Mental illness is physical illness is illness. It’s all the same stuff at rock bottom. Maybe Caplan is in some senses just a dualist. Or he believes in a “faculty of will” that just decides things.
And it’s hard to believe he’s ever really known a severely mentally ill person in his life given how he misunderstands it.
Right. Just because I can't tell you exactly how many grains of sand constitute "a heap" does not mean that "heap" is meaningless or a false category. And no amount of pointing to edge cases on the definition of "heap" will make the Sleeping Bear Dunes cease to be a major geographic feature.
I'm beginning to see the problem with behaviorism, with which I have limited familiarity. The problem is in a clinical setting it serves the function, or is the thing that currently best serves the function, of preventing neurotypical midwits from making bad and abusive decisions based on bad theory of mind. If you let the average behavioral health professional make any inferences at all into the behavior of an autistic person, or a mentally handicapped person, or whatever, that will lead to dark and dangerous roads pretty consistently. If you want examples of this you can just look at the troubled teen industry, which relies on folk psychology and religious theories of the human mind rather than behaviorism.
Complete digression but I have to say it as it reflects an important takeaway I got from practicing ABA for three years.
The distinction between behavior as disease and behavior as preference that I keep coming back to is whether it preserves optionality or not. This is probably strictly as bad as Caplan's because I have never discussed it with anyone (as a general rule I never have an opportunity to discuss anything with anyone: I am immediately dismissed as aggressive and insane whenever I articulate anything).
So anything that causes death trivially fails to preserve optionality. Anything that cripples a person or reduces their intelligence or health trivially fails to preserve optionality. Getting into a machine that injects an optimized dose of heroin into you continuously while keeping you alive indefinitely trivially fails to preserve optionality, etc. Environmentally I think of this as a problem that can sometimes be solved by reducing the strength of incentives or attractors. Some behavioral incentives are basically singularities to humans in some or even most mental states. I can't think of a good reason any environment should be engineered in a way that creates such singularities.
Ironically, Caplan often criticizes his fellow economists for being too inclined toward behaviorism and not taking seriously intuition & reports about mental states. I'm more behaviorist than Caplan and think he relies too much on the latter sort of evidence.
I do think Caplan's gun to the head test is somewhat stronger than you give it credit: even with a gun to the head you will have reduced capacity with a physical illness relative to your capacity without that, and we don't need to look at a bright line like traveling a specific distance when we have other observables like how fast & steadily you're moving, how heavily you're breathing etc.
I said something to this effect on Caplan's post itself, but his ideas on mental illness are the perfect example of the incoherence that results from applying market-based reasoning to areas outside its proper domain. Markets and economistic modes of analysis are useful tools, but when you insist on applying them to literally everything you end up with nonsense like insisting mental illness doesn't exist because something something preferences. Remember people: just because you have a model that can explain a lot of things in a really cool way, doesn't mean you have to apply it to literally everything in the universe!
Horses have no appetite control and can't vomit. If you put enough horse feed in front of a horse, it will continue to eat past the point where it starts injuring its stomach and will eventually die from it.
Caplan's gun-to-the-head distinction between a "preference" and a "constraint" seems so wildly, obviously silly that it's hard for me to believe he actually means it. Reading his original paper, it seems like he's just trying to plug a hole in libertarian philosophy that can't actually be plugged.
Once you are getting into these either or spaces within nosology you have missed the boat in medicine and psychiatry. The huntingtons hemiballism, the tourettic tic and the OCD compulsion are all on a spectrum, with the inevitability of performing each action modulated by shades of increasing agency, but all vastly to the seemingly inevitable and ego-dystonic side of one's perceived agency. Interestingly neuroimaging and demographic data (OCD/tourettes ~30% comorbid with eachother) point to common potential imbalances between the direct and inhibitory pathway in the basal ganglia.
Thus, it's just shades and penumbras between what psychiatrists and neurologists are doing, psychiatrists are like epi-neurologists. On this note, in thinking of preferences and constraints- late stage addiction involves changes in the dorsal striatum and almost becomes like a movement disorder- and the withdrawal state becomes a physiologic constraint that drives the inevitability of use through negative reinforcement- (not to mention the avoidance of hypertensive states, dysphoria, seizures etc). A preference clearly can become a constraint, like eating turns morbid obesity. These are all intricately related. Anyone who is not just armchair commenting and has experience with dual dx populations though, will know the experience well of hearing tales of trauma and hyperarousal etc, driving the original use- was it a preference? Was it not the cause of an original imbalance that constrained the inevitability of pursuing one action over another? It's diffuse and penumbral and deserves individual assessment and formulation, patient by patient, and that's the beauty of psychiatry.
If the difference is supposed to be that a "preference" can be changed with incentives and a "constraint" can't, then I don't think the dichotomy makes sense even in purely economic terms. Any budget "constraint" can be overcome with enough creativity and disregard for the law - it's just that the incentive would have to be much much stronger to match.
Or, in Caplanian terms: I can't afford a house, but if I had a gun to my head, I could probably make it happen.
Hmm, I do not disagree with your point that preferences vs constraints is a very limited framework for evaluating whether something is an illness. However, your parsimony argument is on the weak side: the universe is complex and the apparently simplest models are often wrong. Whether to consider something an illness that needs to be cured/accommodated/empathized with depends on a complex interplay of internal and external factors.
For example, homosexuality can be considered an illness to be cured in one specific society if every member's procreation is essential for the survival of the society (and assuming artificial insemination is not an option).
Having lethal cancer at the age of 30 can be considered normal in a society where people over 30 are a burden for whatever reason, and not getting a cancer is a disease. Taking steps to avoid getting cancer by 30 could be considered a mental illness or a crime.
Star Trek: TNG has a whole episode on Geordi not being considered ill.
The subculture of hearing-impaired often looks askance at those who choose to have an implant. Without implants available poor hearing was an illness, with them available it's a choice.
Many things that we normally think of as symptoms of physical illness, are not in fact directly caused by the disease, but are an evolved behavioral suite that activates in response to the disease!
I thought the debate about whether depression is a disease as a debate mainly about whether depression is a distinct entity, or whether the real problems depressed people have couldn’t be classified better by other disease pathologies.
Or something else. Maybe some set of people who have depression diagnoses are actually lonely, maybe that is their real problem. ”Lonely” is a real problem but it isn’t a disease. You might say, well, they are depressed too. But is that really the most useful way of thinking about it?
But Caplan seems to be arguing that people can’t actually be lonely without choosing it, without its being their revealed preference?
I think you've won this against Brian Caplan-Szasz. (I have some expertise in criminal insanity law, and I'd occasionally see citations to Szasz well past the point where it was defensible.)
I think I've changed my mind after reading this post, in the direction of Scott. That is his position seems more consistent than I thought, nevertheless this issue seems very much to do with what values one regards as important within a particular context, and I think Kirkegaard's emphasis on fitness, makes sense from a particular scientific perspective.
Although perhaps importantly, I don't think the general public and even various experts, have a view that's as self aware as Scott's, such that I think the Szazsian view is still of merit.
"Instead, I would rather describe things that make an action difficult and unpleasant as in some sense real constraints."
You'd think an economist would understand that friction (in the metaphorical sense) making activities more costly (in the economic sense of all costs) doesn't have to be a hard constraint to alter people's behavior. Illness is, well, taxing. Many illnesses, like taxes, just make stuff more costly without imposing hard boundaries.
I've developed, against my will, a strong preference for avoiding cats and smokers. It's nothing personal, but I like breathing better. Medicine has advanced enough that I could live with a cat or smoker and not die, but it would be an unproductive life, since struggling to breathe turns out to be really distracting.
If my only asthma triggers were cats and smokers, I could lead a normal, un-asthmatic life in a society that shunned smoking and cat-keeping – politics! In this society, though, where cat-keeping is normal and smoking is stigmatized but still common, I'll sometimes drug myself extra to disguise my airway's weird preferences as much as possible while I visit loved ones who live with cats or smokers. I'll usually still have symptoms, but I consider it polite to hide them if I can – though "polite" can be overdone:
I once "polited" my way all the way to the ER as a child. I was wheezing at school but didn't want to make a scene, so I hid it for as long as I could. As my parents pointed out, hiding it that much ended up making even *more* of a scene. The etiquette of minimizing the burden we impose on others due to our weird bodily preferences (like asthma or diabetes) can get rather complicated.
What's up with this guy Caplan? After reading Scott's essay, above, I thought he was a mentally ill person who felt dehumanized by being diagnosed as a something-or-other -- and that's a common reaction, and one I have no trouble sympathizing with. So, I thought, this mentally ill guy, maybe somebody bipolar and often manic, has fixated on Scott as a representative of the profession who diagnosed him as a something, rather than seeing *him.* He wants Scott to say that diagnoses are bullshit so that he can have a win against the profession. And I wondered why Scott was continuing to debate with somebody like that.
But in fact Caplan's a professor of economics & has written several books that sound entertaining and politically incorrect: The Case against Education, Selfish Reasons to Have More Kids. Glanced over his blog for about 3 mins and read a few random bits that were smart, witty and well-written.
But he has this weird bee in his bonnet about Scott. In his Twitter post asking whether Scott's take on witches stealing penises shows Scott's a closert Szaszian he ends with a survey asking "am I crazy or not?" and most common response was "yes, you are crazy." Then I looked at his post about Scott's announcement of his marriage, and didn't see any spinning of that regarding mental illness -- in fact mental illness wasn't mentioned. So whattup?
It's easy to see that Caplan's wrong. I'm more interested in why he's got this weird take on Scott. Anyone know more? Scott, do you?
Far from an expert, so feel free to correct errors.
I heard recently that for many mental illnesses, they are more correctly thought of "syndromes" or collections of symptoms. Having a known, identifiable, physical cause means that it _not_ that mental illness, even if all the actual symptoms are identical. If they find a brain tumor, that means you are not depressed, you just have a tumor that is causing exactly all of the standard depression symptoms. You only have depression if a specific physical cause can _not_ be identified.
As far as this is correct, it may be causing Caplan's issue (and to be clear, I think I disagree with him on this topic). We have explicitly defined many (if not all) mental illnesses as "thing that we do not fully understand". As soon as we fully understand it, it is not longer a mental illness and moves into the realm of standard physical illnesses.
The obvious answer to me is to just admit that we don't fully understand them, not to try and wave them away as nothing but preferences. If you moved to various points in time, nearly every single currently understood physical disease would fit into a similar space.
I posted this comment elsewhere but seems relevant (sorry if Scott has already used this example in one of his other rebuttals)—
Bryan needs to explain why someone with schizophrenia who is in the midst of a psychotic episode is fundamentally different than someone in the midst of an epileptic seizure shaking on the floor, in the sense than in both cases the person's brain is in a highly abnormal state which causes various behaviors we wouldn't normally expect. Does the epileptic have a preference for flailing around on the ground? Obviously not.
One central problem (as I see it) is Bryan's belief in free will, which totally clouds his entire analysis. Many of the conditions we are talking about systematically warp and distort peoples' decision-making and judgment. Viewing the mentally ill as just making different choices based on different preferences is the kind of things I would expect to hear from someone who has never actually met a severely mentally ill person in their lives, which I suspect may actually be the case for Bryan (but that's just my suspicion from the way he talks about this stuff).
I think maybe an even better analogy than physical illness is injury.
There is an obvious and blatant malfunction when you break your ankle, or lose a finger, or get shot.
And yet, despite the pain, in extreme circumstances we have many examples of people who walk on a broken limb or continue to function for many minutes despite being shot multiple times.
The ability to damage yourself or accept pain to further an important goal in no way contradicts the existence of the injury. The change in behavior while injured is not the same thing as just having a preference for not walking. The treatment for injury is generally obvious, simple, and results in behavioral changes, like walking again, but the treatment is not about changing preferences, it's about changing the actual physical state of the body.
The repeated focus on genuine psychosis when a person's behavior does not respond to any incentives, does not seem like a good example to focus on in the context of Caplan's argument. If indeed it acts purely as a constraint and lacks any of the characteristics of a preference, then fine - it's an illness - and not subject to Caplan's point.
Caplan repeatedly states or implies that some so called mental illnesses are actual illnesses (although unfortunately he rarely elaborates on which these are). So if (some cases of) psychosis qualify, so be it.
>Again, Caplan could say that this is just a preference for attacking cops and then being killed. But in that case he should stop touting the “gun to the head test” as meaningful.
This really seems to miss Caplan's point. The "gun to the head" is a common metaphor for duress, given that typically people don't want be shot in the head. The question is whether incentives can affect someone's behavior.
In the rare case where someone wants to be shot in the head, then being shot in the head is obviously not a disincentive. Such a case tells us nothing about whether incentives could sway the person's behavior like preferences.
Again, this seems to deliberately misrepresent Caplan to make him seem sillier. The post keeps talking about people choosing their preferences. When does Caplan talk about choosing preferences? What does it even mean to choose a preference?
As coming from a family of alcoholics, this example getting brought up again and again by Caplan is especially irritating, given that once you have maintained a certain blood-alcohol level for a very long time, it can be lethal to suddenly stop drinking. Without meds, best case scenario is delirium tremens, or you will have a 45 minute long seizure before you finally drop dead.
>His current post says that either you have to believe that mental illness doesn’t exist and is just voluntary preferences which are stigmatized by society, or you have to believe that homosexuality is objectively a mental illness.
>Not only are each of these incoherent ideas, they’re not even the same incoherent idea! You could easily accept one of the incoherent ideas and reject the other!
Of course they're different ideas! That's the whole point. If they were the same idea, then it wouldn't be either / or.
Caplan explicitly rejects the idea that homosexuality is an illness.
In between heterosexuality and coke v Pepsi: cilantro tasting like soap. Seems a lot like a preference, but we've found the gene and we know the subjective experience is different.
I don't usually hear it classified as a generic disease, probably because it usually doesn't cause much distress, but in a hypothetical culture that put cilantro in everything, or used it for sacred purposes...
This is starting to sound like Social Model of Disability. Come to think of it, a lot of this post sounded like SMoD. Could you write a full post on that some time? I think it could benefit from your analysis.
I am not sure if you have covered this argument somewhere, but even in terms of observable, economically meaningful behavior, Caplan's approach contradicts reality - I mean, how does he explain depressed patients spending considerable time, money and effort on therapy and various medications (that come with nasty side effects) TO GET RID OF THEIR DEPRESSION if being depressed is just something they chose to do?
Obviously Caplan is arguing from a fallacious, dualist view of human behavior, but it also strikes me that he's performing a bit of rhetorical legerdemain by treating mental illnesses as merely matters of conflicting preferences, whereas I imagine psychotics and schizophrenics would encounter difficulties stemming from their unusual perceptions of reality even if they were living as hermits, or if they inhabited societies exclusively comprising fellow psychotics or schizophrenics
A masterly rebuttal, but your footnote 4 is wrong. You can prefer something because it is less bad than the alternative; what you think is, the only thing worse than staying in this bed, would be getting out of it. Presumably Caplan has to say that you have chosen to believe that.
Caplan's view just seems sort of crazy. Like, you just read his description of schizophrenia as just being a preference to lie around all day claiming one sees demons, and it's so obviously false. Good job with the reply--very convincing.
Caplan : "Here's what I think. Anyone see anything wrong with it?"
Anyone: "Well, since you ask, here is the GIANT MOUNTAIN OF EVIDENCE you ignore, and the dozen major authors on this subject you clearly haven't read or engaged with."
Caplan: "...no one? Guess I am right about everything."
What confuses me about this whole debate is that Caplan long ago admitted that some things can change both preferences and budgets: "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." https://www.econlib.org/scott-alexander-on-mental-illness-a-belated-reply/
Surely mental illness also affects both ability and preferences, though? E.g. if someone has serious anxiety, that will both affect their preference for avoiding stressful situations, and also affect what they are physically able to do (e.g. speak confidently in front of a crowd without having a panic attack). Gun to the head will not calm them down.
So I kind of have no real problem with Caplan's framework, but also just think he isn't actually applying it?
I get that you're intending to ask about willpower in #2, and that in that sense my answer violates the "spirit" of the question, but I also think that the fact that it actually isn't about willpower for a lot of people is relevant and highlights where the spirit has gone astray.
Gun to my head, I'm definitely blacking out due to hypoxia before breathing. This is certainly true for at least any semi-serious freediver, but I suspect far more than that. At some point you're just not "will power" limited and it becomes a question of whether increased incentive can lower heart rate and energy expenditure further -- which is a bit like "As long as you manage to not be afraid, I won't shoot you". Is the person who feels fear there showing a preference for not dying or a preference for dying?
Or just that they're constrained by their ability to organize their preferences?
You might be pleased to learn that when I got as far as the 'restored' painting of Jesus, I laughed out loud (and I'm at work, good job it's early in the morning when there's only one other person in the building as yet).
Mostly this lines up with my views of Bryan Caplan (and to an extent Tyler Cowen) and their views on matters, which are - well, I can't put it the way I feel because that would violate the "Kind/True/Necessary and Principle of Charity" on here.
Let's just say that Caplan annoys me with his total self-assurance that being an expert in one domain means he's an expert on everything under the sun. Ditto Cowen and education.
Would Caplan claim that being diabetic is a choice? You can certainly make that argument about Type II diabetes, and maybe (if you feel like being a particular son of a bitch) about gestational diabetes - after all, nobody *forced* you to get pregnant, but Type I is being born with a deficient pancreas. Unless we're going to invoke karma and the Wheel of the Law and reincarnation, it's tough to argue a Type I diabetic 'chose' that.
" You can imagine the depressed person choosing to throw parties and work hard instead."
This man has his head up his arse, and I'm sorry if this phrasing forces Scott to discipline me, but fucking hell. I'm not formally diagnosed (mostly because I can't convince my doctor) but I'm sorta-kinda depressed at times (at really bad times I have spent something like three days lying in bed sleeping) and yeah, sure, Bryan: I can totes leap up, decide to throw a party (for all zero of my non-existent friends) and have a great fun time getting those extroverted tendencies of mine online and having the ol' happy-reward neurotransmitters flowing! It's only a choice to be crying my fool eyes out over my dumb life!
"One can imagine Bryan Caplan not being a feckin' eejit" but I admit, it's only a thought experiment and not reality.
"In particular, he claims I am FORCED to either accept that all mental illnesses are just “preferences” and so not illnesses at all, or as posited in a response by Emil Kierkegaard, that homosexuality is a mental illness and therefore bad."
I'm willing to bite the bullet on that one. "But - but - that's mean to the gays!" Yeppers, Bryan, I'm not a secular liberal. Whatcha gonna do now?
I have kind of find hard time calling Down syndrome an illness. It is called a syndrome for a reason.
And also it doesn't really matter if we call it an illness or not. It is relevant only for people who care about policies and so on. They can use their own definitions if they wish, it shouldn't impact scientific thought.
This whole discussion sounds more like Plutonians debating if Pluto is a planet or not (a reference from Rick and Morty). If by scientific calculations their activities are damaging their environment what does it matter how they call it? It only matters for politicians who don't care about science but votes even if it leads to the ruin of the whole planet.
The same thing about Down syndrome. It is bad, we know it. We don't need to call it an illness to understand this fact. If we could invent a drug that fixes the genetics of a new-born baby, we would gladly use it. Maybe one day we will have such genetic cure. Maybe for those scientists who work on this problem it is important to call it an illness because those who give grants for these studies, follow bureaucratic rules – if it is an illness, you get money, if it is called something less – nada. But once you get money, you don't need to call it an illness anymore. Just study the thing whatever it is called.
A quick web search on Bryan Caplan reveals that he is an economist. As such he must have had rational actor decision-related concepts, such as "choice" and "preference", drummed into him for years and years and sees the world through that lens, and has a desperate urge to shoehorn everything into the same rubrik.
So it sounds like he is trying to extend this outlook from economics into areas where it is often not appropriate (just as it often isn't in economics itself - hence all economists' notoriously duff predictions!)
"In fact, if you put a gun to the alcoholic’s head and threatened to shoot him if he ever drank again, probably he would stop drinking."
He's never been around hardcore alkies, has he? I know that he's trying to pull the Chestertonian gambit as in "Manalive" collection of short stories, where the protagonist pulls a gun on a professor who is droning on about non-existence being better than life, and shocking him into wanting to live, but that's not a good method in reality (not unless you're sure that the person is only repeating fashionable absurdities and doesn't really hold to them deep down).
Put a gun to a depressed person's head, say you'll shoot unless they start throwing wild parties, and it's likely (if you pick the right - which is to say the wrong -time) that they'll say "Pull the trigger, I'd rather be dead". I've had those moments and I've had to claw my way out of them, and fuck you Caplan, it's NOT a 'choice' to do so. It's a struggle and a fight and I wish there were no necessity for it. I'm not "choosing" to feel like this, and you can't wave about "but you admit you fight your way out of it" as a choice. Mostly it's because I was raised that suicide is a mortal sin. Knock that pillar out from under me, and I'll take the other path one of the dark days.
"If we don’t like them, we should ask the people who have them to choose differently, instead of treating them as diseased."
