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.
Response:
(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, stickK.com 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”?
READER COMMENTS
David Manheim
Jan 6 2020 at 11:24am
It seems clear that both of you are happy to concede a bunch of the extremes. Scott agrees that some psychiatric diseases are usefully thought of in terms of preferences, and you agree that some are clearly constraints. It’s possible that you are disagreeing about where the line goes in the (large) middle – though given that none of this is quantified or concrete, you may not disagree at all.
I’d hate to say either of you aren’t perfectly rational Bayesian agents – maybe you’ve already converged – 😉 But even if you disagree, I’m unclear whether there are concrete policy differences that those claims lead to, or how to tell if you do disagree. In part, this is because we’d need to discuss very concrete specifics to find where the differences are – and even then I’m unsure how to figure out what the disagreement is, or if there is one.
For example, I think you’d agree that if alcoholics say they would prefer to be put in situations where it is easier for them not to drink – cognitive behavioral therapy, AA meetings, whatever – and a reasonable proportion actually take advantage of those offerings – there are societal advantages in providing those services, whether or not this is a disease. But even a concrete estimate of what would be an optimal level of funding or providing these services wouldn’t tell us how far you are from Scott, since we couldn’t disentangle this from your preferences for allowing markets to provide these services instead of the government.
Similarly, I think Scott would agree that some level of sin-taxes or other incentives are optimal when they lead to people engaging in less behavior that society things is harmful to themselves and/or others. But again, even if he were to choose a specific level of pigouvian taxes he thinks are optimal in that case, we couldn’t easily tell where the disagreement is.
NotPeerReviewed
Jan 6 2020 at 12:49pm
Doesn’t type 2 diabetes fail the Gun-to-the-Head-Test? If they never choose to eat sugar or carbohydrates, they won’t display any symptoms.
Of course, you can argue that the diabetic still has underlying physiological problems with their pancreas, and thus still has the disease even when they aren’t displaying symptoms. But is this any different from alcoholism? Alcoholics have physiological problems with the mesolimbic pathways that make it hard for them to form stable, well-ordered preferences with regard to alcohol consumption.
JFA
Jan 6 2020 at 12:50pm
I don’t really buy the gun to the head argument either. In this extreme, almost everyone will change just about any behavior. I used these kinds of examples with intro econ students to “show” there are no needs, only wants. It is more of an exercise to get students thinking about tradeoffs in terms that are broader than money prices.
But with the gun to the head, pretty much everything becomes a preference. I actually would like a minivan but don’t have one due to my budget. If someone held a gun to my head and told me I would die if I didn’t get a minivan in 3 days, I would certainly be able to do something to get a minivan in 3 days. Because my choice changes, does this show that I actually don’t have a preference for a minivan?
Let’s say I am paralyzed from the waste down and need help getting things off the top shelf wherever I go. Someone comes along, puts a gun to my head, and says if I don’t get things off the top shelf by myself for the rest of my life, I will die. Well, chances are I’d find a way to get things off the top shelf without asking anyone for help. In this case, did I just have a preference for staying in my wheelchair and just asking for help?
The sense in which I “prefer” not having a minivan or “prefer” sitting in the wheelchair jettisons any kind of productive usage of the terms “budget constraint” and “preference”.
I believe in the power of economic reasoning in many domains outside of buying a bottle of shampoo. I think one should push the bounds of economic reasoning to the very edge. I also think by doing this, we discover the cases where the fuzziness between budget constraints and preferences becomes a sign that economic logic might not apply. So when we are left with the view that mental illness is a preference even though we observe people willingly pay thousands of dollars to a professional to help them change those “preferences”, spend hundreds of hours in therapy to try to change those “preferences”, and waste many hours in self-loathing agony wishing they weren’t what they were because they want to change those preferences… Maybe, once we are left with that view, we might start to consider that there is actually some internal budget constraint.
Kevin Jackson
Jan 9 2020 at 6:22am
I agree. The gun to the head test only works in a world of either-or: either something is a preference or a constraint. But in a world where people buffer their constraints, you will get false positives when applying the test. If you put a gun to the head of someone staying at home with the flu, you could get them to go to work, but not because there are no physical constraints caused by influenza.
Caplan lists the example in his original article that alcohol and drug users will go cold turkey for a moderate price, proving that theirs is a preference, not a constraint. But it would be easy to draw the same conclusion about food, without careful study. After all, humans can survive a significant time without food, but we know that the preference for eating the times a day hide a very real constraint.
