gun-to-the-Head Test’. If suddenly pointing a gun at alcoholics induces them to stop drinking,
then evidently sober behavior was in their choice set all along. Conversely, if a gun-to-the-head fails to change a person’s behavior, it is highly likely (though not necessarily true) that you are literally asking the impossible.

I then presented multiple forms of evidence that a wide range of alleged mental illnesses are responsive to incentives.  Scott barely mentions said evidence.

Still, does this mean that the flu isn’t “really” an illness either?  No.  Rather it means that physical illness often constrains behavioral and changes preferences.  When sick, the maximum amount of weight I can bench press falls.  (Yes, I’ve actually tried this).  Yet in addition, I don’t feel like lifting weights at all when I’m sick.  Anyone who has worked while ill should be able to appreciate these dual effects.  If you literally get sick, your ability and desire to work both go down.  When you metaphorically get “sick of your job,” in contrast, only your desire goes down.

Scott concludes:

I propose that the preference/budget distinction is a bad way of dealing with anything more complicated than which brand of shampoo to buy. We intuitively talk about our choices as if there were some kind of “mental energy” that allows one to pursue difficult preferences, and I discuss some ways this confuses our intuitive notion of budgeting in Parts II and III here. You don’t have to accept any particular framing of this, but to sweep the entire problem under the rug is to ignore reality because you’re trying to squeeze all of human experience into a theory about shampoo.

This paragraph is quite a leap.  It’s sometimes hard to distinguish between preferences and constraints, so it’s “a bad way of dealing with anything more complicated than which brand of shampoo to buy”?  How about choosing a career?  Or a house?  Or how many kids to have?  Or what religion to join?  These are all major life decisions, but we readily conceptualize them in terms of preferences and constraints.  And contrary to Scott, this is good philosophy, psychology, economics, and common sense.

Second, Scott observes that many people voluntarily consume mental health services:

Szasz and Caplan both says that mental illnesses are attempts to stigmatize those with unusual preferences. I say that mental illnesses can reflect people’s genuine worries about a-thing-sort-of-like-a-budgetary-constraint afflicting them. Which of us is right?

Well, consider that about 95% of people who go to an outpatient psychiatrist do so of their own free choice. This is certainly the case with my own patients. They are people who have gotten tired with the constraints that mental illnesses put on their lives, come in and say “Doctor, please help me”, and I try to help them achieve whatever goals they have for themselves.

Question for Scott: Would your reaction be any different if someone said, “I’ve gotten tired of my self-destructive preferences, please help me”?  Indeed, don’t many forms of therapy (most obviously Cognitive Behavioral therapy) specifically emphasize that people can improve their lives by making better choices?

About 50% of people who go to inpatient psychiatric facilities also go of their own free choice.

And I admit that “danger to others” can sometimes be stretched to the point where if a psychiatrist wants to commit someone they can probably make up a justification. But these implementation problems are a heck of a long way from Caplan and Szasz’s theory of “psychiatry is just a project about finding weird people and locking them up.”

Actually, both Szasz and I emphasize two functions of psychiatry.  Locking up weird people is one such function.  I happily admit that this is much less prevalent than it used to be, though there has been a big increase in the drugging of children.  The second function of psychiatry, though, is excusing weird people.  As in “alcoholism is a disease.”

The psychiatric profession will never live down the thing about homosexuality; I fully expect that in 5000 AD someone will still be complaining that we can’t stigmatize entities infected with superintelligent self-replicating memetic viruses, because DSM-II listed homosexuality as a psychiatric disease.

Question for Scott: According to you, what do we learn about psychiatry from “the thing about homosexuality”?  Do we simply learn that psychiatrists made a mistake?  If so, what precisely was their mistake?  After all, once you reject the distinction between preference and constraint for “anything more complicated than which brand of shampoo to buy,” why shouldn’t you label same-sex attraction as a “constraint” no different from paralysis?

Even today I bet that most gay teens would take a pill that permanently “cured” their same-sex attraction.  Does that show they’re sick?  If not, why not?

In fact, given Scott’s perspective, I see little reason why racism, sexism, homophobia, or love of Slate Star Codex shouldn’t be classified as “a-thing-sort-of-like-a-budgetary-constraint afflicting” people.  Especially if you happen to live in the Bay Area, where I’ve heard these mental conditions can easily make life a living hell.  I say this without ironic intent.

Third, I implausibly accuse the mentally ill of willful deception:

Caplan admits that some mentally ill people seek help voluntarily and are among the most vocal proponents of the “real disease” theory. In order to shoehorn this into his preference-budget dichotomy, he theorizes that this is an attempt at deception. For example, alcoholics’ insistence that they cannot resist drinking alcohol is deceptive:

From an economic point of view, however, what is so puzzling about a person who prefers consuming alcohol to career success or family stability? Life is full of trade-offs. The fact that most of us would make a different choice is hardly evidence of irrationality. Neither is the fact that few alcoholics will admit their priorities; expressing regret and a desire to change is an excellent way to deflect social and legal sanctions.