Okay, I'm crying laughing here. So back in my social housing days, we should have said to our schizophrenic client "I'm sorry, but instead of sending the workmen out to change the locks on your doors yet again, can you instead *choose* not to believe that your neighbours are breaking into your house to smear shit on the kitchen walls and that we are sending cameras up through the toilet in order to spy on you on behalf of the government? Thanks!"
Yes, Bryan, *that* would *surely* work!
Same person on her meds: was stable, was able to hold down a job, did not phone or call into the office in a highly excited state
Same person off her meds: see above for sample of behaviour/thoughts.
>One might as well claim that a paralyzed person could walk if they wanted, but chooses not to.
The kicker being, some of them can. My uncle pulled it off after three years of paralysis (before I was born). He's mentioned a few paralyzed people have had more feeling in their legs than when he started out, but they didn't recover because they didn't have the ridiculous drive necessary to get back up (the kind that lets you focus on standing up for a full year without making any visible progress to standing up, and then fall on your face a thousand times).
Kaplan's a dualist. He's talking about the preferences of a homunculus, not about the preferences of a body. The human brain has been dissected many times and no one has ever found a homunculus. The homunculus is an illusion (a kind of narrative component) that focusses the brain's modelling capacity on the successful survival of the organism. Our modelling is always imperfect, limited and faulty - mental illness makes it even worse.
Modelling human organisms as disembodied preferences is useful in economics. It's still a model.
Caplan is making two fundamental errors, which I think Scott realises but doesn't explicitly name. Caplan shows that it is POSSIBLE to account for the behaviours that mentally ill people exhibit by invoking preferences, but mistakes this for showing that it is PLAUSIBLE. Scott’s counterexamples are basically ways of saying that the way ‘preferences’ are being invoked by Caplan are a) stretching the concept in ad hoc ways one wouldn’t do unless one was trying to win a very specific argument, b) basically unfalsifiable and c) simply not the best explanation of what we observe. The reason they exhibit these flaws is because Caplan treats preference as ‘thing that produces action’ and not noticing. No matter what change in behaviour is observed, it will be trivially true that preferences can explain it on this way of thinking. The only way you could even notice the flaw with this characterisation is by realising that it does a bad job of accounting for how we describe our other observations, and that requires noticing that ‘it is possible to explain their behaviour in this fashion’ is no where near showing that it’s a satisfying explanation. If someone’s behaviour can be explained by preferences no matter what they do, then ‘preference’ isn’t doing any useful explanatory work – it generates no predictions and constrains no anticipations. It’s the same flaw that affected early psychological work on traits. If you say someone is courageous in setting A but not in B, you can salvage any given trait in your explanation by just saying they have the trait of ‘Courageousness-in-A-but-not-in-B’, which works for literally any observation.
The second error is that Caplan’s test for ‘is a preference’ is ‘is voluntary’, but his test for ‘is voluntary’ is simply ‘is changeable by will given a certain stimuli’ [namely a gun to the head]. But he needs an argument for why we should think of ‘voluntary’ and ‘changeable by will given some stimuli’ are the same given they clearly are not the same concept at all, evidenced by a) folk understanding of those concepts, b) volitional will as a capacity clearly comes in degrees, and c) volitional capacity in some circumstances cleraly does not translate to volitional capacity in all cases (gun to head is likely to spike adrenaline which clearly increases some capacities you would otherwise lack).
What is the bottom line? How does this help us find out what criteria justify treating adults as incapable of choosing for themselves, or how how best to deal with them?
It almost makes sense to say, we should treat diseases and have compassion for those infected, and should not treat preferences and perhaps not have compassion in some instances. But then aren’t we ruling out diets or diet pills as treatments for being overweight? Why shouldn’t we treat preferences, if the person with the preference consents to altering that preference?
Szasz was against electroshock therapy, lobotomy, and probably would have resisted many pharmaceutical therapies for depression and other mental complaints. But again it isn’t the preference/disease distinction that is driving things. For adults that seem able to take responsibility for themselves (or whatever we should call the criteria), treating them should depend on do they want to be treated, is the treatment likely to be safe and effective, etc. But there are some people that do not wish to be treated, but also seem unable to take care of themselves. Szasz, Caplan (presumably), and maybe Foucault think that society transforms a social problem into a medical problem, using medical style treatments to control some who are difficult to control otherwise. In the extreme cases, there is something to be said in favor of this, just as society puts violent criminals in jail. The important question concerns when this is justified and when it is not. If murder was a symptom of an untreatable disease, isolation of murderers would still be justified.
So why are we arguing over disease versus preference?
Admire and love both of you (met Bryan&family last Sunday). The controversy pains me - though, as it leads to more posts by both of you, it must be a good thing. Scott "wins" by 42 to 3, I'd say. Nitpicking, here the three: 1. Scott's former "preference is just good for shampoo" was silly, (could count double for not admitting). Scott does much better now, saying "The middle three (straight, gay, even depression!) aren’t obvious, which is why we’re having this debate."
2. Scott about Caplan: "his position: that ALL mental illness is just voluntary preferences" - misrepresentation: even in the last post Caplan writes: "most". (Counting also against Bryan, as he never seems to point out which are "obviously" not preferences and which may not be). Oh, and not sure, Caplan agrees with "just".
3. oops, forgot ... maybe a few very tiny things adding up? Oh: Maybe the Szaszi/Caplan view has its uses?! Like: those addicted/"crazy" enough to defecate on the streets of San Francisco might be more able to control that urge if it resulted in sanctions - maybe birching (Singaporean style - any numbers on how often shit happens there?). But assuming "oh, they can not help it"/"we should help them more" may mostly result in: more crap?
End note: "free will/voluntary/preferences" are ambiguous - see Albert Einstein: "Schopenhauer's saying 'A man may do what he wills, but he cannot will what he wills' has filled me vividly since my youth and has always been a comfort to me seeing and suffering the hardships of life and it remains an inexhaustible source of tolerance."
“Why not say that […] colds are just a preference for lying in bed and blowing your nose a lot?”
Because colds also prevent you from stopping your nose from running, various tissues from swelling, lungs from congesting, etc., even if a gun is held to your head.
What would Caplan say in reply? He is unlikely to respond directly for a long time, if ever, so I will try to imagine his response. I found in composing it that Caplan has already spoken to almost all of Scott's points, albeit perhaps not to Scott's (or my!) satisfaction. As a result, I fear Scott and Caplan are talking almost entirely past each other.
Disclaimer: this is my summary of Caplan's views, not mine. I am not a Caplanian!
Scott thinks I have crudely mischaracterised his views, like an ugly restoration of a beautiful medieval painting. Unfortunately, his picture of my views is no more accurate. I am not asking you to adopt a crude behaviourism, but rather the most parsimonious account of mental illness. It is extremely surprising that Scott would attribute behaviourism to me of all people! But while our models should explain, they should not over-explain. We have strong reasons to be sceptical of people's self-report, in circumstances in which they are strongly incentivised to answer in a particular fashion.
On Internal States
Scott's reply bafflingly attributes a strong behaviourism to me. I cheerfully agree that pain is real, that people have internal mental states, and so on. Scott returns again and again to this theme, but I'll just pick out one example as particularly illuminating:
"Maybe depressed people completely voluntarily choose to lie in bed for a few years while falsely claiming to be miserable and then shoot themselves in the head, and all of this is a perfectly free choice that they are happy with."
No, the depressed person is (presumably) genuinely miserable, and not happy with his choices, because his preference (lie in bed) don't line up with his meta-preference - have a fulfilling life. But that doesn't mean his choices weren't voluntary, or indeed, that there was anything unusual about his situation. This is the normal human condition! No doubt many people wish they were more conscientious, or ambitious, or loving. No doubt many people struggle with time-consistency. There is nothing mysterious or diseased about any of this.
On The Analogy To Physical Diseases
Despite what Scott says, I agree that migraines are a real disease. They are (in part) a constraint, that the sufferer can't look at a light without feeling pain. With a gun to the head, the migraineur would still feel the pain. But sitting in a darkened room is no part of that disease. That is a voluntary response which - as Scott is forced to concede - would change under different incentives. Once again, my gun-to-the-head test is vindicated - headaches are a disease, but sitting in the dark is a preference.
More generally, both physical and mental illness can both constrain behaviour and changes preferences. Scott tries to reject this model for physical diseases, writing:
"The essence of colds is feeling unwell and ugh and wanting to stay in bed and having unpleasant congestion in your nasal passages. None of these particularly change your preferences."
But what is "wanting to stay in bed" other than a change in preferences? Similarly, what is "craving for alcohol" other than a very strong preference for it? I do not deny that mental illnesses may go beyond a change in preferences, and to the extent they do, then they are diseases. My argument is that no preference is a disease, not that all mental illnesses are merely preferences.
When the Gun-To-The-Head test fails
I proposed a gun-to-the-head test not because it represents metaphysical truth, but because it's a quick thought experiment to clarify matters. I'll go further than Scott - the gun-to-the-head test can never fully clarify! Just because someone doesn't change their behaviour in response to a gun to the head doesn't mean they couldn't. But my test is far from unfalsifiable. It correctly identifies a subset of behaviours that respond to incentives, and as such are preferences, even if it does not identify others.
Are Preferences And Constraints the Same Thing?
No, and I'm surprised Scott makes the argument. Every concept has some grey area in the extremes, but for this argument to work for Scott, he needs to demonstrate that these grey areas represent the preponderance of mental illness - which he can't, because they don't. If there are some narrow grey areas, we should tread carefully in them, but it does nothing to impugn the vast rolling fields of black and white.
There is no difficulty whatsoever in categorising his 6 examples. An internal state of desire (i.e. a preference) is not the same kind of thing as an internal state of fatigue. Yes, a state of fatigue may lead to an internal state of desire for low activity (i.e. a preference), but that is perfectly normal - all our preferences are grounded somehow. Examples 4, 5 and 6 are purely preferences, and so cannot be diseases. 1, 2, and 3 involve both constraints and preferences, so the constraint aspects of them (fatigue, pain) are diseases, but the preference aspects of them are not. A skin rash is not merely an out-of-nowhere desire to scratch the skin, but if it were, that would not be a disease.
On Justification
We have already established that the constraints and preferences model works extremely well across a wide domain of applicability. But, it seems, if using it suggests that some people may have strong, socially disapproved preferences, then it becomes vital that we discard it for an ad hoc framework with minimal explanatory power that justifies almost anything. We must pretend that these people are somehow compelled beyond their will to take actions, because that makes it easier for us to:
- Force them to make other choices.
- Pretend that their social preferences are normal and that as such they are "good people."
- Indulge our own neuroticism and avoid blame.
I take no position on whether this pretence is socially useful. I am merely pointing out its dishonesty.
> Or we could stop thinking like behaviorists, a philosophy which nobody has taken seriously since the 1970s.
I'm not a psychiatrist, so there might be some nuances to this that I'm missing, but the first thing I thought of when I read that sentence is that that would definitely be news to my wife. She's a social worker who works with adults with disabilities who are "in services," and sometimes she talks with me about work. An unnamed psychiatrist who she calls "the behaviorist" is an integral part of setting up and reviewing each client's "plan," and she frequently uses the term "behaviors" as a euphemism/jargon for "doing things they shouldn't be doing."
It certainly seems as if the agency she works for takes behaviorists quite seriously in the 2020s.
So suppose that I want Scott to write an essay about (say) giant sloths. At this point it feels like a viable strategy would be for me to write an essay saying how one of his posts says that he must have a bunch of incorrect beliefs about sloths (but I present these as true facts). This requires 0 research on my part (I just have to pick random quotes and make up facts), but seems like it has pretty good odds of getting him to do research on giant sloths for me.
>Consider Prader-Willi syndrome, caused by damage to a region of chromosome 15.
Prader-Willi is quite interesting biologically, since it's an epigenetic disorder. In this region of chromosome 15, the father's copy is unmethylated and the mother's copy is methylated (and therefore silenced). If the father's copy is deleted, or the person accidentally gets both chromosome 15 copies from their mother, the genes aren't expressed.
The opposite can also happen, which causes Angelman syndrome.
"Certain neurological conditions involve intense and frequent pain. One example is trigeminal neuralgia, also known as tic douloureux. The term neuralgia stands for pain with a neural origin, and the term trigeminal refers to the trigeminal nerve, the nerve which supplies face tissues and which ferries signals from the face to the brain. Trigeminal neuralgia affects the face, generally on one side and in one sector, for instance the cheek. Suddenly an innocent act such as touching the skin or an even more innocent breeze caressing the same skin may trigger a sudden excruciating pain. People afflicted complain of the sensation of knives' stabbing their flesh, of pins sticking in their skin and bone. Their whole lives may become focused on the pain; they can do or think of nothing else while the jabbing lasts, and the jabbing may come on frequently. Their bodies close in a tight, defensive coil.
For patients in whom the neuralgia is resistant to all available medication, the condition is classified as intractable or refractory. In such cases, neurosurgery can come to the rescue and offer the possibility of relief with a surgical intervention. One modality of treatment attempted in the past was prefrontal leucotomy (described in chapter 4). The results of this intervention illustrate better than any other fact the distinction between pain itself, that is, the perception of a certain class of sensory signals, and suffering, that is, the feeling that comes from perceiving the emotional reaction to that perception.
Consider the following episode, which I witnessed personally, when I was training with Almeida Lima, the neurosurgeon who had helped Egas Moniz develop cerebral angiography and prefrontal leucotomy and in fact had performed the first such operation. Lima, who was not only a skillful surgeon but a compassionate man, had been using a modified leucotomy for the management of intractable pain and was convinced the procedure was justifiable in desperate cases. He wanted me to see an example of the problem from the very beginning.
I vividly recall the particular patient, sitting in bed waiting for the operation. He was crouched in profound suffering, almost immobile, afraid of triggering further pain. Two days after the operation, when Lima and I visited on rounds, he was a different person. He looked relaxed, like anyone else, and was happily absorbed in a game of cards with a companion in his hospital room. Lima asked him about the pain. The man looked up and said cheerfully: "Oh, the pains are the same, but I feel fine now, thank you." Clearly, what the operation seemed to have done, then, was abolish the emotional reaction that is part of what we call pain. It had ended the man's suffering. His facial expression, his voice, and his deportment were those one associates with pleasant states, not pain. But the operation seemed to have done little to the image oflocal alteration in the body region supplied by the trigeminal nerve, and that is why the patient stated that the pains were the same. While the brain could no longer engender suffering, it was still making "images of pain," that is, processing normally the somatosensory mapping of a pain land scape. In addition to what it may tell us about the mechanisms of pain, this example reveals the separation between the image of an entity (the state of biological tissue which equals a pain image) and the image of a body state which qualifies the entity image by dint of juxtaposition in time."
-- Antonio R. Damasio, "Descartes' Error: Emotion, Reason, and the Human Brain"
> “Should we set every tree in the United States on fire, then dump the entire Strategic Uranium Reserve in the Mississippi River?”
It's got to be telling us something that an Englishman who tries as much as possible to ignore US politics and indeed politics in general, immediately thinks: "I bet that's a Republican policy." Bad system-one. Bad.
In Argentina we have a word for people who think like how Caplan is thinking in this situation: we call them "boludos". This word does not necessarily mean a lack of intelligence. Very intelligent people can be boludos. Boludity stems from applying the wrong model of the world to a given situation, often because that model was successful in other situations. This can very easily happen to specialists, people who are very effective in some domain and are led by that success to believe their expertise transfers to other domains. Nobel Prize winners often hang on to very odd beliefs because of this. Chemistry describes everything, until it does not. Models of the word are optimized to obtain certain kinds of information from the world, and often suck at everything else. So you need to be able to switch between different models and frameworks to operate broadly in the world, and that we call wisdom. If you can't figure out which model to apply to each situation, or if you always apply the same model no matter what, like if you had a hammer and the world was made of nails, then you are a boludo.
"you’ll sleep less, not more" is linking to the same paper four times. You surely intended to either link four different things or make the whole phrase a single hyperlink
- Psychiatric conditions can be modeled using consumer theory.
- Psychiatric conditions can be modeled as changing both budgets and preferences.
- Decisions about classification of conditions, syndroms, diseases, normalcy, etc. involve politics.
- Some psychiatrists engage sometimes engage in what can be modeled as rent seeking behavior.
- The field of psychiatry can be modeled as engaging in some rent seeking behavior (especially historically).
- Some psychiatrists use relatively bad and incoherent models of mental illness.
- Mainstream views in psychiatry (especially historically) have included very flawed models.
The bailey:
- Consumer theory is the best way to model psychiatric conditions.
- All/the vast majority of psychiatric conditions only change preferences.
- Decisions about classification of conditions, syndromes, diseases, normalcy, etc. are entirely political.
- (All) psychiatrists are rent seekers.
- Psychiatry is a homogeneous field (across time and practitioners) and is best understood as primarily engaged in rent seeking behavior.
- (All) psychiatrists use relatively bad and incoherent models of mental illness.
- Models and understanding from the field of psychiatry have nothing to add to our understanding of mental illness and have no benefit over consumer theory.
Gonna be honest, I don’t think you can actually arrive at a super robust “mental illness is very real” position without also embracing teleology. (This is no bitter pill for me, cause I DO embrace it, but I think it’s a bitter pill for a lot of people, and a lot of counter-intuitive, non-parsimonious theories abound as a result.)
I have to believe that if Caplan were to speak to someone with actual, real-deal, no-foolin' psychosis for more than five minutes he would have a much harder time maintaining his position. Thomas Szasz did not have a lot of experience with psychosis during his training, and I think that is reflected in the positions he arrived at as well. I suspect genuine mania would also challenge his conviction, or very severe OCD.
Please explain to me the set of preferences that leads a Conservative Jewish woman to stop sleeping, repetitive give the Nazi salute to passersby on the street, and rant at the top of her lungs about how she would have been the best prison cafeteria cook at Auschwitz while sobbing and taking a hammer to a mailbox.
Please explain to the me the set of preferences that leads a man who loved working as a car mechanic more than just about anything in the world to become so constrained and confined by his rituals that he lost his job because he it took him 7-10 hours to feel prepared to leave the house, started picking at his skin so severely that he opened up patent holes in his cheeks, and begged to be referred for deep brain stimulator implantation because it was absolutely the last hope he had left for living any life he regarded as worth living.
I don't think it is possible to articulate a coherent idea of "preference" that encompasses these things that bears any relationship to what use the word "preference" to mean in ordinary language. At some point you can use the same syllables to describe a concept but it is far enough away that I think it is perfectly legitimate to say then that some "preferences" are, in fact, disordered.
Some truths are difficult to grasp in a non-experiential fashion.
Looking at Caplans argument -- as Scott presents it -- I feel that Caplan started with writing the bottom line "Therefore, mental illness does not exist." before filling the stuff above. Credit where credit is due, I don't think I could come up with a better argument for that proposition.
Just like about every other concept, the concept of illness has some blurry outlines. Preferring Coke to Pepsi is not generally considered an illness, though if Coke had terrible side effects or external costs not present in Pepsi some might give it a fancy Latin name and call it a disease.
Of course, somewhere, someone will call a Deficit in Appreciation for our Supreme Leader a mental illness and try to place people in reeducation camps or something. I think the obvious place to make a stand against this sort of thing is to be against any treatment without (at least prior) consent, not the definition of illness.
Also, why is Scott the one feuding with Caplan over this? Scott's side is not the fringe position here, his opinion is probably shared by more than 80% of the medical professionals. Is it simply that Scott was the most high-profile person to refute Caplan?
Caplan's position is so funny - he's just very obviously taking the abstracted models about human behavior we use to make economic models work and explicitly using them as his understanding of psychology.
I have no horse in this race and no expertise in this field but surely talking cures can’t work unless the brain/mind has a choice. My dad had a major depressive episode a few years back which was cured, only and finally, by pills. Now he is back to normal - and normal is happy and loquacious so that was quite a change and quite a reversal. He had no choice, perhaps, without the pills.
My uncle was treated for alcoholism and as far as I know he just did AA and some retreat or other. Now he doesn’t drink. ( Ok some people say that he still has alcoholism - but I never really believed that - it’s like saying that somebody who eats well still has an eating disorder. Sure both the alcoholic and the ex-anorexic can fall off the bandwagon but while on it they don’t have the disorder).
So in some cases it looks like there is a choice to overcome some mental illness where choice is “this can be fixed without chemical intervention”.
Alfred Marshall, inventor of modern mainstream price theory, used as a motto of his textbook Principles of Economics Latin phrase "Natura non facit saltum", i.e. Nature does not do jumps, attributed to Charles Darwin. Meaning that there are no hard lines between (some) phenomena, just one concept gradually morphing into another through edge cases. Perhaps Caplan needs to be reminded of that, since it obviously applies to a distinction between constraints and preferences.
I just want to say: this post particularly changed my mind. I read Caplan's original piece on how mental illnesses are actually just stigmatized preferences, found it compelling, then went to read your rebuttal but got sidetracked and kind of forgot about the whole thing. As a natural contrarian Bryan's position seemed reasonable to me. Particularly compelling is the parallel to arguments from disgust: people argue condition x is disgusting and therefore immoral, when such a mental model would produce virulent homophobia 70 years ago. Then I read this, remembered the whole thing, and it's pretty clearly wrong. I'm sure you don't particularly enjoy writing posts about this stuff as a psychiatrist, so just know you changed at least one person's mind.