The other problem with the test is a practical one: it doesn’t work as a thought experiment. We need such a test because we can’t trust someone to accurately distinguish between their own preferences and constraints. We need proof. But if we can’t trust the judgement of, say, an alcoholic to make a distinction, we shouldn’t trust the judgement of a non-alcoholic to make the same distinction! Even my flu example above is untrustworthy, because while I have suffered from the flu in the past, I am not currently afflicted.
KevinDC
Jan 6 2020 at 1:27pm
I find Bryan’s rebuttal unpersuasive, in particular his defense of the budget constraint / preference dichotomy. I actually mentioned why I find this paradigm unconvincing in a comment in another post he links to, the one defending the idea of calling “depression” a preference. It seems equally applicable here, so I’ll just mostly plagiarize myself:
As a man well into his middle age and a lifelong econ nerd, Bryan is probably not the most athletic man in the world. The prospect of running a mile in 8 minutes is probably an awful one for him to consider. However, suppose an evil fitness enthusiast promised to inflict horrific torture on all of his children unless he ran a mile in 8 minutes or less. And lets further suppose that Bryan, desperate to save his children, manages to run a mile in 8 minutes. I imagine Bryan’s response would be to say “Yes, you see, this shows that me not running that fast for that long is a preference, not a budget constraint. I could do it, I just find the experience awful and unrewarding so I choose not to.” Rather than refuting his model, he would say this is consistent with his model.
So what’s my point? Well, Bryan knows about ego depletion. He knows that people have mental defaults, and that acting contrary to those defaults takes deliberate effort, and that people’s ability to put forth that effort is limited. Mental energy and willpower are limited resources. And the limits of your mental stamina and willpower are budget constraints just as much as the limits to your physical stamina are a budget constraint. You can’t choose to have limitless mental stamina anymore than you can choose to have limitless physical stamina. Just because Bryan could, given sufficient incentives, run an 8 minute mile, this does not mean he could run at that pace for six hundred miles straight. He would run against the budget constraint of limited physical stamina, regardless of incentives. And just as other people can force themselves to act contrary to their own mental defaults with sufficient incentives, this does not mean they can do so for life, or even for very long. They run into a budget constraint of limited mental stamina. Bryan could avoid this problem by working in an additional premise that “People have unlimited willpower and mental resources for endless amounts of time, therefore limited physical stamina is a budget constraint but limits to willpower are not budget constraints” but I think we’d all agree that’s an absurd premise. But as soon as you acknowledge that willpower is a limited resource, his whole “budgetary constraint vs preference” argument comes crashing down.
Philo
Jan 7 2020 at 10:33pm
Caplan’s distinction between preference and constraint, applied to momentary actions taken one by one, is just common sense. If a depressed person puts a gun to his head and pulls the trigger, usually he could have refrained from doing so on this occasion. But you suggest that after such refraining–resisting the impulse to kill himself–a sufficiently large number of times, he might have exhausted his mental energy and become unable to resist the impulse to kill himself. This would be a straightforward case of constraint, not preference. But how many actual suicides meet this description?
Daniel
Jan 6 2020 at 1:41pm
I wish I could upvote David’s comment.
I want to touch on something: Scott’s point on willfully seeking treatment is really important, and Bryan’s take in The Depression Preference is not fully satisfying.
Start with the idea of choices as revealed preferences. People make choices consistent with their preferences and subject to their constraints. Consider an alcoholic who really likes alcohol, trading off family time and social connections for consuming alcohol. This choice seems to reflect an extreme preference for alcohol. But what if we knew more- that this alcoholic *wants* that family time and social connection. It would seem that the choice, then, is not corresponding to the person’s stated preferences. It could instead reflect a constraint. What do we believe- the self-report or the observed choice? Economists prefer the latter.
In the Szasz piece, Bryan suggests that incentive-sensitivity is a good sign of “preferences” rather than a constraint. As the trade-offs grow, the alcoholic eventually enrolls in rehab, supporting that this was a possible course of action all along. So not only do we like incentivized results, they are very helpful in this situation.
But what about those pesky self-reports? It would have been easy to say they were cheap talk all along, but the depression example undercuts this- we expect people to honestly prefer not to be depressed. In The Depression Preference, Bryan refers to them as meta-preferences. A depressed person might hold the meta-preference to go out with friends but they are constrained by their preference to stay in. I say constrained because I have this question: in the case of meta-preferences, do regular preferences cease to be “preferences” at all and become instead better thought of as “constraints”? Aren’t meta-preferences really just the self-reports we saw earlier? That is, rather than comparing self-reported preferences with incentivized preferences, are we perhaps making the comparison between self-reported meta-preferences and incentivized preferences? If this is the case, it becomes less clear that we should privilege choices over self-reports…they maybe measure different things. And it also becomes less clear that incentive-sensitivity is a good sign of “preferences” rather than a constraint. At the meta-preference level, changing the incentives changes the person-environment interaction that is operating as a constraint.