But in order to fully explain alcoholic behavior, we have to take this theory exceptionally far. Consider a typical alcoholic drinks for several years, then “hits bottom”, goes sober, and joins Alcoholics Anonymous. He attends AA meetings three times a week for three years, then has a really bad day and binges on alcohol. Afterwards he is so embarrassed that he attempts suicide, but is rushed to the hospital and resuscitated successfully. After that he goes back to his AA meetings.

How do I respond?

(a) We don’t need to “fully explain alcoholic behavior” to admit that my story is often illuminating.  “I have a disease” is a convenient excuse for bad behavior; indeed, it’s so convenient that heavy drinkers offer it so casually that they don’t experience it as deception.

(b) People often wish they had different preferences, but this hardly shows that what appear to be preferences are actually diseases.  My original article neglected this issue, but this post addresses it in detail – and explains why it matters.

(c) People often feel inner conflict and remorse.  Consider the Biblical account of Judas’ betrayal of Jesus.  A theologically conflicted Jew betrays his rabbi, feels guilty about it, then hangs himself.  If this doesn’t show that Judas was sick, why does Scott’s vignette show the alcoholic was sick?

Fourth, I’m being absurdly dogmatic:

Does this man have a preference for going to AA meetings three times a week for several years then getting really drunk then attempting suicide? That’s a weird preference to have. Does he have a preference to drink, and in order to be socially acceptable he ‘covers up’ his one episode of binge drinking by years of AA meetings and a serious suicide attempt which he secretly knows will fail? That is a pretty disproportionately big web of lies, especially when probably no one would blame him for binge drinking one night one time.

If we’re willing to be this paranoid, we can basically prove or disprove anything. Bryan Caplan says he’s a libertarian, but my 9th grade Civics textbook says there are only two political parties, Democrats and Republicans. If Bryan says he’s in a third, he must just be trying to “deflect social and legal sanctions”. Maybe he’s secretly a Republican, but he wants to fit in to academic culture, so he says all of this stuff about “libertarianism” as a cover. His work writing hundreds of essays and some pretty decent books supporting his libertarian viewpoint are to maintain the credibility of his signal and throw us off the trail. Any donations he may have made to libertarian causes are the same…

…or we can be skeptical of textbooks that try to reduce things to simple dichotomies, whether that’s Democrat/Republican or preference/budget.


(a) Suppose people with my personality type were harshly treated by society unless we called ourselves “libertarians.”  Wouldn’t that make it reasonable to wonder if I’m sincerely a libertarian?

(b) Misclassification is especially likely when accuracy is widely seen as ugly.  Thus, when people turn down a party invitation, they routinely say, “I can’t come to your party” rather than “I don’t want to come to your party.”  They’re not weaving a web of lies; they’re just avoiding ugliness without vetting their speech for literal accuracy.  See here for a more detailed discussion.

(c) While distinguishing between preferences and constraints (“budget”) is occasionally difficult, these two categories partition logical space; if you do X, you either “wanted to do X” or “had to do X.”  Democrat and Republican, in contrast, are only two tiny clusters of logical space.  Thus, it is much more reasonable to insist on the former “simple dichotomy” than the latter.

(d) Again, what about my Gun-to-the-Head Test?  Changing the incentives of heavy drinkers routinely changes their behavior; how can this happen if they literally “can’t stop drinking”?

Scott goes on to argue that even on my own terms, I’m almost always wrong:

Caplan sort of flirts with admitting this:

Cooter and Ulen probably speak for many economists when they deny that the preferences of the severely mentally ill are well-ordered. But in fact, not only do individuals with mental disorders typically have transitive preferences; they usually have more definite and predictable orderings than the average person…it is also implausible to interpret most mental illness using a ‘hyperbolic discounting’ or ‘multiple selves’ model. These might fit a moderate drug user who says he ‘wants to quit’…but they do not fit the hard-core drug addict whose only wish is to be left alone to pursue his habit. The same holds for most serious mental disorders: they are considered serious in large part because the affected individual continues to pursue the same objectionable behavior over time with no desire to change.

But if we take that middle part seriously he is ceding me 99.9% of the ground without remarking on it. Most people with mental disorders and substance abuse disorders wants to get rid of their disorder or at least alleviate the worst parts of it. If you are willing to accept complicated “multiple selves” models for those, then that is what you should be using to model mental disorders, not the simple consumer price theory.