How we define "disease" doesn't matter one iota politically. What matters is whether the individual is hurting others. If they are not, you should respect their freedom and not lock them up for thought crime, however irrational or abnormal you think their thoughts are.
If you disagree, fuck you and everything you stand for.
I would say the spectrum you describe is strictly a constraint spectrum and preferences are *informed* by that.
Another way to look at the constraint spectrum: if doing X will result in Y bad thing, the degree to which you are constrained from doing X is proportional to the degree to which Y is bad.
I think Bryan has unusually high willpower/self control/whatever you want to call it, so when he sees people behaving a certain way, he concludes they must prefer this.
One example that should also apply to Bryan himself, is tiredness though. He should imagine he's really tired and can't think straight anymore, such that if he was left alone he would go to sleep. But now we put a gun to his head and force him to stay awake. Fearing for his life, he manages. This looks like a preference. But then we pull out a math test and say if he gets everything right he'll get $100. If he wasn't so tired he would be able to do it, but because he's so tired he's careless and makes many mistakes. That sounds like a constraint!
Furthermore, if we offer him a magical pill which would make his tiredness go away without any side effects, just like if he got a good 8 hours of sleep (i.e., a much better pill than caffeine), then he would probably take it in order to earn that $100! How does that fit into his framework?
So Caplan's model is nuts but your response has given me a framework to think about my own concerns with mental illness diagnosis. I generally think destigmatizing efforts are good but also think there's a cost we're ignoring and was having trouble articulating it.
That cost is that while the line between a constraint and a preference is extremely blurred in reality, we tend to dualistically categorize things in mental models. Imagine a universe in which we have a concept of a lower stigma, culturally accepted Can Only Run 5K Disease. In such a universe children whose legs will never carry them 6k won't suffer horrific pain in gym class - they'll be excused. They'll be mocked less for the inability to run. The diagnosis would make life better for thousands.
People with a strong preference for not running 6K can now model it as a constraint though. Maybe it makes them feel tired and gross and they dislike feeling tired and gross more than the average person. They're correct this mental state can be modeled as either preference or constraint, but modeling it as constraint changes how they think of "problems to be solved by running 6K." Where before it was "It would be extremely difficult for me to run 6K" now it's "I cannot run 6K." I can't prove it but I suspect that if you put a gun to the head of a person absolutely convinced they had this condition, who had made this condition part of their identity and made Facebook posts about how it impacted their life, they would be able to run exactly 5K before being shot.
Despite being essentially a perfect rebuttal, this is obviously not going to change Caplan’s mind. Perhaps a day of shadowing in a psychiatric ward would do this trick? After the requisite HIPAA training of course.
I can’t image meeting a poorly controlled Schizophrenic patient and then still thinking mental illness doesn’t exist.
One thing seems to have clearly emerged from all this, uh, debate: we should really be using the “point a gun at the patient’s head” treatment for a whole swathe of somatic and mental illnesses, since it appears relatively effective in many circumstances.
Feels a lot like the Harris/Dennett "debate" about Free Will. Harris says "particles, therefore no free will". Dennett says "I object to the definition you use, because of the following reasons (...)" and then Harris replies with "but particles, therefore no free will!"
I don't think either Harris or Caplan intends to be foil for a more careful thinker.
Scott, you write as if Bryan is doing something nefarious, in his manner of pursuing this issue.
But I think the truth is, he's just not paying that much attention to you. As in, I bet he's not even really reading (at least, with much attention) those long essays you write. He simply isn't *crediting* what you write all that much. He then goes on to reassert his position in a manner that a third-party might (perhaps rudely?) describe as a bit autistic.
Now, you might think that such behavior *is* nefarious. And maybe it is, at some meta-level concerning modes of discourse. But my point is that he's not deliberately trolling, or anything like that. He's just lacking self-awareness in a certain characteristic manner.
Many people, very much including rationalists, behave in exactly this way on other topics. It's just cognitively really difficult to closely attend to arguments that one viscerally does not credit. I've encountered that very mode here, e.g., on the topic of whether witches were historically real (in terms of their own self-understanding and practice).
I think the view that "mental illness is a preference" makes a sort of sense in a dualistic framework. If the incorruptible soul/perfect mind controls the body, then any disorder beyound brute physical constraints (i.e. failure to run due to arthritis) must be a choice, by definition.
If, however, the mind is a function of the body just like everything else a person does, then the mind can be damaged just like every other function. Arthritis makes it impossible for people to run, and depression makes it impossible for them to choose to run, but we have medications to at least mitigate both of these conditions; and in cases where we don't, we're working on it.
So, if that's what it comes down to, then the two positions (mental illness as a preference vs. as an illness) are irreconcilable, because dualism requires a kind of faith by definition (not necessarily religious faith, but still), and faith cannot be adequately communicated (though we're working on it). It just depends on which side of the coin-flip you happened to land, ontologically speaking.
>that all mental illness is just voluntary preferences
is a terrible position, I cannot imagine he actually believes that. That said I do tend to think he is correct that a big portion (possibly a majority) of what is treated as "mental illness" is really just people with poor preferences/behavioral ruts (particularly ADHD/depression).
Though perhaps that is not the central case as I think that is mostly the "frosting" of mental illness treatment, and the cake is the truly crazy people.
Thinking further, the one thing I think is missing from your argument is a discussion of involuntary cognitive distortions that come along with even the "milder" mental illnesses like anxiety and depression. It's not just that part of being socially anxious is that you feel affectively worse about being in crowds of people. The disorder also causes you to make systematically bad predictions about how you'll react to social situations, how given activities will feel, etc. You become irrationally pessimistic in your beliefs.
This sort of cognitive distortion is clearly involuntary--we might choose our actions, but we don't choose our thoughts/beliefs. It can be counteracted with higher-order cognitive tools. But this is another respect in which mental illnesses can't be pigeonholed as "just about preferences"
I'd like to provide a small possible link between willpower and the preference/constraint distinction.
Preference might tentatively be thought as that which one may change under their own willpower and practice. For example, there are foods I used to dislike, then I learned to like by forcing myself to eat them until I got used to them, and afterwards became so cognizant of, they acquired preferences about which variety is like more than others.
And a constraint may be tentatively thought as that which one cannot change under one's own willpower, though it may be changed, in some cases, via external interventions, such as medications, surgeries etc., if available.
And then the overlap may similarly be linked to cases that require both willpower and external interventions.
This would turn the dichotomy into a false one that's in fact a continuum of that which can and cannot be effected via how much willpower.
Sidenote: the word that's usually translated as "desire" in Buddhist sources, "tanha", is better translated as "craving". It doesn't include small desires, such as Coke over Pepsi, or the desire for Enlightenment, but only those things that cause compulsions, and whose absence would lead the person to experience "dukkha". "Dukkha" in turn is usually translated as "suffering", but that's also inaccurate. It's a broader category that includes from dissatisfactions all the way to literal suffering.
Therefore, the lesson isn't that having desires of any kind lead to suffering, but that being overwhelmed by cravings leads to a continuous state of dissatisfaction that can grow into full suffering, which in turn is a major roadblock for the pursuit of that clarity of mind required for achieving Enlightenment. Hence overcoming cravings, addictions, and the like, is a necessary step on the path.
As someone who likes ecological psychology, I am wary of putting too much emphasis on internal states.
Credences, for example, can only be defined insofar as they are coherent; if someone makes different bets about the same thing in different situations, for example if the bet is presented differently.
But it's not like preferences are a perfectly defined concept either! They too can only be defined insofar as they are coherent.
Why is Scott engaging with this? As far as I can tell, Kaplan has identified a theory that the majority of people believe to be true, determined that Scott is somehow exceptional in being a proponent of this theory, and then repeatedly challenged Scott with inane arguments against the theory without actually considering Scott's defense.
I mean, I can do that too. Scott thinks we shouldn't eat babies, but either babies are more delicious than adults, or adults are more delicious than babies. So Scott must concede that if we shouldn't eat babies, we should eat adults. This isn't something Scott is willing to concede, so baby-eating is morally permissible. I'm going to take Scott's failure to argue about this as evidence that he has no counter-argument, and I'm also going to take any counter-argument Scott might make as evidence that he has no counter-argument.
Edited to add: Strike that - reverse it! I had only read the beginning of Caplan's article and assumed it was representative of the rest. Now that I've read more, I am 100% team Scott.
Caplan starts out saying that you can model someone with mental illness as a rational actor with unusual preferences - that is correct. Then he moves into endorsing Szasz and going after psychiatry, and IMHO ends up someplace crazy.
You can model someone who is an alcoholic or has ADHD as just having unusual preferences, but when you say they shouldn't receive psychiatric treatment, as Caplan seems to, you're ignoring that a lot of people with alcoholism or ADHD want to change, in the sense that they voluntarily undergo treatment in an effort to change, they sign up for Beeminder, etc.
Now whether psychiatry is effective at introducing change for a particular condition is an empirical question, but Caplan isn't attacking psychiatry by arguing it's ineffective, he's just arguing that it's inappropriate to change people's "preferences," even voluntarily. That seems crazy.
-------- Old Post ----
I went back and skimmed Caplan's original article, and I'm now more sympathetic to Caplan than I was before, unless the exchanges since then have materially changed the discussion.
The question Caplan originally was trying to address was whether classical economic modeling can apply to the decision making progress of a mentally ill person - not whether an illness should be covered by health insurance or whether we should call it an illness in everyday speech, etc.
Under this framework, a person has priorities and resources, and they spend their resources based on their priorities and their beliefs about the world.
Some examples:
1) If my leg is trapped under a rock and I have the choice of sawing my leg off or staying where I am and hoping help finds me, I won't like that choice at all, but I will make that choice based on my preferences and my beliefs. If you know my preferences and beliefs, you can model my behavior.
2) If I mistakenly believe that my family is spying on me in an effort to prevent me from attending business school, you can model my choices based on those preferences, even if the belief itself is based on a mental disorder.
3) If cilantro tastes like soap to me and I don't like the taste of soap, you can model my choices based on that - I'll pay less for a burrito with cilantro is it, but there might be a sale price where I'll eat the cilantro burrito. This model works whether my dislike of cilantro is genetic or based on some other cause.
The ultimate question is whether the economic preference and budgeting models apply to the mentally ill, not something else. On that front, I wonder if Caplan and Alexander have a misunderstanding, not a disagreement.
As someone who's been on and off stimulant medications for ADHD at various times I've thought a lot about where boundary between "wanting something but not being able to bring myself to do it" and "not actually wanting something" lies. On stimulant medications I'm much more inclined to classify "things I can't do" into the second bucket rather than the first.
I think this is because on stimulants there's a much shorter path between vaguely thinking about doing a thing, and your brain/body actually doing it. This results in there being a much smaller pool of things that you vaguely want to do but just can't seem to make happen, and therefore you're more likely to classify these things as "not actually wanting them".
Parkinson's is probably the most direct way of exploring this connection. The neurotransmitter that turns thought into movement is literally missing. Does this result in a subjective experience of feeling paralyzed, or of feeling like you "want" to move less?
Caplan is applying the "revealed preferences" principle in economics too broadly. Revealed preferences is a term that means that we should look at the behavior of individuals to determine demand, not what they say in surveys or what is assumed by policy makers. For instance, people may say they don't drink alcohol, but a superficial empirical investigation will reveal that alcohol consumption exceeds that which is predicted by surveys. Drug addicts might not want to continue using drugs, but they do and policy makers should assume that they will continue, even if it means addicts will break laws prohibiting drug use, resulting in a cascade of other negative social outcomes (violence, petty crime, etc.).
Revealed preferences is a useful principle in predicting economic behavior in aggregate. Economists are not really concerned with the internal state of individuals, because it doesn't really predict policy outcomes.
The term is not useful in evaluating the internal state of individuals, or what actually drives them to do what they do. That's the realm of psychology.
Caplan is too smart to interpret the term too literally, in that I doubt he really believes that a schizophrenic is just choosing to hear voices because that is what he prefers. Instead, I think Caplan has another model of behavior in mind that he is not articulating well. Without putting words into his mouth, I would suspect he has not integrated mental illness concepts particularly well into his overall thought process, given his training in economics. Also, embracing nonvoluntary mental illness may undermine his commitment to libertarianism, certain versions of which emphasize the voluntary desired nature of individual behavior.
From a practical standpoint, isn’t it more objective to cure a physical illness than an internal state?
The policy implications of this discussion sorta rest on the tangible nature of influencing physical versus mental states. I think Caplan’s metapoint is that you can disincentivize or incentivize internal states (preferences) and the preferences which cause illness.
It's legitimate to debate at what point cancer is a 'disease' and also at what point that disease should be treated. Many people die in their old age from some other condition, yet they had a benign tumor somewhere in their body. It really matters whether a cancerous growth is either (a) malignant, or (b) likely to become malignant before you die.
Does this ever matter in the real world? Yes. Back in the day, they used to use PSA alone to determine whether you likely had (a) or (b). Too high a PSA, and they'd resect your prostate. Sure, you'd struggle with incontinence for the rest of your life, but then you could celebrate being a 'cancer survivor'! Except later studies suggested there was an unacceptably high false-positive rate with this test alone, and that hundreds of thousands of men got their prostates out for no good reason.
Yes, cancer is bad and should be treated. But we should also be paying attention whenever we set out on a medical intervention. ESPECIALLY preventative treatments. Those approaches have the highest probability of medical reversal later, when we realize it was all harm for little to no benefit.
I think any conceptual categorizations beyond a purely descriptive one on the basis of atom configurations and observed behaviors places a burden of proof on the part of the part of the categorizer to explain why their classification scheme does useful work. If you steelmanned Bryan's position, what work is the constraints/preference classification doing? It sounds like it's just trying to do political prescriptive work in terms of telling us how to treat the mentally ill. I would like to see an argument based on data from him that treating the mentally ill as if they have a preference rather than a constraint did things like improve recovery rates or speed, or reduce their burden on society, or have some other effect that he might be able to pitch as positive. If the classification doesn't do work then throw it out, since all models are only as good as the work they do.
This fascinating Invisibilia episode profiles an interesting case where a chronic “augmented pain” syndrome is worsened by paying attention to the pain, and treated by ignoring and therefore desensitization.
Sometimes your preferences change because your circumstances change. It's difficult to say that just because you have a certain preference in the moment that this is an enduring preference, or even to predict what your preference would be when those circumstances change.
Just one more reason that the whole idea of 'preferences' is not practical to drive policy.
I just want to say that I once held my breath until I blacked out. It's a mildly unusual thing that is tangentially related to this article. I was motivated by a competitive spirit and desire to win.
On terminally ill people "holding on" (note 3) this has been studied at a population level.
In countries where Christmas is important, there is an increase in deaths from natural causes in the week immediately following it, with a corresponding dip the preceding week.
Two UCSD sociologists, David Phillips and Elliot King, did a similar study with Passover which is published in the Lancet:
They compared Jews and non-Jews in the same place, which provides a handy control group for factors like the healthcare system not functioning as well the week after a major holiday.
A likely explanation is simply that people "hold on" to reach a major annual family-gathering holiday.
Is there an implicit assumption (or explicit somewhere I have forgotten) that doctors may/should never prescribe treatments, especially pharmaceuticals, for a condition we categorize as a preference rather than a disease? Is this a legal constraint, or medical ethics, or what? Does Caplan take a stance on this?
This leads to the issue of the ethics of self-medication, where presumably Caplan, as a libertarian, sees no objection to any adult treating themselves however they wish, or hiring whoever’s they wish to advise them. I am not sure what Scott's position is. From this perspective, the legal restrictions on prescription are the main sticking point, since whether a condition is a disease or a preference, in a world without legal restrictions on prescription drugs, competent adults in either category could try to improve their lives using whatever treatment they believed would help.
The other issue is under what circumstances bystanders are justified in forcing a treatment upon an unwilling patient (or similarly, to forcefully prevent them from applying a treatment). The current dominant opinion among medical ethicists is that treatment should be voluntary for competent adults. So the interesting question becomes, who counts as a competent adult, and how may we treat infants and invalids? (Of course, existing laws pretty much ignore this analysis.)
It seems to me that the categorization of conditions as diseases or preferences has little relevance for these issues. What is the issue where this controversy does have relevance?
From Categories Made for Man: "Hume’s ethics restrict “bad” to an instrumental criticism – you can condemn something as a bad way to achieve a certain goal, but not as morally bad independent of what the goal is. In the same way, borders can be bad at fulfilling your goals in drawing them, but not bad in an absolute sense or factually incorrect. Namibia’s border is bad from the perspective of Germans who want access to the Indian Ocean. But it’s excellent from the perspective of Englishmen who want to watch Germans plummet into the Lower Zambezi and get eaten by hippos."
I suspect Caplan wants to discuss (and has discussed https://betonit.substack.com/p/lgbt-explosion ) empirical questions of " (1) Are increasing numbers of people falling into mental health/sexual/etc. categories through marketing and self-selection, and (2) is this driven by discussing the categories themselves, (3) thus accruing outcomes XYZ (which are somewhat no-benefit with some cost, or sub-optimal)." This is a very common question, something that doesn't necessarily interact with the inherent political nature of categories so much as whether those politics are good or bad in the goal-fulfillment sense.
Bryan continually names Scott, because he likes him! He wants his favorite psychiatrist to say "I estimate that x% of diagnoses are due to self-selection/marketing/discussion of the diagnosis, and we would be better off limiting discussions of XYZ to prevent social/memetic contagion towards sub-optimal outcomes." Scott could pick any number for x, that'd be an entertaining post, but wildly more political (is this good/bad) than Scott normally does. I think Bryan is an excited and friendly-combative debater who refuses to ask that question, in adherence to the inscrutable norms of online-debate etiquette, and doesn't want to draw a crowd that wouldn't otherwise sit for a discussion of category definition. Caplan, and most of the GMU gang, ran into the same problem while discussing feminism a while back - just a bunch of posts discussing "What does feminism mean" while all dancing around having a stance on whether feminism-as-I-define-it-in-this-post (rather than naming policies XYZ) is good or bad.
Well, there is a qualitative difference between a person who feels excruciating pain when they walk, and a person who has had all the nerves in their legs severed. I'm... just not sure if that qualitative difference is particularly useful for reasoning about anything (except maybe figuring out what medical treatment to apply to get that person walking).
I haven't gone to read what Caplan has written in the past (maybe I should), but in my experience the line of reasoning presented as his in this post is essentially never put forward by someone who has a nuanced contribution to make to philosophy, or who wants academics in medicine or elsewhere to have a more expressive taxonomy available for the conditions of homo sapiens. In my experience it is always, and only, *that they're intent on proposing a way that communities of people can reduce their support and respect for some group of people they've identified as deserving cruelty*.
I’m a psychologist and a therapist, and agree with everyone who’s saying there really isn’t a clear distinction between constraint and preference (or you could call it a distinction between can’t and won’t). So here's a list of :
*7 Denizens of the Constraint-Preference Murk Zone*
(1) Anxiety disorders: expectation of terrible suffering if you have a close encounter with the feared thing.
Ex: I had a patient who feared broken glass as much as I fear jumping off a 100 foot cliff. I think if somebody put a gun to my head and told me to jump, I probably would not, because my picture of dying via the fall is more vivid and terrible than my picture of a bullet to the head. (Yet when I finally convinced my patient to handle some broken glass, her worst moments of fear were in the 3 seconds before her hand touched the first piece of glass. Once she started it wasn’t so bad, and by piece 10 she was hardly scared at all.)
(2) Procrastination: A habit of asking oneself before doing something whether one is up to doing it, whether there’s chance the in the future that the task will look more attractive, and whether it’s possible that doing it now might be a mistake. (If most of us asked ourselves these questions before we did something we’d never do anything). I see this habit a lot in people who are Aspergerish, and the habit is often coupled with a felt certainty that it is important to ask these questions, otherwise life will be too unpredictable and get out of control. Not asking these questions feels to them like I feel about jumping off a cliff.
(3) Addiction: People have addiction-related “delusions” about the consequences of giving up the substance you’re addicted to. I had these about nicotine. Lighting up had gotten so deeply associated for me with reading, writing, thinking and talking to people that I more than half believed that I would not be able to do any of these things nearly as well without nicotine. What made it hard to stop smoking wasn’t inability to face cravings, it was dread of becoming unable to do the activities that were most important to me. (As Stephen KIng said after recovery from addiction to alcohol and cocaine, I found to my surprise that my mind worked fine without the drug.)
(4) Depression: It’s not exactly inability to act, it’s inability to have any positive expectations about acting, and of course that produces failure to act. If the mind had suits, the way a deck of cards does, and there was a fearful suit, a sad suit, an excited suit and a hopeful suit, depression would be playing with a deck where the last 2 suits are missing.
(5) Depression: Inability to hear encouragement from others as anything except invalidation and criticism. Consequently, something that’s often pretty available to unhappy people is unhelpful and toxic to the depressed person.