Basically, it gets back to David’s comment: “It’s possible that you are disagreeing about where the line goes in the (large) middle”, and I think the construals of each term depend on the perspective you’re taking in the hierarchy of constraints to preferences to meta-preferences.
Nathan S Benedict
Jan 6 2020 at 1:49pm
I think Brian needs to define what he thinks is and isn’t a disease in order to have a fruitful conversation here. (Scott has done so here: https://www.lesswrong.com/posts/895quRDaK6gR2rM82/diseased-thinking-dissolving-questions-about-disease). He seems to have taken the position that preferences cannot be diseases, no matter how problematic or debilitating the preference.
Consider the cilantro aversion gene. People with this gene find the taste of cilantro disgusting. But as Brian points out, they’re not physically incapable of eating cilantro. So in his mind, as best as I can figure, this is merely an unusual preference, not a disease. I suppose he would extend the same logic to all food allergies or syndromes that require restricted diets. Sure, Bob has a shellfish allergy, but that just means he has a preference for not bloating up, cramping, and vomiting. If I put a gun to his head, he’d eat shellfish, so it’s really just a preference. Or how about phenylketonuria (PKU)? This is a genetic condition that requires a specialized diet to prevent permanent, severe brain damage and even death. But again, it doesn’t make it impossible to eat phenylalanine. Obviously, people with PKU would prefer not to have it, but that’s just a meta-preference, according to Brian. How about Prader-Willi syndrome? This is a disorder that causes insatiably appetite. Caregivers of children with Prader-Willi must lock cabinets. Children have been known to eat bags of uncooked rice and flour. Again, just an extreme preference for eating?
If we’re willing to acknowledge that all of the above conditions are really diseases, despite the fact that they merely impose unusual preferences, not physical impossibilities, then why can’t we extend the same logic to things like alcoholism and depression? Again, imagine Bob, due to genetic reasons, has a high craving for alcohol and difficulty stopping or controlling his usage of alcohol, far more than the average person. This causes debilitating problems in Bob’s life. According to Brian, Bob merely has an unusual preference for alcohol, not a disease. But why can’t it be both, just like someone with Prader-Willi has a disease that causes an unusual preference for constantly eating?
I feel like Brain is simply defining disease out of existence by stating that a preference can never be a disease. I also notice that Brian did not respond to several of Scott’s best points. For example, Brian never responds to formal-thought disorders as a symptom of schizophrenia. Or Scott mentioning that psychiatrists ask patients whether the voice they are hearing is an inner voice or an external one. Or Scott’s anecdote about the patient who was unable to think strategically. (I’ve worked with many mental patients who were unable to think strategically either, such that many of them would easily pass Brian’s gun-to-the-head test). His weak response to schizophrenia is an acknowledgement that some people do indeed hallucinate, but some people are faking it. Does anyone doubt that *some* people lie and make up stories? So what? Brian spends pages attacking the very idea of schizophrenia as a disease, and when challenged, meekly acknowledges that it exists, but that some people are faking it, so therefore…? What exactly? Some people fake having cancer, but that doesn’t mean that cancer isn’t a disease. His point seems to be that we should be skeptical of such claims, which is a far cry from his original “schizophrenia isn’t real.”
AMT
Jan 6 2020 at 2:25pm
I think both you and Scott are too far to the extremes. I think your view fully applies to alcoholism and perhaps all “addiction” in general (perhaps not heroin? I’m not really sure). However I disagree with you that we should ignore neurobiology and focus exclusively on whether someone is capable of responding to incentives at all (gun to the head). I think that should be the focus on how we define a disease. I agree with Scott’s point on LSD/schizophrenia and hallucinations, how it seems quite clearly about brain chemistry.