My point here is not that I embrace a multiple-selves model.  Instead, I’m claiming that if you embrace a multiple-selves model, you end up with the bizarre position that the people we normally call “severely mentally ill” are not mentally ill at all.  My own view is that if multiple-selves models were empirically important, would be a tech giant, rather than a rounding error.

Fifth, Scott criticizes my skepticism about the classic symptoms of schizophrenia: hallucinations and delusions.

Any time a patient reports a hallucination to me, the first question I ask is whether they’re just embellishing on hearing an inner voice, or whether they actually heard an external voice clearly and distinctly the way they are hearing me talk to them right now. Sometimes they did just hear an inner voice – this is especially common in OCD obsessions – but other times they tell me that no, it was definitely an external voice, totally different from their normal internal voice. Sometimes they thought at first it was a normal non-hallucinatory voice talking to them, and they got up to try to figure out who it was before they realized no one was around and it had to have been a hallucination.

This should not be surprising to anyone who has ever taken drugs, heard from people who took drugs, or been vaguely aware of the existence of drugs. Drugs can cause vivid, realistic hallucinations. Caplan says he doesn’t want to talk about neurobiology, and that’s all nice and well, but drugs provide a pretty good neurobiological proof of concept. LSD, which is infamous for its hallucinations, is a 5-HT2A agonist. You can treat schizophrenic hallucinations with Seroquel, which is a 5HT2A antagonist; placebo Seroquel doesn’t work nearly as well. Coincidence? I feel like at this point we’re getting into paranoid are-we-sure-anyone-is-a-libertarian territory again.

I don’t doubt that people sometimes have genuine hallucinations.  Yet as I explain in the original piece, it is reasonable to doubt people when they have shown themselves to be broadly unreliable.  Thus, I assume that Scott disbelieves self-reports of alien abduction.  Why?  Because the kind of people who report alien abduction seem unreliable.  So they’re all a bunch of liars?  Some are, but most probably just resist the simple dichotomy between fact and fiction.

Aside: I have learned something notable about hallucinations since I wrote the original piece.  Namely: a surprisingly high share of otherwise functional people say they “hear voices.”  There is even a movement to destigmatize the hearing of voices.

On delusions, Scott acknowledges my point that delusions often respond to incentives, but says it doesn’t really matter:

I don’t think the ability of psychiatric inpatients to hide their condition in response to incentives changes things much. I firmly and genuinely believe that Greenland is in the northern hemisphere, but if someone threatened to give me old-timey scary electroconvulsive therapy for believing this, I would tell them it was however far south they wanted it to be. This doesn’t mean my belief about Greenland is insincere, it just means I can think strategically. That even very deeply mentally ill people can think strategically can sometimes be surprising, but no one who has worked with them would deny it can be true.

But I foresaw this objection in my original article:

At least for many delusions, the fact that you would try to feign recovery shows that your degree of irrationality – not just outward behavior – is incentive-sensitive. Nash is once again an excellent example. ‘I thought I was a Messianic godlike figure with secret ideas’, he tells us. ‘I became a person of delusionally influenced thinking but of relatively moderate behavior and thus tended to avoid hospitalization and the direct attention of  psychiatrists’ (Nasar 1998: 335). But if Nash were literally constrained to see himself as a ‘godlike figure’, he would have imagined that he could free himself at any moment.21 He would be unable to grasp that – in reality – his freedom depended on a psychiatrist’s diagnosis, so he would have no motive to ‘beat the system’.

Where’s Scott’s response?

More importantly, though, Scott neglects my point that psychiatrists explicitly refuse to classify popular delusions – especially religiously-based delusions – as symptoms of mental illness.  Are they wrong to do so?  If not, then I ask again: If religious believers can have severe delusions without being “sick,” why can’t anyone?

Bottom line: While I have great respect for Scott’s judgment, I don’t see that he’s raised any objection to my view that I didn’t already anticipate.  While he’s correct to point out important gray areas, I acknowledged those gray areas all along.  Furthermore, while he talks as if these gray areas as vast, they only seem marginal to me.  Finally, if the gray areas are as vast as he says, Scott should abandon his support for the mainstream psychiatric theory of mind in favor of agnosticism.

Last point: I tailored my original article for readers who believe in the broad applicability of economic reasoning.  To escape my conclusion, Scott denies this broad applicability.  As a matter of intellectual chess, he made the right move.  If the economic approach to human behavior is “a bad way of dealing with anything more complicated than which brand of shampoo to buy,” then it’s obviously a bad way of dealing with mental illness.

Yet those of us who have witnessed the power of economic reasoning to illuminate questions far bigger than shampoo need to reverse his reasoning.  Do you agree that we’ve already used the standard economic framework to understand work, housing, family, politics, crime, and religion?  Then why not the behavior that non-economists so casually dismiss as “disease”?