(6) Avoidant and dependent take on life: People with any of the above who are also seriously dependent or avoidant have an extra constraint/preference: They believe that if they overcome the condition that has them stuck they will lose their status as a beloved and sheltered person, and be cast out into the lonesome cold.
It seems to me that it’s too simple to think of there being a spectrum running from constraint to preference, with lots of things in between. You can see in the above examples how people can be constrained by the false expectations ofwhat would happen if they did or didn’t do something — or by the sheer inability to conceive of certain things.
It’s kind of interesting to break the word disease down into its components.
Dis-ease.
A lack of ease.. that is a big umbrella.
Mental illness is a big umbrella.
My problem with this conversation is the generalities implicit in the vocabulary.
Let’s take two things; liver cancer, and diabetes. They are both diseases.
Diabetes has been narrowed down to a very particular chemical deficiency that can be remedied.
Liver cancer on the other hand, as far as I know, is way more wacky than that.
One form of Mental illness is tricky, because as anyone who’s ever dealt with it knows, one’s own participation in its cure (or management? )is essential. See the classic joke about how many psychiatrists it takes to change a lightbulb.
But
The brain is also a physical organ and can malfunction. Godspeed to the people who are trying to crack that nut… I have to believe that some of the pharmaceutical interventions developed over the last 40 years have actual relevance in that world. I am not at all in a position to speak to it. I am more interested in what I consider the other half of mental illness..
What ever happened to the word neurotic? It really seems to of fallen off the bus. I never see it in any of these discussions anymore. Perhaps it is a concept that is extremely out of favor. I happen to think it’s an important distinction.
A disease if you will, of emotional dysregulation? Is this a failure of will or a condition to be treated as a disease, in the classic sense?
What if someone was born and had a brace put on one of their legs, a brace that dictated the growth and shape of their limb over a period of time? What if eventually that brace was removed? Would the affected limb then spontaneously assume it’s rightful shape?
Or is it more likely that a lot of physiotherapy and conscious exercise would be necessary to even begin to restore it to what it should’ve been?
There are lots of people who I believe are mentally ill in the most fundamental sense of that expression; meaning, they have very little volition to bring to the task of understanding who they are. And there are others, who I would refer to as neurotic, that given the opportunity can direct their attention towards their own management or recovery. It’s very difficult to find a border between those two things.
So finally, is this a philosophical discussion or a discussion about social policy?
I would be very interested in some granular information about what it is to pay attention in some technical sense. The ability to direct your self towards paying attention to something. I think it’s a very significant thing, this ability to redirect one’s attention.
Caplan skimmed the DSM and now he thinks he’s a psych expert. I took a look at his 2006 article that started all this. He linked to it this month, so he still endorses it.
His section on ADHD is based on a shallow reading of the DSM diagnostic criteria with almost no context. He uses this to suggest economically modeling ADHD as “a high disutility of work combined with a strong taste for variety.” The first part doesn’t make sense. The DSM-listed symptom regarding avoiding tasks requiring sustained mental effort can apply to work, but it can also inhibit people from returning to books they were enjoying or even watching TV episodes with a lot of hard-to-process stimuli.
He also claims the forgetfulness symptom refers to people with ADHD “conveniently forgetting to do things they would rather avoid.” But ADHD forgetfulness also includes things like, I don’t know, forgetting to eat dinner and drink water because of reading an article by someone too lazy to do thorough research on ADHD. Would this be modeled as a high disutility of eating and drinking?
The DSM criteria also don’t include commonly reported symptoms like rejection sensitivity or hyperfixations. These would indicate that ADHD isn’t “medicalized laziness” but a distinct type of brain with characteristics that tend to come together for a non-obvious reason.
I learned the hard way that preferences *are* constraints.
I was in a community that put very strong social pressure on me to disavow and avoid satisfying many of my preferences. I tried very hard to conform, and to tell myself "they're just preferences, they aren't real tangible things, I can just not listen to them."
This seems to me (with the usual caveat that it's very difficult to have much certainty about the causes of one's own internal states, because n=1 and it's all being seen from the inside) to have caused me to enter a very bad mental state that has lasted 6+ years after I both left that community and recognized the problem and started making serious efforts to improve my mental health.
"they're just preferences, they're not real" transitioned smoothly into "I'm not real, I don't exist" which caused a lot of dissociation and loss of executive function.
I am gradually getting over this, but it's ongoing, and I'm not fully convinced I'll ever feel as real and as sure of myself as I did before.
(ETA: I do recognize that my desire to be accepted by the community was also "just a preference", but I'm not sure why I accepted that one as more real than the ones it was trading off against.)
Need to write a large response here later today, as i have a lot of thoughts on this. Ive also had email conversations with bryan caplan, that i need to look through
Caplan had a point about constraints, but was wrong about constraints and preferences being opposite.
The "if you can do it with a gun to your head, it's not a constraint" example is horrible. Lots of people have something like arthritis where some actions are impossible and some actions are entirely possible but incredibly painful. That situation is a restriction on your life by any sensible colloquial, moral or legal standard, and correspondingly is a disease.
I think the distinction he was looking for was, if we think a restriction is an IMPORTANT restriction, we're likely to think of the cause as a disease rather than not. That's not universal, the restriction will be important in some situations and not in others, depending on our judgement of the person, the judgement of people around them, and the amount society is accessible to people with that limitation.
I haven't read what Caplan wrote, so I'm probably missing the good bits, but I suspected it was a combination of:
1. He says there's not a neat objective criteria for what is a disease and what isn't. (Scott agrees, I agree) And he thought that Scott thought that WAS an objective criteria (he was wrong, that's why he thought Scott changed his mind)
2. He thinks that he has a better definition with constraint vs preference (Scott disagrees repeatedly, I mostly disagree as described at the start of this comment). I suspect that he saw Scott disagreeing with his particular definition as if Scott disagreed with point #1.
3. He thinks that modern categorisation of mental illnesses include too many things that shouldn't be included, because of these disagreements. I think that that HAS BEEN true and is true of SOME things, but that it's much less true now. I suspect if he talks about specifics, he'd talk about lots of things which psychiatrists think are illnesses which he doesn't, and I would probably agree with which are which, but that he thinks that the false-diagnoses are much more prevalent than I do.
On the last point, I have ADHD. I know first, second and third hand that there are people with a real, treatable disease which manifests in a variety of ways which are very real but hard to measure from the outside (e.g. inability to concentrate, inability to start doing important tasks. And yes, most people can do them for a few minutes if they have a gun to their head, but can't KEEP doing them every day without an immediate threat to their existence, and can't be threatened into doing them without long term damage).
I also know that there are people who suffer unable to fit into a regimented school routine, but flourish perfectly well in jobs which suit them (which jobs vary, but programming, EMT, crafter, financial trader, etc depending on their combination of needs).
I also know that there are SOME people who have adhd-like problems in life and seek out or are forced into treatment or into attitudes about it which are counterproductive in helping them. I think that's something to be aware of, especially if people are forced into treatment which is bad for them, but I don't know HOW widespread that is, and that doesn't constitute ADHD being fake for everyone else.
While there are conditions associated with intellectual disability that do predispose people to being, crudely, "happy and kind" this is often just a stereotype of people with intellectual disability that is simply not true. While it may seem harmless because it's a positive stereotype, it does tend to promote a kind of dehumanization where people aren't seen as part of the full range of human experience. Down syndrome is an example of this. In fact, people with Down Syndrome have a higher prevalence of depression.
“While the person may choose whether or not to scratch themselves, they cannot choose whether or not to feel the suffering”
It’s interesting to me that you even think it’s a choice to scratch. As an itchy person I can maybe delay it 15 seconds tops, and the whole time I won’t be thinking of anything but “it itches so bad but I’m not gonna scratch it.” If some other thought grabs my attention, it doesn’t mean it distracts me and the itch goes away on its own, it means I impulsively/unconsciously scratch because I’m no longer focusing on not scratching.
Once when I was 13 I was on a Boy Scout canoeing trip and my legs had gotten literally dozens of bug bites. I’d scratched them to the point that I had polka dots of blood all over my pants, and one of my friends asked me why I didn’t “just stop scratching”. I think I just looked at him confusedly like he had two heads, wondering how he even thought that was humanly possible, and immediately recommenced scratching. But I’ve since learned that apparently I’m the weird one? I don’t know, I can’t imagine how people are apparently able to just ignore it.
Caplan is a provocateur who believes he is always the smartest man in the room. Too often he is out of his lane and does not know what he is talking about.
Cowan seems to have two versions of Mental Illness is Preference. One is that it just unusual or disapproved preference; the other a matter of conflicted preferences.
"Question for Scott: Would your reaction be any different if someone said, “I’ve gotten tired of my self-destructive preferences, please help me”
"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?"
But the conflicted preferences version doesn't support Szaszian claims anywhere nearly as well. Someone with conflicting preferences could voluntarily seek treatment to resolve the conflict, without any of their preferences being disapproved of.
I'd argue that in basically all cases, it's more illuminating and promoting of empathy if we think of the issue as a constraint or a fact about the relevant person. For example, gay people have the same preference for emotional and physical intimacy as straights, but while straight people can best/only satisfy these preferences through a relationship with someone of the opposite sex, gays can best/only satisfy the exact same preferences through a relationship with someone of the same sex. This avoids ascribing to gays a poor taste in sexual partners and instead facilitates empathy with their situation. More generally, preferences often carry moral or aesthetic overtones, which facts don't have.
I have read both bryan caplan and scott alexander for a long time, and i have high respect for both. But mental health is the part where i think bryan caplan is almost entirely wrong.
I have written a bit to caplan, and have gotten a few responses back and forth. I cant find the original responses, so i have to remember them, with the unreliability that comes with it.
(Personal note: i have adhd, autism, and is gay and have had depression and suicedal thoughts struggles for most of my life. Im a 27 year old swedish guy.)
I think this mental health, “preference vs constraints” debacle can be broken down into 3 parts worth digging into
1: “preference vs constrainsts” is a flawed model of humans
2: bryan caplans ideological beliefs and worries that economic and personal freedom is reduced by common disability and mental health narratives, and my thoughts on that
3: bryan caplans personal psychology and philosophy
I will then go over the thought experiments and illustrate how these points helps explain key disagreements
Lets start with point 1:
1: “preference vs constraints” is a flawed model of humans
I think this model is highly useful as a tool of analysis. But all models are useful because they SIMPLIFY reality, and remove other variables.
While I believe its much more relevant then most people here, i do think that there actually 2 MORE ASPECTS of it that is neglected. Those are…
“Harmony”:
And…
“Outside signals”
Lets go into harmony first.
Preference and constraint is seeing a person as one single entity that is consistent, and dont conflict.
But as split brain patients show, we are actually a ton of smaller modules that work together, and often conflict.
Anyone that has tried to quit smoking or to diet have some 3
Experience with feeling that they have different preferences and constraints at different times.
Most normal people dont have too much disharmony in them. But some people have very big disharmony. An alcoholic can have parts of him that desperately wants alcohol, while most parts dont.
Other people have very much harmony in them: i think that naturally conscientious people are like this: the differents parts of themself dont have much conflict.
We have limited energy and willpower, and if there is too much stuff happening mentally or physically we become overwhelmed. So if you have disharmony in you, then things usually require more willpower and work to make the parts of you work together, which makes you less conscientious.
I personally have low contentiousness, while i believe bryan caplan to be unusually extremely high on conscientiousness and harmony: so he has never to a significant degree experienced that clash of motives, and thus see everyone else as being the same
“Outside signals” is more straightforward; its basically that you always have to interact with other agents, and being able to consistently show what preferences or constraints you have heavily influences the interactions you have. If you have very low outside signals (like having an invisible disability) then your ability to negotiate or get social support is lowered.
One note: outside threats(gun to the head) or desperation can temporarily bring you disharmony’s parts into an alliance, the same way an outside threat makes polarized peoples cooperate. But this requires tons of effort, and as soon as the threat is removed the disharmony is back
Point 2:
2: bryan caplans ideological beliefs and worries that economic and personal freedom is reduced by common disability and mental health narratives, and my thoughts on that
Ive noticed that in climate change discussions, climate change deniers are usually worried that if they say that climate change IS a problem, then their freedooms will be taken away simce its usually seen as collective problem, outside of personal responsibility and agency.
I think many libertarians get stuck into this mentality on the topic of disabilities or mental health, cause mental health is in a way built on the idea that you are not fully rational or consistent. That weakens the individuals strength and rationality, and has to be fair in the past been used to completely imprison and abuse people since mental ilness has been a way to say “their opinions dont matter”
As i earlier said, ive written to bryan caplan a number of times. And one of them i wrote along the lines of “i feel super depressed and i wonder if im a burden since im on welfare, am i that?”
And bryan caplan wrote something along the lines of “im busy and cant respond to much right now, but im sorry your feeling horrible. I suggest reading the book doing great. Good luck”
This seems at first to be a contradiction to his deppression preference article. And i think it is!! But i think that when BC is interacting with one individual that expresses suffering and advice, that it doesnt really challenge the individual liberty intuition he has, it is strengthened as he sees someone taking personal responsibility and putting in effort.
But when it comes to the abstract, his intuition is that adults are adults and should be left alone first and foremost, and only jn extreme circumstances have liberty taken from them.
To be fair, the mental heath and disability rights movements are generally left leaning, pro redistribution, and somewhat anti econ freedom. I think this is a mistaken view myself; im libertarian, socially liberal, and think capitalism and econ freedom is awesome for disabled people. Anyhow, the last point;
3: bryan caplans personal psychology and philosophy
Bryan caplan is a huge fan of michael huemer, who is a philosopher that advocates for conservative epistemics; the idea that before we use logic, we must appraise what appears in front of us. Its skeptical towards principle based or utility based formulas, and thinks we often fool ourselfs. Its heavily leaned towards trusting intuition and appearances first, and only trusting abstract reasoning if it has repeatedly and clearly demontrably outperformed appearances
From what i can tell, bryan caplan also has a very strong intuition about just desserts; people should get what they deserve, and etc. he also is heavily skeptical about abstract moral or philosophy claims made by people like peter singer
He seems to go by “revealed preferences shows what people actually care about” in morality. Which he uses to dismiss the idea that animals morally matter, since we treat them like garbage, and even vegans prioritize small comforts for themself over animals.
He wants very very clear and obvious proof that someone is disabled and constrained; if its vague then his intuition about people faking or should be left alone is much stronger then the intuition to help someone in pain.
To summarize:
1; {preference vs constraints} has two more prts: {harmony and outside signals} (lets shorten this as PCHO)
2: {BC worrys that mental health ideas takes personal agency away from people}
3:{BC goss with intuition first, and distrusts vague abstract and hard to judge things that are hypothetical}
So i just went over all of this. But how does this interact with the thought experiments and debates BC and SA have? Well, lets see:
A: the alcoholic.
SA thinks he is a victim but BC thinks hes blameworthy
On the PCHO spectrum…
BC dont see the alcoholic as being disharmonious, and sees him as consistently and visibly prefering alcohol to the family.
SA sees him as having conflicting parts and because of his therapist background, can see a lot more of the signals the alcoholic gives that he actually hates this situation.
Additionally, BC is going off “is this person worth associating with or a pain in the butt to help?” Intuition, for which the answer is “yeah get away from them”
While SA dont have these as much
B: tweaking the variable
Lets say now that we have a completely normal non alcoholic person. If they decide to start drinking copiously, or deliberately takes a pill that turns them into an alcoholic, then i think both SA and BC would see him as fully responsible and preferring alcoholism
But if he person is at first normal, but then an goverment agency feeds him a drug that turns him into an alcoholic, then i think even BC would agree with SA that this alcoholic is a victim and deserves help or sympathy
In these cases, the first one of personal deliberation has HIGH HARMONY and HIGH OUTSIDE SIGNALS. Its very easy to see that this person wanted this consistently, and its very easy to judge this as an outside viever.
The latter one has an LOW HARMONY and HIGH OUTSIDE SIGNALS: aside from just normal morals about coercion, its easy to see that this person did not at all consistently want this alcoholism, and its obvious viewers.
Ok ive written a lot and is tired now. Hopefully this is interesting and helpful
What most bothers me here is the conflation of different kinds of things under the heading of "disease" or "illness". There are often good reasons to treat these things together, but there are also important reasons to treat them separately.
Prader-Willi syndrome [side note: it is not caused by "damage to a region of chromosome 15". It is caused exclusively by damage to that region in the paternal copy of chromosome 15; the same damage on the copy inherited from the mother gets you the radically different Angelman syndrome], Down syndrome, and cancer are all examples of the body breaking down. There is an intended state of affairs and an intended functionality, and those things have failed to be. But the failure is spontaneous.
The stomach flu this essay mentions in passing is a phenomenon of a radically different kind. There the body is functioning according to plan, but it's been invaded by hostile forces which impair its functionality anyway.
Both types of problem commonly cause the victim to complain that something is wrong. It's also common that they don't. The archetype for problem-without-complaint is of course the brain slug that takes over your mind, causing you to do things like protecting the brain slug and resisting efforts to have it removed and incubating its children.
So we can reject the idea that if someone isn't complaining about a problem they have, then no such problem actually exists.
Aging is similar to the two categories above in that it involves a breakdown in bodily functionality and sufferers complain that things have gone wrong.
But it's unlike them in that it's not a deviation from the plan. Aging is normal, intended functionality. It's just bad functionality that we wish we didn't have. I strongly suspect that this is why people reject the idea of calling aging a disease. I can be certain that that's why *I* reject the idea of calling aging a disease.
I think Bryan Caplan may be a philosophical zombie. He appears human and so we assume that he, like us, has interior experiences. But he does not. It's the only way to understand the depth of delusion to which his argument takes him.
Sociologically, I think something is probably a disease when it is an obstacle for satisfying the values of either the person with the condition or of society at large.
For homosexuality, we decided as a society that we should reorganize such that gays have a place within society, and a lot of people's values shifted, and so being gay is no longer considered a disease.
For Down Syndrome, we're still sorting out what we value, and even the people with the condition probably vary from being frustrated by their limitations to being completely content with the way they are.
For let's say a panic disorder basically no one values the condition of randomly suffering and freaking out, and panic attacks get in the way of quite a lot of things that people and society do value, so we consider it a disease non-controversially. If we believed as a society that people in a state of panic were getting closer to God or something like that, we probably would have a different opinion.
ADHD is just going to be an easy target for a long time. In the last hundred years the society has changed in terms of how much attention needs to be paid to activities, particular ones you get paid for. Sometimes the needs are intense, and people who had some difficulty adapting to the slower pace in other eras (even within memory) are now thriving. But this doesn't stretch indefinitely. A fourth-grade teacher from the 1950s might have to adjust her metrics a bit, and everyone might start looking at various professions with different eyes, but the ability to focus on a task and see it through ain't that different. This mild ambiguity in our era allows clever people to create fun anecdotes in their attempt to prove that it is all hogwash. But they are just fools with large vocabularies.
I was a psychiatric social worker in an institutional setting for forty years, and you have heard most of the arguments by the end of year one.
You may have mentioned in your writing, but I will mention now. Szasz never treated a schizophrenic patient and may never have met one. At this point I have to wonder what people are hiding.
This is interesting, but can you please address how this might apply to something like obesity? Is that the result of someone having constant suffering unless they eat (like Prader-Willi) and constant suffering if they try to exercise? Or is it the result of someone clearly and rationally choosing to overeat and not exercise fully aware of the tradeoffs? Is it a little of each? Is it different for different people? Should we just politely assume that it's the Prader-Willi-esque explanation for everybody? Is that even more polite than assigning them agency? Should we just give everyone semaglutide and stop talking about it?
One additional point is pain as a warning for future damage. I once kept working despite increasing pain — until I literally couldn't any more (finally passing the constraint test). I had reached the point where I would drop coffee cups etc because of damage done by continuing. The preceding pain was screaming at me STOP DOING THIS RIGHT NOW, but I kept going, stupidly, in part because I though of the pain as just an experience and not as a warning that I was in the process of destroying myself.
And people do this all the time. Some tear muscles at the gym because they ignore the pain, others burn out, and so on. They CAN keep going so they DO keep going — until they can't. You can even die by ignoring pain. It's clearly not just an experience or a preference.
Mental illness is physical illness is illness. It’s all the same stuff at rock bottom. Maybe Caplan is in some senses just a dualist. Or he believes in a “faculty of will” that just decides things.
And it’s hard to believe he’s ever really known a severely mentally ill person in his life given how he misunderstands it.
Great article thanks for writing.
Right. Just because I can't tell you exactly how many grains of sand constitute "a heap" does not mean that "heap" is meaningless or a false category. And no amount of pointing to edge cases on the definition of "heap" will make the Sleeping Bear Dunes cease to be a major geographic feature.
I'm beginning to see the problem with behaviorism, with which I have limited familiarity. The problem is in a clinical setting it serves the function, or is the thing that currently best serves the function, of preventing neurotypical midwits from making bad and abusive decisions based on bad theory of mind. If you let the average behavioral health professional make any inferences at all into the behavior of an autistic person, or a mentally handicapped person, or whatever, that will lead to dark and dangerous roads pretty consistently. If you want examples of this you can just look at the troubled teen industry, which relies on folk psychology and religious theories of the human mind rather than behaviorism.