However the ADHD example is less clear, but I’ll use bipolar, which I think is a better example. It seems clear that there is something biological going on causing the massive changes in mood (that cannot be controlled by a bipolar individual, like the heartbeat example). However, the individual is still perfectly capable of controlling their behavior. So should we call that a disease, or is that just giving this person an excuse? I think it is certainly an explanation for why their behavior changes, because we all have finite willpower, and do not always act in the short run according to our long run preferences. However, you can have a biological mental condition, which affects preferences, but that is not mutually exclusive with still having control over one’s actions. But does that mean this person does not have a disease? It seems to me, that the underlying biological condition is the focus here on whether there is a disease. Whether one’s biological makeup rises to the level of a “disease” is this arbitrary, gray area. Alcoholism? Food addiction? Laziness? Even if these are influenced by biology, letting every personal shortcoming be excused by the “disease” classification seems horrible for absolving willpower of any relevance. As you correctly point out the moral hazard problem, we can’t let people say “I deserve disability payments because I have the mental disease of laziness,” or “I couldn’t do my homework because I have ADHD [and played video games instead].”
So it seems the question may be just how powerful is that biological influence? If someone is able to control their behavior because they have a gun to the head, is it not a disease then? That might be a bit too extreme, because I think we still might decide that there is an underlying disease, if there is something biological that severely, negatively impacts their ability to function like most other people. (I think this is the key to the homosexuality issue, where society changed its mind and decided that these people were different, but that it was not a problem (disease). I love how you point out religious delusions are ignored! This fits in the same way: society deciding it is not a “problem.”). But this line will be a normative decision, and hard to define. Do heroin addicts qualify? I don’t think I’ll be trying it out to get a personal view on how powerful that addiction is. (And for that example, does trying and becoming addicted to heroin create the disease, that does not exist in for example their twin who has not tried heroin? If you create your own disease should you be able to then use the disease as an excuse? Should we look at it ex ante?)
I think we should be willing to consider the “disease” classification, because it can allow us to help people. I.e. it’s a good thing that people can use Adderall to help focus. (But, it might not be necessary to classify something as a disease. If it were legal for anyone to procure Adderall or similar drugs over the counter then this point would be moot.) We just have to balance that with excusing bad behavior via the “disease” label and the resulting “I couldn’t help it” attitude, and therefore failing to discourage the bad behavior.
So I am wondering, do you concede that schizophrenia actually is a disease? Do we know sufficiently more since you wrote in 2006 to conclude it is about neurobiology? Are there other mental illnesses you would add as being explained by neurobiology?
It seems to me your discussion of Nash is rather weak, and that for a while he just gave up on trying to succeed in life and interact with the world and retreated into fantasies, but that does not prove that he didn’t have a mental illness. As I say above, still having control over your actions is separate from having a disease. Basically, you go too far by implying that any control over your actions means you have no mental illness (“necessary to show that individuals with the ‘Christian gene’ are literally unable—not merely unwilling—to think rationally about their worldview.”). I have to side with Scott regarding psychiatric patients, that cogently concealing the symptoms of your disease doesn’t mean the disease doesn’t exist. Put a gun to someone’s head who is hallucinating a monster in the corner, and they’re going to say they don’t see a monster there if that keeps them from being shot. If your goal is to treat the symptoms (change behavior) of course people will respond to incentives, but that doesn’t cure a disease or disprove its existence. I think a severe, but less than infinite impact to your preferences (willingness to be shot in the head) might be sufficient to call something a disease…
It’s not obviously a contradiction for Nash to think he is a “godlike” figure, but to still moderate his behavior, unless he meant he had infinite power (I don’t know). Perhaps Superman has “godlike” powers, but he is not completely invulnerable to kryptonite…
For the 20% of Americans with a mental illness during a given year, isn’t that due to including depression as a mental illness, and then finding from survey results that some people were really, really sad at some point in the year? “I was depressed for a week after my girlfriend dumped me.” =Mental illness?
Hazel Meade
Jan 6 2020 at 5:21pm
I like your point about the disease classification allowing us to help people in ways that the “preference” classification doesn’t.
In my comment below, I was musing about how certain things aren’t really diseases but they aren’t really preferences either. It’s possible that certain things like autism and ADHD are skill deficiencies that could be remedied with additional training. Incentivizing changes in behavior is a blunt instrument – just dangle a carrot (or stick) in front of someone and leave it to them to figure out how to get it. A situation which seems almost cruel if you’re dealing with people whose problem is not really voluntary or a preference. Instead, you show them how to get the carrot, through explicit instruction. That’s a very different approach from the one that thinking of them as “preferences” leads you do.