Complete digression but I have to say it as it reflects an important takeaway I got from practicing ABA for three years.
The distinction between behavior as disease and behavior as preference that I keep coming back to is whether it preserves optionality or not. This is probably strictly as bad as Caplan's because I have never discussed it with anyone (as a general rule I never have an opportunity to discuss anything with anyone: I am immediately dismissed as aggressive and insane whenever I articulate anything).
So anything that causes death trivially fails to preserve optionality. Anything that cripples a person or reduces their intelligence or health trivially fails to preserve optionality. Getting into a machine that injects an optimized dose of heroin into you continuously while keeping you alive indefinitely trivially fails to preserve optionality, etc. Environmentally I think of this as a problem that can sometimes be solved by reducing the strength of incentives or attractors. Some behavioral incentives are basically singularities to humans in some or even most mental states. I can't think of a good reason any environment should be engineered in a way that creates such singularities.
Please critique, develop, or steal this.
Ironically, Caplan often criticizes his fellow economists for being too inclined toward behaviorism and not taking seriously intuition & reports about mental states. I'm more behaviorist than Caplan and think he relies too much on the latter sort of evidence.
I do think Caplan's gun to the head test is somewhat stronger than you give it credit: even with a gun to the head you will have reduced capacity with a physical illness relative to your capacity without that, and we don't need to look at a bright line like traveling a specific distance when we have other observables like how fast & steadily you're moving, how heavily you're breathing etc.
The Prader–Willi syndrome reminds me of the taxxons from the Animorphs series.
I said something to this effect on Caplan's post itself, but his ideas on mental illness are the perfect example of the incoherence that results from applying market-based reasoning to areas outside its proper domain. Markets and economistic modes of analysis are useful tools, but when you insist on applying them to literally everything you end up with nonsense like insisting mental illness doesn't exist because something something preferences. Remember people: just because you have a model that can explain a lot of things in a really cool way, doesn't mean you have to apply it to literally everything in the universe!
Well, I've never gotten much value from Bryan Caplan in any context. YMMV.
Horses have no appetite control and can't vomit. If you put enough horse feed in front of a horse, it will continue to eat past the point where it starts injuring its stomach and will eventually die from it.
Do horses have Prader-Willi syndrome,?
It's hard for me to be polite about Caplan's last post on mental illness. I imagine it was even harder for Scott.
Kudos for such a thorough, mostly-not-sarcastic dismantling of such an obviously silly, half-baked position.
Caplan's gun-to-the-head distinction between a "preference" and a "constraint" seems so wildly, obviously silly that it's hard for me to believe he actually means it. Reading his original paper, it seems like he's just trying to plug a hole in libertarian philosophy that can't actually be plugged.
Once you are getting into these either or spaces within nosology you have missed the boat in medicine and psychiatry. The huntingtons hemiballism, the tourettic tic and the OCD compulsion are all on a spectrum, with the inevitability of performing each action modulated by shades of increasing agency, but all vastly to the seemingly inevitable and ego-dystonic side of one's perceived agency. Interestingly neuroimaging and demographic data (OCD/tourettes ~30% comorbid with eachother) point to common potential imbalances between the direct and inhibitory pathway in the basal ganglia.
Thus, it's just shades and penumbras between what psychiatrists and neurologists are doing, psychiatrists are like epi-neurologists. On this note, in thinking of preferences and constraints- late stage addiction involves changes in the dorsal striatum and almost becomes like a movement disorder- and the withdrawal state becomes a physiologic constraint that drives the inevitability of use through negative reinforcement- (not to mention the avoidance of hypertensive states, dysphoria, seizures etc). A preference clearly can become a constraint, like eating turns morbid obesity. These are all intricately related. Anyone who is not just armchair commenting and has experience with dual dx populations though, will know the experience well of hearing tales of trauma and hyperarousal etc, driving the original use- was it a preference? Was it not the cause of an original imbalance that constrained the inevitability of pursuing one action over another? It's diffuse and penumbral and deserves individual assessment and formulation, patient by patient, and that's the beauty of psychiatry.
If the difference is supposed to be that a "preference" can be changed with incentives and a "constraint" can't, then I don't think the dichotomy makes sense even in purely economic terms. Any budget "constraint" can be overcome with enough creativity and disregard for the law - it's just that the incentive would have to be much much stronger to match.
Or, in Caplanian terms: I can't afford a house, but if I had a gun to my head, I could probably make it happen.
Hmm, I do not disagree with your point that preferences vs constraints is a very limited framework for evaluating whether something is an illness. However, your parsimony argument is on the weak side: the universe is complex and the apparently simplest models are often wrong. Whether to consider something an illness that needs to be cured/accommodated/empathized with depends on a complex interplay of internal and external factors.
For example, homosexuality can be considered an illness to be cured in one specific society if every member's procreation is essential for the survival of the society (and assuming artificial insemination is not an option).
Having lethal cancer at the age of 30 can be considered normal in a society where people over 30 are a burden for whatever reason, and not getting a cancer is a disease. Taking steps to avoid getting cancer by 30 could be considered a mental illness or a crime.
Star Trek: TNG has a whole episode on Geordi not being considered ill.
The subculture of hearing-impaired often looks askance at those who choose to have an implant. Without implants available poor hearing was an illness, with them available it's a choice.
Useful term worth linking here (one of your earlier posts mentions it but this one doesn't): Sickness behavior https://en.wikipedia.org/wiki/Sickness_behavior
Many things that we normally think of as symptoms of physical illness, are not in fact directly caused by the disease, but are an evolved behavioral suite that activates in response to the disease!
Great essay.
I thought the debate about whether depression is a disease as a debate mainly about whether depression is a distinct entity, or whether the real problems depressed people have couldn’t be classified better by other disease pathologies.
Or something else. Maybe some set of people who have depression diagnoses are actually lonely, maybe that is their real problem. ”Lonely” is a real problem but it isn’t a disease. You might say, well, they are depressed too. But is that really the most useful way of thinking about it?
But Caplan seems to be arguing that people can’t actually be lonely without choosing it, without its being their revealed preference?
I think you've won this against Brian Caplan-Szasz. (I have some expertise in criminal insanity law, and I'd occasionally see citations to Szasz well past the point where it was defensible.)
I think I've changed my mind after reading this post, in the direction of Scott. That is his position seems more consistent than I thought, nevertheless this issue seems very much to do with what values one regards as important within a particular context, and I think Kirkegaard's emphasis on fitness, makes sense from a particular scientific perspective.
Although perhaps importantly, I don't think the general public and even various experts, have a view that's as self aware as Scott's, such that I think the Szazsian view is still of merit.
"Instead, I would rather describe things that make an action difficult and unpleasant as in some sense real constraints."
You'd think an economist would understand that friction (in the metaphorical sense) making activities more costly (in the economic sense of all costs) doesn't have to be a hard constraint to alter people's behavior. Illness is, well, taxing. Many illnesses, like taxes, just make stuff more costly without imposing hard boundaries.
I've developed, against my will, a strong preference for avoiding cats and smokers. It's nothing personal, but I like breathing better. Medicine has advanced enough that I could live with a cat or smoker and not die, but it would be an unproductive life, since struggling to breathe turns out to be really distracting.
If my only asthma triggers were cats and smokers, I could lead a normal, un-asthmatic life in a society that shunned smoking and cat-keeping – politics! In this society, though, where cat-keeping is normal and smoking is stigmatized but still common, I'll sometimes drug myself extra to disguise my airway's weird preferences as much as possible while I visit loved ones who live with cats or smokers. I'll usually still have symptoms, but I consider it polite to hide them if I can – though "polite" can be overdone:
I once "polited" my way all the way to the ER as a child. I was wheezing at school but didn't want to make a scene, so I hid it for as long as I could. As my parents pointed out, hiding it that much ended up making even *more* of a scene. The etiquette of minimizing the burden we impose on others due to our weird bodily preferences (like asthma or diabetes) can get rather complicated.
What's up with this guy Caplan? After reading Scott's essay, above, I thought he was a mentally ill person who felt dehumanized by being diagnosed as a something-or-other -- and that's a common reaction, and one I have no trouble sympathizing with. So, I thought, this mentally ill guy, maybe somebody bipolar and often manic, has fixated on Scott as a representative of the profession who diagnosed him as a something, rather than seeing *him.* He wants Scott to say that diagnoses are bullshit so that he can have a win against the profession. And I wondered why Scott was continuing to debate with somebody like that.
But in fact Caplan's a professor of economics & has written several books that sound entertaining and politically incorrect: The Case against Education, Selfish Reasons to Have More Kids. Glanced over his blog for about 3 mins and read a few random bits that were smart, witty and well-written.
But he has this weird bee in his bonnet about Scott. In his Twitter post asking whether Scott's take on witches stealing penises shows Scott's a closert Szaszian he ends with a survey asking "am I crazy or not?" and most common response was "yes, you are crazy." Then I looked at his post about Scott's announcement of his marriage, and didn't see any spinning of that regarding mental illness -- in fact mental illness wasn't mentioned. So whattup?
It's easy to see that Caplan's wrong. I'm more interested in why he's got this weird take on Scott. Anyone know more? Scott, do you?
This was a cathartic read as someone whose opinion of Caplan has been going downhill for a few years now.
Far from an expert, so feel free to correct errors.
I heard recently that for many mental illnesses, they are more correctly thought of "syndromes" or collections of symptoms. Having a known, identifiable, physical cause means that it _not_ that mental illness, even if all the actual symptoms are identical. If they find a brain tumor, that means you are not depressed, you just have a tumor that is causing exactly all of the standard depression symptoms. You only have depression if a specific physical cause can _not_ be identified.
As far as this is correct, it may be causing Caplan's issue (and to be clear, I think I disagree with him on this topic). We have explicitly defined many (if not all) mental illnesses as "thing that we do not fully understand". As soon as we fully understand it, it is not longer a mental illness and moves into the realm of standard physical illnesses.
The obvious answer to me is to just admit that we don't fully understand them, not to try and wave them away as nothing but preferences. If you moved to various points in time, nearly every single currently understood physical disease would fit into a similar space.
>who thought were were
Should be "who thought *we* were.
I posted this comment elsewhere but seems relevant (sorry if Scott has already used this example in one of his other rebuttals)—
Bryan needs to explain why someone with schizophrenia who is in the midst of a psychotic episode is fundamentally different than someone in the midst of an epileptic seizure shaking on the floor, in the sense than in both cases the person's brain is in a highly abnormal state which causes various behaviors we wouldn't normally expect. Does the epileptic have a preference for flailing around on the ground? Obviously not.
One central problem (as I see it) is Bryan's belief in free will, which totally clouds his entire analysis. Many of the conditions we are talking about systematically warp and distort peoples' decision-making and judgment. Viewing the mentally ill as just making different choices based on different preferences is the kind of things I would expect to hear from someone who has never actually met a severely mentally ill person in their lives, which I suspect may actually be the case for Bryan (but that's just my suspicion from the way he talks about this stuff).
>>who thought were were unfairly stigmatizing <<
--> we were
I think maybe an even better analogy than physical illness is injury.
There is an obvious and blatant malfunction when you break your ankle, or lose a finger, or get shot.
And yet, despite the pain, in extreme circumstances we have many examples of people who walk on a broken limb or continue to function for many minutes despite being shot multiple times.
The ability to damage yourself or accept pain to further an important goal in no way contradicts the existence of the injury. The change in behavior while injured is not the same thing as just having a preference for not walking. The treatment for injury is generally obvious, simple, and results in behavioral changes, like walking again, but the treatment is not about changing preferences, it's about changing the actual physical state of the body.
The repeated focus on genuine psychosis when a person's behavior does not respond to any incentives, does not seem like a good example to focus on in the context of Caplan's argument. If indeed it acts purely as a constraint and lacks any of the characteristics of a preference, then fine - it's an illness - and not subject to Caplan's point.
Caplan repeatedly states or implies that some so called mental illnesses are actual illnesses (although unfortunately he rarely elaborates on which these are). So if (some cases of) psychosis qualify, so be it.
>Again, Caplan could say that this is just a preference for attacking cops and then being killed. But in that case he should stop touting the “gun to the head test” as meaningful.
This really seems to miss Caplan's point. The "gun to the head" is a common metaphor for duress, given that typically people don't want be shot in the head. The question is whether incentives can affect someone's behavior.
In the rare case where someone wants to be shot in the head, then being shot in the head is obviously not a disincentive. Such a case tells us nothing about whether incentives could sway the person's behavior like preferences.
>is just voluntary preferences
Again, this seems to deliberately misrepresent Caplan to make him seem sillier. The post keeps talking about people choosing their preferences. When does Caplan talk about choosing preferences? What does it even mean to choose a preference?
As coming from a family of alcoholics, this example getting brought up again and again by Caplan is especially irritating, given that once you have maintained a certain blood-alcohol level for a very long time, it can be lethal to suddenly stop drinking. Without meds, best case scenario is delirium tremens, or you will have a 45 minute long seizure before you finally drop dead.
Try to solve that with a gun.
>His current post says that either you have to believe that mental illness doesn’t exist and is just voluntary preferences which are stigmatized by society, or you have to believe that homosexuality is objectively a mental illness.
>Not only are each of these incoherent ideas, they’re not even the same incoherent idea! You could easily accept one of the incoherent ideas and reject the other!
Of course they're different ideas! That's the whole point. If they were the same idea, then it wouldn't be either / or.
Caplan explicitly rejects the idea that homosexuality is an illness.
In between heterosexuality and coke v Pepsi: cilantro tasting like soap. Seems a lot like a preference, but we've found the gene and we know the subjective experience is different.
I don't usually hear it classified as a generic disease, probably because it usually doesn't cause much distress, but in a hypothetical culture that put cilantro in everything, or used it for sacred purposes...
This is starting to sound like Social Model of Disability. Come to think of it, a lot of this post sounded like SMoD. Could you write a full post on that some time? I think it could benefit from your analysis.
I am not sure if you have covered this argument somewhere, but even in terms of observable, economically meaningful behavior, Caplan's approach contradicts reality - I mean, how does he explain depressed patients spending considerable time, money and effort on therapy and various medications (that come with nasty side effects) TO GET RID OF THEIR DEPRESSION if being depressed is just something they chose to do?
Obviously Caplan is arguing from a fallacious, dualist view of human behavior, but it also strikes me that he's performing a bit of rhetorical legerdemain by treating mental illnesses as merely matters of conflicting preferences, whereas I imagine psychotics and schizophrenics would encounter difficulties stemming from their unusual perceptions of reality even if they were living as hermits, or if they inhabited societies exclusively comprising fellow psychotics or schizophrenics
Typo, missing "not" - You can imagine the depressed person choosing to throw parties and work hard instead.
A masterly rebuttal, but your footnote 4 is wrong. You can prefer something because it is less bad than the alternative; what you think is, the only thing worse than staying in this bed, would be getting out of it. Presumably Caplan has to say that you have chosen to believe that.
Caplan's view just seems sort of crazy. Like, you just read his description of schizophrenia as just being a preference to lie around all day claiming one sees demons, and it's so obviously false. Good job with the reply--very convincing.
Bryan Caplan has this wonderful way of debating:
Caplan : "Here's what I think. Anyone see anything wrong with it?"
Anyone: "Well, since you ask, here is the GIANT MOUNTAIN OF EVIDENCE you ignore, and the dozen major authors on this subject you clearly haven't read or engaged with."
Caplan: "...no one? Guess I am right about everything."
Case in point:
https://skepticink.com/prussian/2020/03/24/seal-the-borders/
What confuses me about this whole debate is that Caplan long ago admitted that some things can change both preferences and budgets: "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." https://www.econlib.org/scott-alexander-on-mental-illness-a-belated-reply/
Surely mental illness also affects both ability and preferences, though? E.g. if someone has serious anxiety, that will both affect their preference for avoiding stressful situations, and also affect what they are physically able to do (e.g. speak confidently in front of a crowd without having a panic attack). Gun to the head will not calm them down.
So I kind of have no real problem with Caplan's framework, but also just think he isn't actually applying it?
I get that you're intending to ask about willpower in #2, and that in that sense my answer violates the "spirit" of the question, but I also think that the fact that it actually isn't about willpower for a lot of people is relevant and highlights where the spirit has gone astray.
Gun to my head, I'm definitely blacking out due to hypoxia before breathing. This is certainly true for at least any semi-serious freediver, but I suspect far more than that. At some point you're just not "will power" limited and it becomes a question of whether increased incentive can lower heart rate and energy expenditure further -- which is a bit like "As long as you manage to not be afraid, I won't shoot you". Is the person who feels fear there showing a preference for not dying or a preference for dying?
Or just that they're constrained by their ability to organize their preferences?
You might be pleased to learn that when I got as far as the 'restored' painting of Jesus, I laughed out loud (and I'm at work, good job it's early in the morning when there's only one other person in the building as yet).
Mostly this lines up with my views of Bryan Caplan (and to an extent Tyler Cowen) and their views on matters, which are - well, I can't put it the way I feel because that would violate the "Kind/True/Necessary and Principle of Charity" on here.
Let's just say that Caplan annoys me with his total self-assurance that being an expert in one domain means he's an expert on everything under the sun. Ditto Cowen and education.
Would Caplan claim that being diabetic is a choice? You can certainly make that argument about Type II diabetes, and maybe (if you feel like being a particular son of a bitch) about gestational diabetes - after all, nobody *forced* you to get pregnant, but Type I is being born with a deficient pancreas. Unless we're going to invoke karma and the Wheel of the Law and reincarnation, it's tough to argue a Type I diabetic 'chose' that.
" You can imagine the depressed person choosing to throw parties and work hard instead."
This man has his head up his arse, and I'm sorry if this phrasing forces Scott to discipline me, but fucking hell. I'm not formally diagnosed (mostly because I can't convince my doctor) but I'm sorta-kinda depressed at times (at really bad times I have spent something like three days lying in bed sleeping) and yeah, sure, Bryan: I can totes leap up, decide to throw a party (for all zero of my non-existent friends) and have a great fun time getting those extroverted tendencies of mine online and having the ol' happy-reward neurotransmitters flowing! It's only a choice to be crying my fool eyes out over my dumb life!
"One can imagine Bryan Caplan not being a feckin' eejit" but I admit, it's only a thought experiment and not reality.
"In particular, he claims I am FORCED to either accept that all mental illnesses are just “preferences” and so not illnesses at all, or as posited in a response by Emil Kierkegaard, that homosexuality is a mental illness and therefore bad."
I'm willing to bite the bullet on that one. "But - but - that's mean to the gays!" Yeppers, Bryan, I'm not a secular liberal. Whatcha gonna do now?
I have kind of find hard time calling Down syndrome an illness. It is called a syndrome for a reason.
And also it doesn't really matter if we call it an illness or not. It is relevant only for people who care about policies and so on. They can use their own definitions if they wish, it shouldn't impact scientific thought.
This whole discussion sounds more like Plutonians debating if Pluto is a planet or not (a reference from Rick and Morty). If by scientific calculations their activities are damaging their environment what does it matter how they call it? It only matters for politicians who don't care about science but votes even if it leads to the ruin of the whole planet.
The same thing about Down syndrome. It is bad, we know it. We don't need to call it an illness to understand this fact. If we could invent a drug that fixes the genetics of a new-born baby, we would gladly use it. Maybe one day we will have such genetic cure. Maybe for those scientists who work on this problem it is important to call it an illness because those who give grants for these studies, follow bureaucratic rules – if it is an illness, you get money, if it is called something less – nada. But once you get money, you don't need to call it an illness anymore. Just study the thing whatever it is called.
A quick web search on Bryan Caplan reveals that he is an economist. As such he must have had rational actor decision-related concepts, such as "choice" and "preference", drummed into him for years and years and sees the world through that lens, and has a desperate urge to shoehorn everything into the same rubrik.
So it sounds like he is trying to extend this outlook from economics into areas where it is often not appropriate (just as it often isn't in economics itself - hence all economists' notoriously duff predictions!)
"In fact, if you put a gun to the alcoholic’s head and threatened to shoot him if he ever drank again, probably he would stop drinking."
He's never been around hardcore alkies, has he? I know that he's trying to pull the Chestertonian gambit as in "Manalive" collection of short stories, where the protagonist pulls a gun on a professor who is droning on about non-existence being better than life, and shocking him into wanting to live, but that's not a good method in reality (not unless you're sure that the person is only repeating fashionable absurdities and doesn't really hold to them deep down).
Put a gun to a depressed person's head, say you'll shoot unless they start throwing wild parties, and it's likely (if you pick the right - which is to say the wrong -time) that they'll say "Pull the trigger, I'd rather be dead". I've had those moments and I've had to claw my way out of them, and fuck you Caplan, it's NOT a 'choice' to do so. It's a struggle and a fight and I wish there were no necessity for it. I'm not "choosing" to feel like this, and you can't wave about "but you admit you fight your way out of it" as a choice. Mostly it's because I was raised that suicide is a mortal sin. Knock that pillar out from under me, and I'll take the other path one of the dark days.
"If we don’t like them, we should ask the people who have them to choose differently, instead of treating them as diseased."
Okay, I'm crying laughing here. So back in my social housing days, we should have said to our schizophrenic client "I'm sorry, but instead of sending the workmen out to change the locks on your doors yet again, can you instead *choose* not to believe that your neighbours are breaking into your house to smear shit on the kitchen walls and that we are sending cameras up through the toilet in order to spy on you on behalf of the government? Thanks!"
Yes, Bryan, *that* would *surely* work!
Same person on her meds: was stable, was able to hold down a job, did not phone or call into the office in a highly excited state
Same person off her meds: see above for sample of behaviour/thoughts.
Where's the "choosing" there?
>One might as well claim that a paralyzed person could walk if they wanted, but chooses not to.
The kicker being, some of them can. My uncle pulled it off after three years of paralysis (before I was born). He's mentioned a few paralyzed people have had more feeling in their legs than when he started out, but they didn't recover because they didn't have the ridiculous drive necessary to get back up (the kind that lets you focus on standing up for a full year without making any visible progress to standing up, and then fall on your face a thousand times).
Kaplan's a dualist. He's talking about the preferences of a homunculus, not about the preferences of a body. The human brain has been dissected many times and no one has ever found a homunculus. The homunculus is an illusion (a kind of narrative component) that focusses the brain's modelling capacity on the successful survival of the organism. Our modelling is always imperfect, limited and faulty - mental illness makes it even worse.
Modelling human organisms as disembodied preferences is useful in economics. It's still a model.
Caplan is making two fundamental errors, which I think Scott realises but doesn't explicitly name. Caplan shows that it is POSSIBLE to account for the behaviours that mentally ill people exhibit by invoking preferences, but mistakes this for showing that it is PLAUSIBLE. Scott’s counterexamples are basically ways of saying that the way ‘preferences’ are being invoked by Caplan are a) stretching the concept in ad hoc ways one wouldn’t do unless one was trying to win a very specific argument, b) basically unfalsifiable and c) simply not the best explanation of what we observe. The reason they exhibit these flaws is because Caplan treats preference as ‘thing that produces action’ and not noticing. No matter what change in behaviour is observed, it will be trivially true that preferences can explain it on this way of thinking. The only way you could even notice the flaw with this characterisation is by realising that it does a bad job of accounting for how we describe our other observations, and that requires noticing that ‘it is possible to explain their behaviour in this fashion’ is no where near showing that it’s a satisfying explanation. If someone’s behaviour can be explained by preferences no matter what they do, then ‘preference’ isn’t doing any useful explanatory work – it generates no predictions and constrains no anticipations. It’s the same flaw that affected early psychological work on traits. If you say someone is courageous in setting A but not in B, you can salvage any given trait in your explanation by just saying they have the trait of ‘Courageousness-in-A-but-not-in-B’, which works for literally any observation.
The second error is that Caplan’s test for ‘is a preference’ is ‘is voluntary’, but his test for ‘is voluntary’ is simply ‘is changeable by will given a certain stimuli’ [namely a gun to the head]. But he needs an argument for why we should think of ‘voluntary’ and ‘changeable by will given some stimuli’ are the same given they clearly are not the same concept at all, evidenced by a) folk understanding of those concepts, b) volitional will as a capacity clearly comes in degrees, and c) volitional capacity in some circumstances cleraly does not translate to volitional capacity in all cases (gun to head is likely to spike adrenaline which clearly increases some capacities you would otherwise lack).
@Bryan Caplan
Same thing I told Kyrie Irving
Stick to basketball buddy
What is the bottom line? How does this help us find out what criteria justify treating adults as incapable of choosing for themselves, or how how best to deal with them?
It almost makes sense to say, we should treat diseases and have compassion for those infected, and should not treat preferences and perhaps not have compassion in some instances. But then aren’t we ruling out diets or diet pills as treatments for being overweight? Why shouldn’t we treat preferences, if the person with the preference consents to altering that preference?
Szasz was against electroshock therapy, lobotomy, and probably would have resisted many pharmaceutical therapies for depression and other mental complaints. But again it isn’t the preference/disease distinction that is driving things. For adults that seem able to take responsibility for themselves (or whatever we should call the criteria), treating them should depend on do they want to be treated, is the treatment likely to be safe and effective, etc. But there are some people that do not wish to be treated, but also seem unable to take care of themselves. Szasz, Caplan (presumably), and maybe Foucault think that society transforms a social problem into a medical problem, using medical style treatments to control some who are difficult to control otherwise. In the extreme cases, there is something to be said in favor of this, just as society puts violent criminals in jail. The important question concerns when this is justified and when it is not. If murder was a symptom of an untreatable disease, isolation of murderers would still be justified.
So why are we arguing over disease versus preference?
Admire and love both of you (met Bryan&family last Sunday). The controversy pains me - though, as it leads to more posts by both of you, it must be a good thing. Scott "wins" by 42 to 3, I'd say. Nitpicking, here the three: 1. Scott's former "preference is just good for shampoo" was silly, (could count double for not admitting). Scott does much better now, saying "The middle three (straight, gay, even depression!) aren’t obvious, which is why we’re having this debate."
2. Scott about Caplan: "his position: that ALL mental illness is just voluntary preferences" - misrepresentation: even in the last post Caplan writes: "most". (Counting also against Bryan, as he never seems to point out which are "obviously" not preferences and which may not be). Oh, and not sure, Caplan agrees with "just".
3. oops, forgot ... maybe a few very tiny things adding up? Oh: Maybe the Szaszi/Caplan view has its uses?! Like: those addicted/"crazy" enough to defecate on the streets of San Francisco might be more able to control that urge if it resulted in sanctions - maybe birching (Singaporean style - any numbers on how often shit happens there?). But assuming "oh, they can not help it"/"we should help them more" may mostly result in: more crap?
End note: "free will/voluntary/preferences" are ambiguous - see Albert Einstein: "Schopenhauer's saying 'A man may do what he wills, but he cannot will what he wills' has filled me vividly since my youth and has always been a comfort to me seeing and suffering the hardships of life and it remains an inexhaustible source of tolerance."
Bryan still needs to tell us how long his magical gun to the head test lasts.
“Why not say that […] colds are just a preference for lying in bed and blowing your nose a lot?”
Because colds also prevent you from stopping your nose from running, various tissues from swelling, lungs from congesting, etc., even if a gun is held to your head.
What would Caplan say in reply? He is unlikely to respond directly for a long time, if ever, so I will try to imagine his response. I found in composing it that Caplan has already spoken to almost all of Scott's points, albeit perhaps not to Scott's (or my!) satisfaction. As a result, I fear Scott and Caplan are talking almost entirely past each other.
Disclaimer: this is my summary of Caplan's views, not mine. I am not a Caplanian!
Scott thinks I have crudely mischaracterised his views, like an ugly restoration of a beautiful medieval painting. Unfortunately, his picture of my views is no more accurate. I am not asking you to adopt a crude behaviourism, but rather the most parsimonious account of mental illness. It is extremely surprising that Scott would attribute behaviourism to me of all people! But while our models should explain, they should not over-explain. We have strong reasons to be sceptical of people's self-report, in circumstances in which they are strongly incentivised to answer in a particular fashion.
On Internal States
Scott's reply bafflingly attributes a strong behaviourism to me. I cheerfully agree that pain is real, that people have internal mental states, and so on. Scott returns again and again to this theme, but I'll just pick out one example as particularly illuminating:
"Maybe depressed people completely voluntarily choose to lie in bed for a few years while falsely claiming to be miserable and then shoot themselves in the head, and all of this is a perfectly free choice that they are happy with."
No, the depressed person is (presumably) genuinely miserable, and not happy with his choices, because his preference (lie in bed) don't line up with his meta-preference - have a fulfilling life. But that doesn't mean his choices weren't voluntary, or indeed, that there was anything unusual about his situation. This is the normal human condition! No doubt many people wish they were more conscientious, or ambitious, or loving. No doubt many people struggle with time-consistency. There is nothing mysterious or diseased about any of this.
On The Analogy To Physical Diseases
Despite what Scott says, I agree that migraines are a real disease. They are (in part) a constraint, that the sufferer can't look at a light without feeling pain. With a gun to the head, the migraineur would still feel the pain. But sitting in a darkened room is no part of that disease. That is a voluntary response which - as Scott is forced to concede - would change under different incentives. Once again, my gun-to-the-head test is vindicated - headaches are a disease, but sitting in the dark is a preference.
More generally, both physical and mental illness can both constrain behaviour and changes preferences. Scott tries to reject this model for physical diseases, writing:
"The essence of colds is feeling unwell and ugh and wanting to stay in bed and having unpleasant congestion in your nasal passages. None of these particularly change your preferences."
But what is "wanting to stay in bed" other than a change in preferences? Similarly, what is "craving for alcohol" other than a very strong preference for it? I do not deny that mental illnesses may go beyond a change in preferences, and to the extent they do, then they are diseases. My argument is that no preference is a disease, not that all mental illnesses are merely preferences.
When the Gun-To-The-Head test fails
I proposed a gun-to-the-head test not because it represents metaphysical truth, but because it's a quick thought experiment to clarify matters. I'll go further than Scott - the gun-to-the-head test can never fully clarify! Just because someone doesn't change their behaviour in response to a gun to the head doesn't mean they couldn't. But my test is far from unfalsifiable. It correctly identifies a subset of behaviours that respond to incentives, and as such are preferences, even if it does not identify others.
Are Preferences And Constraints the Same Thing?
No, and I'm surprised Scott makes the argument. Every concept has some grey area in the extremes, but for this argument to work for Scott, he needs to demonstrate that these grey areas represent the preponderance of mental illness - which he can't, because they don't. If there are some narrow grey areas, we should tread carefully in them, but it does nothing to impugn the vast rolling fields of black and white.
There is no difficulty whatsoever in categorising his 6 examples. An internal state of desire (i.e. a preference) is not the same kind of thing as an internal state of fatigue. Yes, a state of fatigue may lead to an internal state of desire for low activity (i.e. a preference), but that is perfectly normal - all our preferences are grounded somehow. Examples 4, 5 and 6 are purely preferences, and so cannot be diseases. 1, 2, and 3 involve both constraints and preferences, so the constraint aspects of them (fatigue, pain) are diseases, but the preference aspects of them are not. A skin rash is not merely an out-of-nowhere desire to scratch the skin, but if it were, that would not be a disease.
On Justification
We have already established that the constraints and preferences model works extremely well across a wide domain of applicability. But, it seems, if using it suggests that some people may have strong, socially disapproved preferences, then it becomes vital that we discard it for an ad hoc framework with minimal explanatory power that justifies almost anything. We must pretend that these people are somehow compelled beyond their will to take actions, because that makes it easier for us to:
- Force them to make other choices.
- Pretend that their social preferences are normal and that as such they are "good people."
- Indulge our own neuroticism and avoid blame.
I take no position on whether this pretence is socially useful. I am merely pointing out its dishonesty.
Some sources I used:
https://econfaculty.gmu.edu/bcaplan/pdfs/szasz.pdf
https://www.econlib.org/the-depression-preference/
https://betonit.substack.com/p/scott-alexander-on-mental-illness-a-belated-reply
https://betonit.substack.com/p/the-szaszian-fork-another-reply-to
"Diseases are constraints, not preferences" is a completely incoherent definition.
> Or we could stop thinking like behaviorists, a philosophy which nobody has taken seriously since the 1970s.
I'm not a psychiatrist, so there might be some nuances to this that I'm missing, but the first thing I thought of when I read that sentence is that that would definitely be news to my wife. She's a social worker who works with adults with disabilities who are "in services," and sometimes she talks with me about work. An unnamed psychiatrist who she calls "the behaviorist" is an integral part of setting up and reviewing each client's "plan," and she frequently uses the term "behaviors" as a euphemism/jargon for "doing things they shouldn't be doing."
It certainly seems as if the agency she works for takes behaviorists quite seriously in the 2020s.
Someone should give Caplan some psychiatric drugs with known side effects to see how easily his "preferences" can be changed.
> There are lots of stories of some cancer patient who “holds on” until their beloved spouse can be by their bedside.
Those are the stories we hear because those are the ones that get told.
https://www.theonion.com/loved-ones-recall-local-mans-cowardly-battle-with-cance-1819565052
So suppose that I want Scott to write an essay about (say) giant sloths. At this point it feels like a viable strategy would be for me to write an essay saying how one of his posts says that he must have a bunch of incorrect beliefs about sloths (but I present these as true facts). This requires 0 research on my part (I just have to pick random quotes and make up facts), but seems like it has pretty good odds of getting him to do research on giant sloths for me.
>Consider Prader-Willi syndrome, caused by damage to a region of chromosome 15.
Prader-Willi is quite interesting biologically, since it's an epigenetic disorder. In this region of chromosome 15, the father's copy is unmethylated and the mother's copy is methylated (and therefore silenced). If the father's copy is deleted, or the person accidentally gets both chromosome 15 copies from their mother, the genes aren't expressed.
The opposite can also happen, which causes Angelman syndrome.
"Certain neurological conditions involve intense and frequent pain. One example is trigeminal neuralgia, also known as tic douloureux. The term neuralgia stands for pain with a neural origin, and the term trigeminal refers to the trigeminal nerve, the nerve which supplies face tissues and which ferries signals from the face to the brain. Trigeminal neuralgia affects the face, generally on one side and in one sector, for instance the cheek. Suddenly an innocent act such as touching the skin or an even more innocent breeze caressing the same skin may trigger a sudden excruciating pain. People afflicted complain of the sensation of knives' stabbing their flesh, of pins sticking in their skin and bone. Their whole lives may become focused on the pain; they can do or think of nothing else while the jabbing lasts, and the jabbing may come on frequently. Their bodies close in a tight, defensive coil.
For patients in whom the neuralgia is resistant to all available medication, the condition is classified as intractable or refractory. In such cases, neurosurgery can come to the rescue and offer the possibility of relief with a surgical intervention. One modality of treatment attempted in the past was prefrontal leucotomy (described in chapter 4). The results of this intervention illustrate better than any other fact the distinction between pain itself, that is, the perception of a certain class of sensory signals, and suffering, that is, the feeling that comes from perceiving the emotional reaction to that perception.
Consider the following episode, which I witnessed personally, when I was training with Almeida Lima, the neurosurgeon who had helped Egas Moniz develop cerebral angiography and prefrontal leucotomy and in fact had performed the first such operation. Lima, who was not only a skillful surgeon but a compassionate man, had been using a modified leucotomy for the management of intractable pain and was convinced the procedure was justifiable in desperate cases. He wanted me to see an example of the problem from the very beginning.
I vividly recall the particular patient, sitting in bed waiting for the operation. He was crouched in profound suffering, almost immobile, afraid of triggering further pain. Two days after the operation, when Lima and I visited on rounds, he was a different person. He looked relaxed, like anyone else, and was happily absorbed in a game of cards with a companion in his hospital room. Lima asked him about the pain. The man looked up and said cheerfully: "Oh, the pains are the same, but I feel fine now, thank you." Clearly, what the operation seemed to have done, then, was abolish the emotional reaction that is part of what we call pain. It had ended the man's suffering. His facial expression, his voice, and his deportment were those one associates with pleasant states, not pain. But the operation seemed to have done little to the image oflocal alteration in the body region supplied by the trigeminal nerve, and that is why the patient stated that the pains were the same. While the brain could no longer engender suffering, it was still making "images of pain," that is, processing normally the somatosensory mapping of a pain land scape. In addition to what it may tell us about the mechanisms of pain, this example reveals the separation between the image of an entity (the state of biological tissue which equals a pain image) and the image of a body state which qualifies the entity image by dint of juxtaposition in time."
-- Antonio R. Damasio, "Descartes' Error: Emotion, Reason, and the Human Brain"
> “Should we set every tree in the United States on fire, then dump the entire Strategic Uranium Reserve in the Mississippi River?”
It's got to be telling us something that an Englishman who tries as much as possible to ignore US politics and indeed politics in general, immediately thinks: "I bet that's a Republican policy." Bad system-one. Bad.
In Argentina we have a word for people who think like how Caplan is thinking in this situation: we call them "boludos". This word does not necessarily mean a lack of intelligence. Very intelligent people can be boludos. Boludity stems from applying the wrong model of the world to a given situation, often because that model was successful in other situations. This can very easily happen to specialists, people who are very effective in some domain and are led by that success to believe their expertise transfers to other domains. Nobel Prize winners often hang on to very odd beliefs because of this. Chemistry describes everything, until it does not. Models of the word are optimized to obtain certain kinds of information from the world, and often suck at everything else. So you need to be able to switch between different models and frameworks to operate broadly in the world, and that we call wisdom. If you can't figure out which model to apply to each situation, or if you always apply the same model no matter what, like if you had a hammer and the world was made of nails, then you are a boludo.
"you’ll sleep less, not more" is linking to the same paper four times. You surely intended to either link four different things or make the whole phrase a single hyperlink
The motte:
- Psychiatric conditions can be modeled using consumer theory.
- Psychiatric conditions can be modeled as changing both budgets and preferences.
- Decisions about classification of conditions, syndroms, diseases, normalcy, etc. involve politics.
- Some psychiatrists engage sometimes engage in what can be modeled as rent seeking behavior.
- The field of psychiatry can be modeled as engaging in some rent seeking behavior (especially historically).
- Some psychiatrists use relatively bad and incoherent models of mental illness.
- Mainstream views in psychiatry (especially historically) have included very flawed models.
The bailey:
- Consumer theory is the best way to model psychiatric conditions.
- All/the vast majority of psychiatric conditions only change preferences.
- Decisions about classification of conditions, syndromes, diseases, normalcy, etc. are entirely political.
- (All) psychiatrists are rent seekers.
- Psychiatry is a homogeneous field (across time and practitioners) and is best understood as primarily engaged in rent seeking behavior.
- (All) psychiatrists use relatively bad and incoherent models of mental illness.
- Models and understanding from the field of psychiatry have nothing to add to our understanding of mental illness and have no benefit over consumer theory.
Yes, I know, economists are retardeds.
SA writes: "But it’s a political question whether or not to classify any condition, including physical conditions, as illnesses."
Could I get some clarity about how the phrase "political question" is being used here?
Gonna be honest, I don’t think you can actually arrive at a super robust “mental illness is very real” position without also embracing teleology. (This is no bitter pill for me, cause I DO embrace it, but I think it’s a bitter pill for a lot of people, and a lot of counter-intuitive, non-parsimonious theories abound as a result.)
I have to believe that if Caplan were to speak to someone with actual, real-deal, no-foolin' psychosis for more than five minutes he would have a much harder time maintaining his position. Thomas Szasz did not have a lot of experience with psychosis during his training, and I think that is reflected in the positions he arrived at as well. I suspect genuine mania would also challenge his conviction, or very severe OCD.
Please explain to me the set of preferences that leads a Conservative Jewish woman to stop sleeping, repetitive give the Nazi salute to passersby on the street, and rant at the top of her lungs about how she would have been the best prison cafeteria cook at Auschwitz while sobbing and taking a hammer to a mailbox.
Please explain to the me the set of preferences that leads a man who loved working as a car mechanic more than just about anything in the world to become so constrained and confined by his rituals that he lost his job because he it took him 7-10 hours to feel prepared to leave the house, started picking at his skin so severely that he opened up patent holes in his cheeks, and begged to be referred for deep brain stimulator implantation because it was absolutely the last hope he had left for living any life he regarded as worth living.
I don't think it is possible to articulate a coherent idea of "preference" that encompasses these things that bears any relationship to what use the word "preference" to mean in ordinary language. At some point you can use the same syllables to describe a concept but it is far enough away that I think it is perfectly legitimate to say then that some "preferences" are, in fact, disordered.
Some truths are difficult to grasp in a non-experiential fashion.
Looking at Caplans argument -- as Scott presents it -- I feel that Caplan started with writing the bottom line "Therefore, mental illness does not exist." before filling the stuff above. Credit where credit is due, I don't think I could come up with a better argument for that proposition.
Just like about every other concept, the concept of illness has some blurry outlines. Preferring Coke to Pepsi is not generally considered an illness, though if Coke had terrible side effects or external costs not present in Pepsi some might give it a fancy Latin name and call it a disease.
Of course, somewhere, someone will call a Deficit in Appreciation for our Supreme Leader a mental illness and try to place people in reeducation camps or something. I think the obvious place to make a stand against this sort of thing is to be against any treatment without (at least prior) consent, not the definition of illness.
Also, why is Scott the one feuding with Caplan over this? Scott's side is not the fringe position here, his opinion is probably shared by more than 80% of the medical professionals. Is it simply that Scott was the most high-profile person to refute Caplan?
Caplan's position is so funny - he's just very obviously taking the abstracted models about human behavior we use to make economic models work and explicitly using them as his understanding of psychology.
My advice is to not engage with this person.
I have no horse in this race and no expertise in this field but surely talking cures can’t work unless the brain/mind has a choice. My dad had a major depressive episode a few years back which was cured, only and finally, by pills. Now he is back to normal - and normal is happy and loquacious so that was quite a change and quite a reversal. He had no choice, perhaps, without the pills.