ExistentialStoic
Jan 6 2020 at 3:23pm
I think it is important to recognize that psychiatric diagnoses are created by fiat, unlike other diseases, psychiatric ones are voted on! Voting is inherently a political act, not a scientific one. Let us not forget that masturbation was also a “serious” mental illness, as well as dropetomania (slaves wanting to run from their masters), women wanting to use birth control, and hysteria (a woman doing other things than a man wants). Now suicide, talking to oneself and having self-reported imaginings is considered “serious” mental illness. Mutatis mutandi – reporting that Jesus lives in your heart is not a disease, reporting that your ARE Jesus is a disease called schizophrenia is absurd!
Hazel Meade
Jan 6 2020 at 5:03pm
I’m inclined to agree with you that there are a lot of things, like ADHD and autism (in my mind) which are classified as mental illnesses which are really just unusual “preferences” – though I would use the term personality types or “behaviors”. The term “preference” implies a degree of control over these behaviors which doesn’t exist for many people who exhibit them. Nevertheless, having unusual behaviors is not in itself an illness, even if you can’t control them. And society can accomodate people with unusual behaviors in lots of ways at little cost, rather than sending them for treatment. (if a cog doesn’t fit in a wheel, is the problem the cog, or the wheel?)
However, I think your position that the *entire thing* is a sham is too absolutist, and a bit anti-scientific as well. There certainly is a great deal of neurobiology under pinning the reality of disorders ranging from schizophrenia to depression, and not only are the behaviors exhibited *unusual* but they impair rational thought and functioning, including self-care.
To some extent the distinction becomes semantic, but whether we think of these things as “preferences” or “disorders” informs how society approaches dealing with them. A “preference” implies that someones choice to exhibit a certain behavior was voluntary which makes punishment for making bad choices a more reasonable option. I.e. if a schizophrenic kills someone, then you just put him in prison like anyone else. But if that person has a mental illness, you provide them with treatment. I.e. you get them into psychiatric care, in a psychiatric prison. If all mental illnesses are preferences, then nobody should ever be found not guilty by reason of insanity. Nobody gets psychiatric treatment, they just go to prison.
Now, I do happen to think that autism and ADHD, at least in less extreme forms, are not real disorders – but I also don’t think that the way to deal with them is to assume that they are voluntary choices and simply incentivize people, via punishments or rewards, to behave differently. I think they are involuntary variations within the normal personality range of humans. Some people are just naturally more easily distracted, for instance. Rather than treat variation from the norm as an illness, we should design our education system to accommodate a wider spectrum of “normal” behavior. Modern classrooms are designed around a politically conceived idea of what is “normal” – but that doesn’t mean we punish bad “preferences” and discipline children more harshly for deviating from the norm.
Similarly, cognitive behavioral therapy does acknowledge that some things can be changed by choice, but it also requires *training* to make different choices to overcome involuntary dispositions.
In other words, by regarding deviant psychology as a “preference” rather than an involuntary personality disposition, we are led into the mistake of thinking that the way to modify it is via reward/punishment, rather than via teaching and training. People can’t be punished or incentivized out of depression or drug addition. There is a learning process that requires training involved in CBT. It’s not about dangling a reward in front of someone for not being depressed – you have to acknowledge the involuntary nature of the problem to provide guidance for that person to train themselves out of it. Just like you can’t teach someone math by yelling at them until they get the problem right. Math isn’t innate, and knowing math isn’t a choice. You have to show them how to do it. Trying to incentivize someone out of depression is like throwing a book at an illiterate person and demanding that they learn to read.
Eliezer Yudkowsky
Jan 6 2020 at 7:00pm
It’s not obvious to me that Bryan wishes to put forth a different material model of particular human beings – I can’t put a truth-condition on his claims that differs from Scott’s, or say how the universe would look if Bryan’s theory were true or false, even. It seems to me that Bryan is making a purely moral claim which I summarize as follows:
“If anyone could do ~X if we held a gun to their head, we should hold them morally responsible for doing X.”
Bryan argues for this viewpoint as follows:
– If somebody executes behavior X because of a preference for doing X, they are morally responsible for doing X.
– If having a very strong preference for ~X would counterfactually override your doing X, you must be doing X out of preference for it, because preferences can only override other preferences (rather than states of the world).
I think I have a different basic view of the whole world, here, in which people don’t have atomic free will and my moral theses aren’t constructed around it and the notion of “moral responsibility” is not nearly as fundamental to my axiology.
But I would nonetheless offer the following counterargument: I think it’s appropriate for the amount of “moral responsibility” for a choice X, insofar as there is any such thing, to vary depending on what the person’s alternatives were to X and what the costs were to them of ~X.