My uncle was treated for alcoholism and as far as I know he just did AA and some retreat or other. Now he doesn’t drink. ( Ok some people say that he still has alcoholism - but I never really believed that - it’s like saying that somebody who eats well still has an eating disorder. Sure both the alcoholic and the ex-anorexic can fall off the bandwagon but while on it they don’t have the disorder).
So in some cases it looks like there is a choice to overcome some mental illness where choice is “this can be fixed without chemical intervention”.
Alfred Marshall, inventor of modern mainstream price theory, used as a motto of his textbook Principles of Economics Latin phrase "Natura non facit saltum", i.e. Nature does not do jumps, attributed to Charles Darwin. Meaning that there are no hard lines between (some) phenomena, just one concept gradually morphing into another through edge cases. Perhaps Caplan needs to be reminded of that, since it obviously applies to a distinction between constraints and preferences.
I just want to say: this post particularly changed my mind. I read Caplan's original piece on how mental illnesses are actually just stigmatized preferences, found it compelling, then went to read your rebuttal but got sidetracked and kind of forgot about the whole thing. As a natural contrarian Bryan's position seemed reasonable to me. Particularly compelling is the parallel to arguments from disgust: people argue condition x is disgusting and therefore immoral, when such a mental model would produce virulent homophobia 70 years ago. Then I read this, remembered the whole thing, and it's pretty clearly wrong. I'm sure you don't particularly enjoy writing posts about this stuff as a psychiatrist, so just know you changed at least one person's mind.
Well done. Caplan is comically bad and intellectually dishonest in his thinking when it comes to this subject.
How we define "disease" doesn't matter one iota politically. What matters is whether the individual is hurting others. If they are not, you should respect their freedom and not lock them up for thought crime, however irrational or abnormal you think their thoughts are.
If you disagree, fuck you and everything you stand for.
I would say the spectrum you describe is strictly a constraint spectrum and preferences are *informed* by that.
Another way to look at the constraint spectrum: if doing X will result in Y bad thing, the degree to which you are constrained from doing X is proportional to the degree to which Y is bad.
I think Bryan has unusually high willpower/self control/whatever you want to call it, so when he sees people behaving a certain way, he concludes they must prefer this.
One example that should also apply to Bryan himself, is tiredness though. He should imagine he's really tired and can't think straight anymore, such that if he was left alone he would go to sleep. But now we put a gun to his head and force him to stay awake. Fearing for his life, he manages. This looks like a preference. But then we pull out a math test and say if he gets everything right he'll get $100. If he wasn't so tired he would be able to do it, but because he's so tired he's careless and makes many mistakes. That sounds like a constraint!
Furthermore, if we offer him a magical pill which would make his tiredness go away without any side effects, just like if he got a good 8 hours of sleep (i.e., a much better pill than caffeine), then he would probably take it in order to earn that $100! How does that fit into his framework?
So Caplan's model is nuts but your response has given me a framework to think about my own concerns with mental illness diagnosis. I generally think destigmatizing efforts are good but also think there's a cost we're ignoring and was having trouble articulating it.
That cost is that while the line between a constraint and a preference is extremely blurred in reality, we tend to dualistically categorize things in mental models. Imagine a universe in which we have a concept of a lower stigma, culturally accepted Can Only Run 5K Disease. In such a universe children whose legs will never carry them 6k won't suffer horrific pain in gym class - they'll be excused. They'll be mocked less for the inability to run. The diagnosis would make life better for thousands.
People with a strong preference for not running 6K can now model it as a constraint though. Maybe it makes them feel tired and gross and they dislike feeling tired and gross more than the average person. They're correct this mental state can be modeled as either preference or constraint, but modeling it as constraint changes how they think of "problems to be solved by running 6K." Where before it was "It would be extremely difficult for me to run 6K" now it's "I cannot run 6K." I can't prove it but I suspect that if you put a gun to the head of a person absolutely convinced they had this condition, who had made this condition part of their identity and made Facebook posts about how it impacted their life, they would be able to run exactly 5K before being shot.
Despite being essentially a perfect rebuttal, this is obviously not going to change Caplan’s mind. Perhaps a day of shadowing in a psychiatric ward would do this trick? After the requisite HIPAA training of course.
I can’t image meeting a poorly controlled Schizophrenic patient and then still thinking mental illness doesn’t exist.
One thing seems to have clearly emerged from all this, uh, debate: we should really be using the “point a gun at the patient’s head” treatment for a whole swathe of somatic and mental illnesses, since it appears relatively effective in many circumstances.
Feels a lot like the Harris/Dennett "debate" about Free Will. Harris says "particles, therefore no free will". Dennett says "I object to the definition you use, because of the following reasons (...)" and then Harris replies with "but particles, therefore no free will!"
I don't think either Harris or Caplan intends to be foil for a more careful thinker.
Scott, you write as if Bryan is doing something nefarious, in his manner of pursuing this issue.
But I think the truth is, he's just not paying that much attention to you. As in, I bet he's not even really reading (at least, with much attention) those long essays you write. He simply isn't *crediting* what you write all that much. He then goes on to reassert his position in a manner that a third-party might (perhaps rudely?) describe as a bit autistic.
Now, you might think that such behavior *is* nefarious. And maybe it is, at some meta-level concerning modes of discourse. But my point is that he's not deliberately trolling, or anything like that. He's just lacking self-awareness in a certain characteristic manner.
Many people, very much including rationalists, behave in exactly this way on other topics. It's just cognitively really difficult to closely attend to arguments that one viscerally does not credit. I've encountered that very mode here, e.g., on the topic of whether witches were historically real (in terms of their own self-understanding and practice).
I'm uncertain you and Caplan actually disagree about anything except what the word "preference" means.
I think the view that "mental illness is a preference" makes a sort of sense in a dualistic framework. If the incorruptible soul/perfect mind controls the body, then any disorder beyound brute physical constraints (i.e. failure to run due to arthritis) must be a choice, by definition.
If, however, the mind is a function of the body just like everything else a person does, then the mind can be damaged just like every other function. Arthritis makes it impossible for people to run, and depression makes it impossible for them to choose to run, but we have medications to at least mitigate both of these conditions; and in cases where we don't, we're working on it.
So, if that's what it comes down to, then the two positions (mental illness as a preference vs. as an illness) are irreconcilable, because dualism requires a kind of faith by definition (not necessarily religious faith, but still), and faith cannot be adequately communicated (though we're working on it). It just depends on which side of the coin-flip you happened to land, ontologically speaking.
>that all mental illness is just voluntary preferences
is a terrible position, I cannot imagine he actually believes that. That said I do tend to think he is correct that a big portion (possibly a majority) of what is treated as "mental illness" is really just people with poor preferences/behavioral ruts (particularly ADHD/depression).
Though perhaps that is not the central case as I think that is mostly the "frosting" of mental illness treatment, and the cake is the truly crazy people.
Thinking further, the one thing I think is missing from your argument is a discussion of involuntary cognitive distortions that come along with even the "milder" mental illnesses like anxiety and depression. It's not just that part of being socially anxious is that you feel affectively worse about being in crowds of people. The disorder also causes you to make systematically bad predictions about how you'll react to social situations, how given activities will feel, etc. You become irrationally pessimistic in your beliefs.
This sort of cognitive distortion is clearly involuntary--we might choose our actions, but we don't choose our thoughts/beliefs. It can be counteracted with higher-order cognitive tools. But this is another respect in which mental illnesses can't be pigeonholed as "just about preferences"
See: https://www.youtube.com/watch?v=lGZCZUUtLGQ&ab_channel=PennMindCORE - "All Mental Disorders Involve Systematic Misrepresentation of Value: Mental Illness from a Neuroeconomic Point of View"
I'd like to provide a small possible link between willpower and the preference/constraint distinction.
Preference might tentatively be thought as that which one may change under their own willpower and practice. For example, there are foods I used to dislike, then I learned to like by forcing myself to eat them until I got used to them, and afterwards became so cognizant of, they acquired preferences about which variety is like more than others.
And a constraint may be tentatively thought as that which one cannot change under one's own willpower, though it may be changed, in some cases, via external interventions, such as medications, surgeries etc., if available.
And then the overlap may similarly be linked to cases that require both willpower and external interventions.
This would turn the dichotomy into a false one that's in fact a continuum of that which can and cannot be effected via how much willpower.
Sidenote: the word that's usually translated as "desire" in Buddhist sources, "tanha", is better translated as "craving". It doesn't include small desires, such as Coke over Pepsi, or the desire for Enlightenment, but only those things that cause compulsions, and whose absence would lead the person to experience "dukkha". "Dukkha" in turn is usually translated as "suffering", but that's also inaccurate. It's a broader category that includes from dissatisfactions all the way to literal suffering.
Therefore, the lesson isn't that having desires of any kind lead to suffering, but that being overwhelmed by cravings leads to a continuous state of dissatisfaction that can grow into full suffering, which in turn is a major roadblock for the pursuit of that clarity of mind required for achieving Enlightenment. Hence overcoming cravings, addictions, and the like, is a necessary step on the path.
As someone who likes ecological psychology, I am wary of putting too much emphasis on internal states.
Credences, for example, can only be defined insofar as they are coherent; if someone makes different bets about the same thing in different situations, for example if the bet is presented differently.
But it's not like preferences are a perfectly defined concept either! They too can only be defined insofar as they are coherent.
Why is Scott engaging with this? As far as I can tell, Kaplan has identified a theory that the majority of people believe to be true, determined that Scott is somehow exceptional in being a proponent of this theory, and then repeatedly challenged Scott with inane arguments against the theory without actually considering Scott's defense.
I mean, I can do that too. Scott thinks we shouldn't eat babies, but either babies are more delicious than adults, or adults are more delicious than babies. So Scott must concede that if we shouldn't eat babies, we should eat adults. This isn't something Scott is willing to concede, so baby-eating is morally permissible. I'm going to take Scott's failure to argue about this as evidence that he has no counter-argument, and I'm also going to take any counter-argument Scott might make as evidence that he has no counter-argument.
What's the value of even paying attention to Bryan Caplan at this point? It seems mostly like a waste of everybody's time.
Edited to add: Strike that - reverse it! I had only read the beginning of Caplan's article and assumed it was representative of the rest. Now that I've read more, I am 100% team Scott.
Caplan starts out saying that you can model someone with mental illness as a rational actor with unusual preferences - that is correct. Then he moves into endorsing Szasz and going after psychiatry, and IMHO ends up someplace crazy.
You can model someone who is an alcoholic or has ADHD as just having unusual preferences, but when you say they shouldn't receive psychiatric treatment, as Caplan seems to, you're ignoring that a lot of people with alcoholism or ADHD want to change, in the sense that they voluntarily undergo treatment in an effort to change, they sign up for Beeminder, etc.
Now whether psychiatry is effective at introducing change for a particular condition is an empirical question, but Caplan isn't attacking psychiatry by arguing it's ineffective, he's just arguing that it's inappropriate to change people's "preferences," even voluntarily. That seems crazy.
-------- Old Post ----
I went back and skimmed Caplan's original article, and I'm now more sympathetic to Caplan than I was before, unless the exchanges since then have materially changed the discussion.
https://econfaculty.gmu.edu/bcaplan/pdfs/szasz.pdf
The question Caplan originally was trying to address was whether classical economic modeling can apply to the decision making progress of a mentally ill person - not whether an illness should be covered by health insurance or whether we should call it an illness in everyday speech, etc.
Under this framework, a person has priorities and resources, and they spend their resources based on their priorities and their beliefs about the world.
Some examples:
1) If my leg is trapped under a rock and I have the choice of sawing my leg off or staying where I am and hoping help finds me, I won't like that choice at all, but I will make that choice based on my preferences and my beliefs. If you know my preferences and beliefs, you can model my behavior.
2) If I mistakenly believe that my family is spying on me in an effort to prevent me from attending business school, you can model my choices based on those preferences, even if the belief itself is based on a mental disorder.
3) If cilantro tastes like soap to me and I don't like the taste of soap, you can model my choices based on that - I'll pay less for a burrito with cilantro is it, but there might be a sale price where I'll eat the cilantro burrito. This model works whether my dislike of cilantro is genetic or based on some other cause.
The ultimate question is whether the economic preference and budgeting models apply to the mentally ill, not something else. On that front, I wonder if Caplan and Alexander have a misunderstanding, not a disagreement.
As someone who's been on and off stimulant medications for ADHD at various times I've thought a lot about where boundary between "wanting something but not being able to bring myself to do it" and "not actually wanting something" lies. On stimulant medications I'm much more inclined to classify "things I can't do" into the second bucket rather than the first.
I think this is because on stimulants there's a much shorter path between vaguely thinking about doing a thing, and your brain/body actually doing it. This results in there being a much smaller pool of things that you vaguely want to do but just can't seem to make happen, and therefore you're more likely to classify these things as "not actually wanting them".
Parkinson's is probably the most direct way of exploring this connection. The neurotransmitter that turns thought into movement is literally missing. Does this result in a subjective experience of feeling paralyzed, or of feeling like you "want" to move less?
Caplan is applying the "revealed preferences" principle in economics too broadly. Revealed preferences is a term that means that we should look at the behavior of individuals to determine demand, not what they say in surveys or what is assumed by policy makers. For instance, people may say they don't drink alcohol, but a superficial empirical investigation will reveal that alcohol consumption exceeds that which is predicted by surveys. Drug addicts might not want to continue using drugs, but they do and policy makers should assume that they will continue, even if it means addicts will break laws prohibiting drug use, resulting in a cascade of other negative social outcomes (violence, petty crime, etc.).
Revealed preferences is a useful principle in predicting economic behavior in aggregate. Economists are not really concerned with the internal state of individuals, because it doesn't really predict policy outcomes.
The term is not useful in evaluating the internal state of individuals, or what actually drives them to do what they do. That's the realm of psychology.
Caplan is too smart to interpret the term too literally, in that I doubt he really believes that a schizophrenic is just choosing to hear voices because that is what he prefers. Instead, I think Caplan has another model of behavior in mind that he is not articulating well. Without putting words into his mouth, I would suspect he has not integrated mental illness concepts particularly well into his overall thought process, given his training in economics. Also, embracing nonvoluntary mental illness may undermine his commitment to libertarianism, certain versions of which emphasize the voluntary desired nature of individual behavior.
This seems to be a conflict between mind–body dualism and mental-illness–mind dualism. If you reject both, this entire debate seems to be ill-posed.
From a practical standpoint, isn’t it more objective to cure a physical illness than an internal state?
The policy implications of this discussion sorta rest on the tangible nature of influencing physical versus mental states. I think Caplan’s metapoint is that you can disincentivize or incentivize internal states (preferences) and the preferences which cause illness.
A minor point about cancer:
It's legitimate to debate at what point cancer is a 'disease' and also at what point that disease should be treated. Many people die in their old age from some other condition, yet they had a benign tumor somewhere in their body. It really matters whether a cancerous growth is either (a) malignant, or (b) likely to become malignant before you die.
Does this ever matter in the real world? Yes. Back in the day, they used to use PSA alone to determine whether you likely had (a) or (b). Too high a PSA, and they'd resect your prostate. Sure, you'd struggle with incontinence for the rest of your life, but then you could celebrate being a 'cancer survivor'! Except later studies suggested there was an unacceptably high false-positive rate with this test alone, and that hundreds of thousands of men got their prostates out for no good reason.
Yes, cancer is bad and should be treated. But we should also be paying attention whenever we set out on a medical intervention. ESPECIALLY preventative treatments. Those approaches have the highest probability of medical reversal later, when we realize it was all harm for little to no benefit.
I think any conceptual categorizations beyond a purely descriptive one on the basis of atom configurations and observed behaviors places a burden of proof on the part of the part of the categorizer to explain why their classification scheme does useful work. If you steelmanned Bryan's position, what work is the constraints/preference classification doing? It sounds like it's just trying to do political prescriptive work in terms of telling us how to treat the mentally ill. I would like to see an argument based on data from him that treating the mentally ill as if they have a preference rather than a constraint did things like improve recovery rates or speed, or reduce their burden on society, or have some other effect that he might be able to pitch as positive. If the classification doesn't do work then throw it out, since all models are only as good as the work they do.
This fascinating Invisibilia episode profiles an interesting case where a chronic “augmented pain” syndrome is worsened by paying attention to the pain, and treated by ignoring and therefore desensitization.
https://www.npr.org/programs/invisibilia/701219878/the-fifth-vital-sign
IMO this complicates even a simple continuum of preference-constraint.
There's a great discussion about changing preferences from EconTalk a few years back: https://www.econtalk.org/l-a-paul-on-vampires-life-choices-and-transformation/ (Yes, it includes a serious discussion on vampires.)
Sometimes your preferences change because your circumstances change. It's difficult to say that just because you have a certain preference in the moment that this is an enduring preference, or even to predict what your preference would be when those circumstances change.
Just one more reason that the whole idea of 'preferences' is not practical to drive policy.
I just want to say that I once held my breath until I blacked out. It's a mildly unusual thing that is tangentially related to this article. I was motivated by a competitive spirit and desire to win.
Would Scott *prefer* that Caplan respond to these four points?
Or is he suffering from a terrible constraint where he suffers unless Caplan actually responds to the content of his argument?
It seems to me this might be the real question.
On terminally ill people "holding on" (note 3) this has been studied at a population level.
In countries where Christmas is important, there is an increase in deaths from natural causes in the week immediately following it, with a corresponding dip the preceding week.
Two UCSD sociologists, David Phillips and Elliot King, did a similar study with Passover which is published in the Lancet:
https://www.sciencedirect.com/science/article/abs/pii/S0140673688901985
They compared Jews and non-Jews in the same place, which provides a handy control group for factors like the healthcare system not functioning as well the week after a major holiday.
A likely explanation is simply that people "hold on" to reach a major annual family-gathering holiday.
Is there an implicit assumption (or explicit somewhere I have forgotten) that doctors may/should never prescribe treatments, especially pharmaceuticals, for a condition we categorize as a preference rather than a disease? Is this a legal constraint, or medical ethics, or what? Does Caplan take a stance on this?
This leads to the issue of the ethics of self-medication, where presumably Caplan, as a libertarian, sees no objection to any adult treating themselves however they wish, or hiring whoever’s they wish to advise them. I am not sure what Scott's position is. From this perspective, the legal restrictions on prescription are the main sticking point, since whether a condition is a disease or a preference, in a world without legal restrictions on prescription drugs, competent adults in either category could try to improve their lives using whatever treatment they believed would help.
The other issue is under what circumstances bystanders are justified in forcing a treatment upon an unwilling patient (or similarly, to forcefully prevent them from applying a treatment). The current dominant opinion among medical ethicists is that treatment should be voluntary for competent adults. So the interesting question becomes, who counts as a competent adult, and how may we treat infants and invalids? (Of course, existing laws pretty much ignore this analysis.)
It seems to me that the categorization of conditions as diseases or preferences has little relevance for these issues. What is the issue where this controversy does have relevance?
From Categories Made for Man: "Hume’s ethics restrict “bad” to an instrumental criticism – you can condemn something as a bad way to achieve a certain goal, but not as morally bad independent of what the goal is. In the same way, borders can be bad at fulfilling your goals in drawing them, but not bad in an absolute sense or factually incorrect. Namibia’s border is bad from the perspective of Germans who want access to the Indian Ocean. But it’s excellent from the perspective of Englishmen who want to watch Germans plummet into the Lower Zambezi and get eaten by hippos."
I suspect Caplan wants to discuss (and has discussed https://betonit.substack.com/p/lgbt-explosion ) empirical questions of " (1) Are increasing numbers of people falling into mental health/sexual/etc. categories through marketing and self-selection, and (2) is this driven by discussing the categories themselves, (3) thus accruing outcomes XYZ (which are somewhat no-benefit with some cost, or sub-optimal)." This is a very common question, something that doesn't necessarily interact with the inherent political nature of categories so much as whether those politics are good or bad in the goal-fulfillment sense.
Bryan continually names Scott, because he likes him! He wants his favorite psychiatrist to say "I estimate that x% of diagnoses are due to self-selection/marketing/discussion of the diagnosis, and we would be better off limiting discussions of XYZ to prevent social/memetic contagion towards sub-optimal outcomes." Scott could pick any number for x, that'd be an entertaining post, but wildly more political (is this good/bad) than Scott normally does. I think Bryan is an excited and friendly-combative debater who refuses to ask that question, in adherence to the inscrutable norms of online-debate etiquette, and doesn't want to draw a crowd that wouldn't otherwise sit for a discussion of category definition. Caplan, and most of the GMU gang, ran into the same problem while discussing feminism a while back - just a bunch of posts discussing "What does feminism mean" while all dancing around having a stance on whether feminism-as-I-define-it-in-this-post (rather than naming policies XYZ) is good or bad.
Well, there is a qualitative difference between a person who feels excruciating pain when they walk, and a person who has had all the nerves in their legs severed. I'm... just not sure if that qualitative difference is particularly useful for reasoning about anything (except maybe figuring out what medical treatment to apply to get that person walking).