In particular, suppose that the mad Doctor Nalpac has threatened to stab me in the foot unless I drop a piece of litter in the street. So I do it. Caplan now comes along and says, “Ah, but you wouldn’t have dropped that piece of litter if I’d threatened to shoot you in the head, so you are morally responsible for having dropped that piece of litter.” I reply, “I suppose I hold myself ‘responsible’ in the sense that I’ll be considering and reviewing the sensibility of my own actions, but I wasn’t in anything like the same situation as somebody who drops litter on the street because it’s easier than finding a trash can, and I expect a legal judge in full possession of the facts would be blaming Doctor Nalpac rather than me, or any other sensible person; your Headgun Test fails to pick up on this.”
“Resource constraints” are an example of this general point about people who’ll suffer more from not making particular choices, and this also points up an inconsistency or problem of the Headgun Test: I could do all sorts of things over the course of one minute with a gun to my head, that I could not sustain over one year even if the gun stayed pointed at my head; I would just die when I couldn’t do any more pushups. So the Headgun Test can be used to argue that someone is “morally responsible” for all of the acts individually but not morally responsible for the whole package, even though the intuition from atomic free will says the person must have been atomically responsible for each element of the whole package. In the same sense, a lot of people certainly present as being able to do things requiring great mental stamina under Headgun conditions if they only need to do it for a day, or a week, but if you stretch it out to a year they would die. If you believe that presentation, it is a reductio of the Headgun argument over individual actions being used to argue that whole lives lived are due to preferences.
I expect Bryan denies the presentation – he doesn’t believe the people incapable of doing for a year what they are capable of doing for a day – because it’s the sort of thing somebody who believes in atomic free will would deny. My model of Bryan would say that maybe if you pile up the bad days for a year, their preference against those bad days gets stronger, and so Bryan would just say that you need something even worse than the Headgun to induce a ~X preference stronger than the preference to live. Maybe they would work hard for whole years at a time if the alternative was being damned by God to Hell? But I think the Scott model is that people would just keel over even if they were Catholics. This is the closest I can come to wringing out a different experimental prediction from the two worldviews.
My model of Bryan replies that obviously Catholics who sin don’t really believe in Hell, since many professed Catholics also sin over much more trivial matters that they wouldn’t sin over if somebody was holding a Headgun on them at that moment; and so the Hellgun, if people actually believed that a la Unsong, would counterfactually enable people to go on working under otherwise horribly unpreferred mental conditions even for years, thereby proving that the behavior was due to preference all along.
To which Eliezer replies that somebody who gets stung by a bee each time they throw litter in a garbage can instead of the street, even if they’d go through that in the face of Hell, is still not making a blameworthy choice if they drop litter in the street instead. I’d tell them to do the same, and even if they’re a little careless about sometimes buying foods that will generate more litter, I wouldn’t hold them to nearly the standard of blame as somebody who didn’t have the bees to worry about. And neither Headguns or Hellguns would change that.
Michael Bishop (@thatMikeBishop)
Jan 7 2020 at 10:53pm
+1 as we used to say
Phil H
Jan 8 2020 at 10:16pm
+1 again. What’s especially nice about EY’s argument is how economic the thinking is, introducing marginal, time-bound preferences.
Phil H
Jan 6 2020 at 10:54pm
AMT made what I think is the right point above, but it was buried in a long comment, so I’ll just put it to the top of mine: diagnoses are how we currently provide breathing space for people with unusual preferences. Medicalisation is quite a bad solution, so I think Bryan is right to criticize it. But it’s also worrying to think about what would happen if we got rid of it.
Think back to the gay marriage debate of the 1990s. There was endless talk about whether homosexuality is nature or nurture. The answer is, it doesn’t matter, gays don’t hurt anyone, and they should be free to sleep with/marry whoever they like, for whatever reason. But for social reasons, declaring homosexuality to be “genetic” allowed many people to relax about it. Compare stimming by people on the spectrum: If someone not on the spectrum starts muttering, rocking, hugging themselves, or spinning something, we ask them what’s up, and indicate that they should stop. If someone with Aspergers does it, in more enlightened places we now know to leave them alone. The diagnosis helps.
Incidentally, this isn’t just people being assholes. We ask those rocking themselves what their problem is because in non-spectrum people, that behaviour indicates intense trauma, and that person needs help. We’re trying to negotiate a path of concern for our fellow humans and tolerance of their differences. Calling all human behaviour “preferences” is not *wrong*, but erases some useful distinctions. It’s not helpful for people trying to get through their day.
A Country Farmer
Jan 7 2020 at 1:13am
I was hoping you’d write this one day!
I’ve never heard a good response to psychiatry’s thorny problem of classifying and then unclassifying homosexuality. I stopped reading Scott’s article after his non-answer answer to this.
I can imagine it’s hard to seriously confront such flaws of something you have a career in.
Hazel Meade
Jan 7 2020 at 11:34am
Here’s another way of thinking about this:
Let’s imagine a society where nearly everyone is born knowing how to play piano. Such a society might involve a lot of really sophisticated piano playing, including communicating various ideas via piano, telling stories, having discussions of sorts all via piano. There would likely be a whole piano playing culture of extreme sophistication.
Now for the tiny percentage of people who didn’t have this piano playing skill, they wouldn’t be able to participate in this culture without receiving specialize training – i.e. piano lessons. Something there might be a shortage of teachers for given the fact that everyone else is born knowing it. In fact, the concept of *teaching* piano might seem quite alien and bizarre to people who were just born knowing how to do it.
So in a real sense, these people would be disabled. They might be labeled as having a disorder.
Now let’s make this a bit more complicated and say it’s not just people who know how to play piano and people who don’t, but a spectrum of piano playing ability from excellent to poor, but with very few people having no innate piano playing ability at all. So people on the low end of the spectrum, maybe they could use a few lessons as well, but it’s not so obvious that they have low innate ability. Then maybe those people might by labeled as having “unmusical spectrum disorder” or something. And others might say “well that person is just lazy, he could play piano better, but he prefers not to”.
My point is that the definition of something as a disorder is largely dependent on the social context. Autism is defined as a disorder relative to an ideal of social behavior, same with ADHD. Many psychiatric conditions are defined as disorders only because they create difficulties navigating in *current* social environments with current social norms. In other contexts and societies they would not be considered disorders. So Bryan (and Szasz) aren’t wrong about that. However, it also seems incorrect to define them as “preferences” instead. A person who lacks innate ability to play piano does not do so by choice. They might strongly desire to be able to play the piano like everyone else, but have difficulty finding (or affording) the piano playing lessons they need. Maybe there aren’t that many books on how to play the piano because the piano playing society never has had a need to write down how to do it to train people. Maybe they don’t quite understand how piano playing works in their own brains. I.e. Like with autism or depression or addiction. It could be there there is some innate emotional competence that some people are better at than others. So there are some people who can just snap themselves out of depression and other people who just don’t quite know *how* to do that.
You could argue that it’s a “preference” if they are offered incentives to learn and don’t take them, but it’s not just a bugetary constraint either. There are specific resources that have to be available. In other words, in different social context, the costs associated with changing behaviors can vary. In some cases, the costs associated with behavior X can be high, but without adequate resources the cost of switching to ~X can be even higher, because changing to ~X is not cost-free. The term “preference” thus implies that changing from X to ~X is a frictionless, cost-free transition, when in reality it actually requires some amount of formal effort and training. By thinking of it as an involuntary “disorder” we start thinking about how to create the resources that make the transition from X to ~X less costly, and we also might start thinking about how we as a society can simply accomodate X instead of trying to get people to change their behavior.
Mark Bahner
Jan 7 2020 at 1:12pm
In the Rationality and Society piece, Bryan Kaplan writes:
Here are some common conditions labeled as mental illnesses:
1) Depression
2) Bipolar Affective Disorder
3) Schizophrenia
4) Dementia
I can not understand how any rational and clear-thinking person could argue that those are not mental illnesses, but are instead some example of “extreme preferences.” Further, knowing and having known individuals and their loved ones who have suffered under the burdens of these mental illnesses, it angers me that some economist would minimize the problems of these mental illnesses, apparently out of some bizarre sense of the appropriateness of “economic imperialism.”
Bryan would be wise to listen to Dirty Harry’s advice way back in 1973:
Carol Eldridge
Jan 7 2020 at 3:24pm
You are totally ignoring the fight or flight response on your preference and gun to the head analysis.
If a terrorist comes into my home, raises his machete in the air to cut my head off, and I shoot and kill him, does that mean my preference is to kill people? No, I’m terrified for my life and I can and will do anything at that moment in time to save it. Notice the word “moment”.
If I perform the superhuman feat of lifting a car off of my trapped husband, does that mean my preference is to lift cars? No, in fact I would probably never be able to lift a car again, maybe even under similar circumstances, because I could not simulate my response. Otherwise, I’d be walking up and down the street lifting every car I see just to show off my amazing skill.
If I am a homosexual man, does that mean if someone put a gun to my head and told me I, at that moment, had to have intercourse with a woman or I would die and I did it, my preference is really to be heterosexual? No, my preference is to still be homosexual; but not when I’m terrified for my life.
My examples may be a bit extreme but no more so than your arguments.
Don’t you think terrifying situations can cause people to behave in unusual ways that they would never be able to do again under any other circumstance? What you’re saying is that even if a person is terrified into action, that means they prefer to execute that action? Yes, maybe they can do it that one time because that terrifying situation throws their body into certain reactions; but is the behavior repeatable on will? Probably not, and it may not even be repeatable given a similar circumstance.
No wonder our society is so screwed up!
Mark Bahner
Jan 7 2020 at 9:57pm
…and another thing, you’re the one who is casually dismissing disease, Dr. (and I don’t mean medical doctor) Caplan!
Philo
Jan 7 2020 at 10:38pm
Actions stem from preferences and beliefs. It is misguided to attribute strange behavior in general just to strange preferences, when strange beliefs may just as well be involved.
Midge
Jan 7 2020 at 11:17pm
Szasz should have said, “The business of all medicine is to provide society with excuses disguised as diagnoses, and with coercions justified as treatments.” This is just as true of non-psychiatric medicine as it is of psychiatric medicine, as so many patients managing demonstrably physical diseases, who navigate all the social awkwardness such management entails, know all to well.
Seems like there’s another reply Caplan hasn’t read:
Contra Caplan on Physical Illness, Too
Excerpt, bolding added:
Medicine is still, at its base, a moral science, whose purpose is to help people live well in the bodies they have, whether by modifying those bodies (the stereotypical medical treatments) or by helping people cope with what can’t be modified (what a lot of medical treatments end up being). Since we’re social beings, much of “living well” simply means not burdening others in ways they’re unprepared to tolerate, through some combination of compensating for our infirmity and persuading them to tolerate what we haven’t compensated for.
Sudo Nym
Jan 8 2020 at 3:55pm
I struggle with attention and memory problems. It was precisely my inability to respond to certain kinds of incentives that eventually led me to seek psychiatric treatment.
I have lost thousands of dollars from my inability to focus on a task for extended periods of time. I have tried setting up social reward systems to help me complete tasks, and I’ve even tried betting with someone else that I would be able to complete a task.
The only thing that has enabled me to control my attention is stimulant medication.
And while on stimulants, it doesn’t feel like my preferences are changed. I still get the desire to stop reading, and start a painting or design a wooden gearbox or whatever. But I can acknowledge that desire, and then decide whether to actually switch tasks. Off stimulants, that new idea just automatically becomes my new task without a conscious decision.
Introspection can be unreliable, but the internal sensation of being on stimulants isn’t one of desiring to work more. Rather, it’s the addition of some cognitive tool that I previously did not have access to.
So I agree that there is a component of ADHD that can be characterized as a high preference for diversity. However, there is also absolutely a component to is more akin to a computational constraint.
And where I feel you may be getting muddled is that there are good reasons to suspect that unusual preferences and unusual constraints are comorbid. (Just like how the flu is associated with both decreased physical ability and a decreased preference for physical activity). I appreciate your attempts to destigmatize unusual preferences, but usually there really is a budget constraint.
Weir
Jan 9 2020 at 2:39am
Robert Plomin: “Heart attacks and strokes are often so mild we don’t know that we have had one.”
Meaning there’s no cliff edge. There’s no Rubicon. You could have a small heart attack and not know it. It’s still a real heart attack. There’s no border or threshold separating “a real stroke” and something you dismiss as not real. That’s not how bodies work.
Robert Plomin: “There is no point at which genetic risk tips over into pathology. We all have thousands of DNA differences that predispose us to schizophrenia; genetic risk depends on how many of these differences we have. It’s all quantitative, a matter of more or less. Genetically speaking, there are no disorders, just dimensions.”
So the mistake is to assume there’s a qualitative difference dividing the normal from the not normal. In reality there are people who score a thousand points on the spectrum and other people stuck on less than a hundred points. Having X number of points doesn’t mean you have a disease or a disorder. There’s no specific number we can point to and say that’s the magic number.
You could be David Beckham or David Byrne or David Sedaris or David Niven. There are extremes at either end but there’s no single point on the spectrum we can point to and say one side is sick and the other side isn’t.
Comments are closed.