I haven't gone to read what Caplan has written in the past (maybe I should), but in my experience the line of reasoning presented as his in this post is essentially never put forward by someone who has a nuanced contribution to make to philosophy, or who wants academics in medicine or elsewhere to have a more expressive taxonomy available for the conditions of homo sapiens. In my experience it is always, and only, *that they're intent on proposing a way that communities of people can reduce their support and respect for some group of people they've identified as deserving cruelty*.
The obvious compromise solution is for both Scott and Caplan to accept that all preferences are in fact mental illnesses.
I’m a psychologist and a therapist, and agree with everyone who’s saying there really isn’t a clear distinction between constraint and preference (or you could call it a distinction between can’t and won’t). So here's a list of :
*7 Denizens of the Constraint-Preference Murk Zone*
(1) Anxiety disorders: expectation of terrible suffering if you have a close encounter with the feared thing.
Ex: I had a patient who feared broken glass as much as I fear jumping off a 100 foot cliff. I think if somebody put a gun to my head and told me to jump, I probably would not, because my picture of dying via the fall is more vivid and terrible than my picture of a bullet to the head. (Yet when I finally convinced my patient to handle some broken glass, her worst moments of fear were in the 3 seconds before her hand touched the first piece of glass. Once she started it wasn’t so bad, and by piece 10 she was hardly scared at all.)
(2) Procrastination: A habit of asking oneself before doing something whether one is up to doing it, whether there’s chance the in the future that the task will look more attractive, and whether it’s possible that doing it now might be a mistake. (If most of us asked ourselves these questions before we did something we’d never do anything). I see this habit a lot in people who are Aspergerish, and the habit is often coupled with a felt certainty that it is important to ask these questions, otherwise life will be too unpredictable and get out of control. Not asking these questions feels to them like I feel about jumping off a cliff.
(3) Addiction: People have addiction-related “delusions” about the consequences of giving up the substance you’re addicted to. I had these about nicotine. Lighting up had gotten so deeply associated for me with reading, writing, thinking and talking to people that I more than half believed that I would not be able to do any of these things nearly as well without nicotine. What made it hard to stop smoking wasn’t inability to face cravings, it was dread of becoming unable to do the activities that were most important to me. (As Stephen KIng said after recovery from addiction to alcohol and cocaine, I found to my surprise that my mind worked fine without the drug.)
(4) Depression: It’s not exactly inability to act, it’s inability to have any positive expectations about acting, and of course that produces failure to act. If the mind had suits, the way a deck of cards does, and there was a fearful suit, a sad suit, an excited suit and a hopeful suit, depression would be playing with a deck where the last 2 suits are missing.
(5) Depression: Inability to hear encouragement from others as anything except invalidation and criticism. Consequently, something that’s often pretty available to unhappy people is unhelpful and toxic to the depressed person.
(6) Avoidant and dependent take on life: People with any of the above who are also seriously dependent or avoidant have an extra constraint/preference: They believe that if they overcome the condition that has them stuck they will lose their status as a beloved and sheltered person, and be cast out into the lonesome cold.
It seems to me that it’s too simple to think of there being a spectrum running from constraint to preference, with lots of things in between. You can see in the above examples how people can be constrained by the false expectations ofwhat would happen if they did or didn’t do something — or by the sheer inability to conceive of certain things.
It’s kind of interesting to break the word disease down into its components.
Dis-ease.
A lack of ease.. that is a big umbrella.
Mental illness is a big umbrella.
My problem with this conversation is the generalities implicit in the vocabulary.
Let’s take two things; liver cancer, and diabetes. They are both diseases.
Diabetes has been narrowed down to a very particular chemical deficiency that can be remedied.
Liver cancer on the other hand, as far as I know, is way more wacky than that.
One form of Mental illness is tricky, because as anyone who’s ever dealt with it knows, one’s own participation in its cure (or management? )is essential. See the classic joke about how many psychiatrists it takes to change a lightbulb.
But
The brain is also a physical organ and can malfunction. Godspeed to the people who are trying to crack that nut… I have to believe that some of the pharmaceutical interventions developed over the last 40 years have actual relevance in that world. I am not at all in a position to speak to it. I am more interested in what I consider the other half of mental illness..
What ever happened to the word neurotic? It really seems to of fallen off the bus. I never see it in any of these discussions anymore. Perhaps it is a concept that is extremely out of favor. I happen to think it’s an important distinction.
A disease if you will, of emotional dysregulation? Is this a failure of will or a condition to be treated as a disease, in the classic sense?
What if someone was born and had a brace put on one of their legs, a brace that dictated the growth and shape of their limb over a period of time? What if eventually that brace was removed? Would the affected limb then spontaneously assume it’s rightful shape?
Or is it more likely that a lot of physiotherapy and conscious exercise would be necessary to even begin to restore it to what it should’ve been?
There are lots of people who I believe are mentally ill in the most fundamental sense of that expression; meaning, they have very little volition to bring to the task of understanding who they are. And there are others, who I would refer to as neurotic, that given the opportunity can direct their attention towards their own management or recovery. It’s very difficult to find a border between those two things.
So finally, is this a philosophical discussion or a discussion about social policy?
I would be very interested in some granular information about what it is to pay attention in some technical sense. The ability to direct your self towards paying attention to something. I think it’s a very significant thing, this ability to redirect one’s attention.
Why do you care a 'rat's ass' what Caplan thinks? Seems like it would be better for you to ignore him.
(But I have no idea, so feel free to ignore this.)
https://www.productgems.io/blog/tag/mark-twain/
Is the boy crazy?
Caplan skimmed the DSM and now he thinks he’s a psych expert. I took a look at his 2006 article that started all this. He linked to it this month, so he still endorses it.
His section on ADHD is based on a shallow reading of the DSM diagnostic criteria with almost no context. He uses this to suggest economically modeling ADHD as “a high disutility of work combined with a strong taste for variety.” The first part doesn’t make sense. The DSM-listed symptom regarding avoiding tasks requiring sustained mental effort can apply to work, but it can also inhibit people from returning to books they were enjoying or even watching TV episodes with a lot of hard-to-process stimuli.
He also claims the forgetfulness symptom refers to people with ADHD “conveniently forgetting to do things they would rather avoid.” But ADHD forgetfulness also includes things like, I don’t know, forgetting to eat dinner and drink water because of reading an article by someone too lazy to do thorough research on ADHD. Would this be modeled as a high disutility of eating and drinking?
The DSM criteria also don’t include commonly reported symptoms like rejection sensitivity or hyperfixations. These would indicate that ADHD isn’t “medicalized laziness” but a distinct type of brain with characteristics that tend to come together for a non-obvious reason.
I learned the hard way that preferences *are* constraints.
I was in a community that put very strong social pressure on me to disavow and avoid satisfying many of my preferences. I tried very hard to conform, and to tell myself "they're just preferences, they aren't real tangible things, I can just not listen to them."
This seems to me (with the usual caveat that it's very difficult to have much certainty about the causes of one's own internal states, because n=1 and it's all being seen from the inside) to have caused me to enter a very bad mental state that has lasted 6+ years after I both left that community and recognized the problem and started making serious efforts to improve my mental health.
"they're just preferences, they're not real" transitioned smoothly into "I'm not real, I don't exist" which caused a lot of dissociation and loss of executive function.
I am gradually getting over this, but it's ongoing, and I'm not fully convinced I'll ever feel as real and as sure of myself as I did before.
(ETA: I do recognize that my desire to be accepted by the community was also "just a preference", but I'm not sure why I accepted that one as more real than the ones it was trading off against.)
Need to write a large response here later today, as i have a lot of thoughts on this. Ive also had email conversations with bryan caplan, that i need to look through
Hmmmmmm
> Call it unibating, or monobating, or another word ending in -bating which is less polite but as far as I can tell equally appropriate.
I would use an homophone: baiting.
Caplan had a point about constraints, but was wrong about constraints and preferences being opposite.
The "if you can do it with a gun to your head, it's not a constraint" example is horrible. Lots of people have something like arthritis where some actions are impossible and some actions are entirely possible but incredibly painful. That situation is a restriction on your life by any sensible colloquial, moral or legal standard, and correspondingly is a disease.
I think the distinction he was looking for was, if we think a restriction is an IMPORTANT restriction, we're likely to think of the cause as a disease rather than not. That's not universal, the restriction will be important in some situations and not in others, depending on our judgement of the person, the judgement of people around them, and the amount society is accessible to people with that limitation.
I haven't read what Caplan wrote, so I'm probably missing the good bits, but I suspected it was a combination of:
1. He says there's not a neat objective criteria for what is a disease and what isn't. (Scott agrees, I agree) And he thought that Scott thought that WAS an objective criteria (he was wrong, that's why he thought Scott changed his mind)
2. He thinks that he has a better definition with constraint vs preference (Scott disagrees repeatedly, I mostly disagree as described at the start of this comment). I suspect that he saw Scott disagreeing with his particular definition as if Scott disagreed with point #1.
3. He thinks that modern categorisation of mental illnesses include too many things that shouldn't be included, because of these disagreements. I think that that HAS BEEN true and is true of SOME things, but that it's much less true now. I suspect if he talks about specifics, he'd talk about lots of things which psychiatrists think are illnesses which he doesn't, and I would probably agree with which are which, but that he thinks that the false-diagnoses are much more prevalent than I do.
On the last point, I have ADHD. I know first, second and third hand that there are people with a real, treatable disease which manifests in a variety of ways which are very real but hard to measure from the outside (e.g. inability to concentrate, inability to start doing important tasks. And yes, most people can do them for a few minutes if they have a gun to their head, but can't KEEP doing them every day without an immediate threat to their existence, and can't be threatened into doing them without long term damage).
I also know that there are people who suffer unable to fit into a regimented school routine, but flourish perfectly well in jobs which suit them (which jobs vary, but programming, EMT, crafter, financial trader, etc depending on their combination of needs).
I also know that there are SOME people who have adhd-like problems in life and seek out or are forced into treatment or into attitudes about it which are counterproductive in helping them. I think that's something to be aware of, especially if people are forced into treatment which is bad for them, but I don't know HOW widespread that is, and that doesn't constitute ADHD being fake for everyone else.
While there are conditions associated with intellectual disability that do predispose people to being, crudely, "happy and kind" this is often just a stereotype of people with intellectual disability that is simply not true. While it may seem harmless because it's a positive stereotype, it does tend to promote a kind of dehumanization where people aren't seen as part of the full range of human experience. Down syndrome is an example of this. In fact, people with Down Syndrome have a higher prevalence of depression.
“While the person may choose whether or not to scratch themselves, they cannot choose whether or not to feel the suffering”
It’s interesting to me that you even think it’s a choice to scratch. As an itchy person I can maybe delay it 15 seconds tops, and the whole time I won’t be thinking of anything but “it itches so bad but I’m not gonna scratch it.” If some other thought grabs my attention, it doesn’t mean it distracts me and the itch goes away on its own, it means I impulsively/unconsciously scratch because I’m no longer focusing on not scratching.
Once when I was 13 I was on a Boy Scout canoeing trip and my legs had gotten literally dozens of bug bites. I’d scratched them to the point that I had polka dots of blood all over my pants, and one of my friends asked me why I didn’t “just stop scratching”. I think I just looked at him confusedly like he had two heads, wondering how he even thought that was humanly possible, and immediately recommenced scratching. But I’ve since learned that apparently I’m the weird one? I don’t know, I can’t imagine how people are apparently able to just ignore it.
Caplan is a provocateur who believes he is always the smartest man in the room. Too often he is out of his lane and does not know what he is talking about.
Cowan seems to have two versions of Mental Illness is Preference. One is that it just unusual or disapproved preference; the other a matter of conflicted preferences.
"Question for Scott: Would your reaction be any different if someone said, “I’ve gotten tired of my self-destructive preferences, please help me”
"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?"
But the conflicted preferences version doesn't support Szaszian claims anywhere nearly as well. Someone with conflicting preferences could voluntarily seek treatment to resolve the conflict, without any of their preferences being disapproved of.
"or another word ending in -bating which is less polite but as far as I can tell equally appropriate"
On yerself, Scot
I'd argue that in basically all cases, it's more illuminating and promoting of empathy if we think of the issue as a constraint or a fact about the relevant person. For example, gay people have the same preference for emotional and physical intimacy as straights, but while straight people can best/only satisfy these preferences through a relationship with someone of the opposite sex, gays can best/only satisfy the exact same preferences through a relationship with someone of the same sex. This avoids ascribing to gays a poor taste in sexual partners and instead facilitates empathy with their situation. More generally, preferences often carry moral or aesthetic overtones, which facts don't have.
I have read both bryan caplan and scott alexander for a long time, and i have high respect for both. But mental health is the part where i think bryan caplan is almost entirely wrong.
I have written a bit to caplan, and have gotten a few responses back and forth. I cant find the original responses, so i have to remember them, with the unreliability that comes with it.
(Personal note: i have adhd, autism, and is gay and have had depression and suicedal thoughts struggles for most of my life. Im a 27 year old swedish guy.)
I think this mental health, “preference vs constraints” debacle can be broken down into 3 parts worth digging into
1: “preference vs constrainsts” is a flawed model of humans
2: bryan caplans ideological beliefs and worries that economic and personal freedom is reduced by common disability and mental health narratives, and my thoughts on that
3: bryan caplans personal psychology and philosophy
I will then go over the thought experiments and illustrate how these points helps explain key disagreements
Lets start with point 1:
1: “preference vs constraints” is a flawed model of humans
I think this model is highly useful as a tool of analysis. But all models are useful because they SIMPLIFY reality, and remove other variables.
While I believe its much more relevant then most people here, i do think that there actually 2 MORE ASPECTS of it that is neglected. Those are…
“Harmony”:
And…
“Outside signals”
Lets go into harmony first.
Preference and constraint is seeing a person as one single entity that is consistent, and dont conflict.
But as split brain patients show, we are actually a ton of smaller modules that work together, and often conflict.
Anyone that has tried to quit smoking or to diet have some 3
Experience with feeling that they have different preferences and constraints at different times.
Most normal people dont have too much disharmony in them. But some people have very big disharmony. An alcoholic can have parts of him that desperately wants alcohol, while most parts dont.
Other people have very much harmony in them: i think that naturally conscientious people are like this: the differents parts of themself dont have much conflict.
We have limited energy and willpower, and if there is too much stuff happening mentally or physically we become overwhelmed. So if you have disharmony in you, then things usually require more willpower and work to make the parts of you work together, which makes you less conscientious.
I personally have low contentiousness, while i believe bryan caplan to be unusually extremely high on conscientiousness and harmony: so he has never to a significant degree experienced that clash of motives, and thus see everyone else as being the same
“Outside signals” is more straightforward; its basically that you always have to interact with other agents, and being able to consistently show what preferences or constraints you have heavily influences the interactions you have. If you have very low outside signals (like having an invisible disability) then your ability to negotiate or get social support is lowered.
One note: outside threats(gun to the head) or desperation can temporarily bring you disharmony’s parts into an alliance, the same way an outside threat makes polarized peoples cooperate. But this requires tons of effort, and as soon as the threat is removed the disharmony is back
Point 2:
2: bryan caplans ideological beliefs and worries that economic and personal freedom is reduced by common disability and mental health narratives, and my thoughts on that
Ive noticed that in climate change discussions, climate change deniers are usually worried that if they say that climate change IS a problem, then their freedooms will be taken away simce its usually seen as collective problem, outside of personal responsibility and agency.
I think many libertarians get stuck into this mentality on the topic of disabilities or mental health, cause mental health is in a way built on the idea that you are not fully rational or consistent. That weakens the individuals strength and rationality, and has to be fair in the past been used to completely imprison and abuse people since mental ilness has been a way to say “their opinions dont matter”
As i earlier said, ive written to bryan caplan a number of times. And one of them i wrote along the lines of “i feel super depressed and i wonder if im a burden since im on welfare, am i that?”
And bryan caplan wrote something along the lines of “im busy and cant respond to much right now, but im sorry your feeling horrible. I suggest reading the book doing great. Good luck”
This seems at first to be a contradiction to his deppression preference article. And i think it is!! But i think that when BC is interacting with one individual that expresses suffering and advice, that it doesnt really challenge the individual liberty intuition he has, it is strengthened as he sees someone taking personal responsibility and putting in effort.
But when it comes to the abstract, his intuition is that adults are adults and should be left alone first and foremost, and only jn extreme circumstances have liberty taken from them.
To be fair, the mental heath and disability rights movements are generally left leaning, pro redistribution, and somewhat anti econ freedom. I think this is a mistaken view myself; im libertarian, socially liberal, and think capitalism and econ freedom is awesome for disabled people. Anyhow, the last point;
3: bryan caplans personal psychology and philosophy
Bryan caplan is a huge fan of michael huemer, who is a philosopher that advocates for conservative epistemics; the idea that before we use logic, we must appraise what appears in front of us. Its skeptical towards principle based or utility based formulas, and thinks we often fool ourselfs. Its heavily leaned towards trusting intuition and appearances first, and only trusting abstract reasoning if it has repeatedly and clearly demontrably outperformed appearances
From what i can tell, bryan caplan also has a very strong intuition about just desserts; people should get what they deserve, and etc. he also is heavily skeptical about abstract moral or philosophy claims made by people like peter singer
He seems to go by “revealed preferences shows what people actually care about” in morality. Which he uses to dismiss the idea that animals morally matter, since we treat them like garbage, and even vegans prioritize small comforts for themself over animals.
He wants very very clear and obvious proof that someone is disabled and constrained; if its vague then his intuition about people faking or should be left alone is much stronger then the intuition to help someone in pain.
To summarize:
1; {preference vs constraints} has two more prts: {harmony and outside signals} (lets shorten this as PCHO)
2: {BC worrys that mental health ideas takes personal agency away from people}
3:{BC goss with intuition first, and distrusts vague abstract and hard to judge things that are hypothetical}
So i just went over all of this. But how does this interact with the thought experiments and debates BC and SA have? Well, lets see:
A: the alcoholic.
SA thinks he is a victim but BC thinks hes blameworthy
On the PCHO spectrum…
BC dont see the alcoholic as being disharmonious, and sees him as consistently and visibly prefering alcohol to the family.
SA sees him as having conflicting parts and because of his therapist background, can see a lot more of the signals the alcoholic gives that he actually hates this situation.
Additionally, BC is going off “is this person worth associating with or a pain in the butt to help?” Intuition, for which the answer is “yeah get away from them”
While SA dont have these as much
B: tweaking the variable
Lets say now that we have a completely normal non alcoholic person. If they decide to start drinking copiously, or deliberately takes a pill that turns them into an alcoholic, then i think both SA and BC would see him as fully responsible and preferring alcoholism
But if he person is at first normal, but then an goverment agency feeds him a drug that turns him into an alcoholic, then i think even BC would agree with SA that this alcoholic is a victim and deserves help or sympathy
In these cases, the first one of personal deliberation has HIGH HARMONY and HIGH OUTSIDE SIGNALS. Its very easy to see that this person wanted this consistently, and its very easy to judge this as an outside viever.
The latter one has an LOW HARMONY and HIGH OUTSIDE SIGNALS: aside from just normal morals about coercion, its easy to see that this person did not at all consistently want this alcoholism, and its obvious viewers.
Ok ive written a lot and is tired now. Hopefully this is interesting and helpful
I wish I had both your intelligence and humor!
mental illness - when someone adopts one or more preferences which produce a significant negative impact on their lives vs. their alternatives.
We're done here.
What most bothers me here is the conflation of different kinds of things under the heading of "disease" or "illness". There are often good reasons to treat these things together, but there are also important reasons to treat them separately.
Prader-Willi syndrome [side note: it is not caused by "damage to a region of chromosome 15". It is caused exclusively by damage to that region in the paternal copy of chromosome 15; the same damage on the copy inherited from the mother gets you the radically different Angelman syndrome], Down syndrome, and cancer are all examples of the body breaking down. There is an intended state of affairs and an intended functionality, and those things have failed to be. But the failure is spontaneous.
The stomach flu this essay mentions in passing is a phenomenon of a radically different kind. There the body is functioning according to plan, but it's been invaded by hostile forces which impair its functionality anyway.
Both types of problem commonly cause the victim to complain that something is wrong. It's also common that they don't. The archetype for problem-without-complaint is of course the brain slug that takes over your mind, causing you to do things like protecting the brain slug and resisting efforts to have it removed and incubating its children.
So we can reject the idea that if someone isn't complaining about a problem they have, then no such problem actually exists.
Aging is similar to the two categories above in that it involves a breakdown in bodily functionality and sufferers complain that things have gone wrong.
But it's unlike them in that it's not a deviation from the plan. Aging is normal, intended functionality. It's just bad functionality that we wish we didn't have. I strongly suspect that this is why people reject the idea of calling aging a disease. I can be certain that that's why *I* reject the idea of calling aging a disease.
I think Bryan Caplan may be a philosophical zombie. He appears human and so we assume that he, like us, has interior experiences. But he does not. It's the only way to understand the depth of delusion to which his argument takes him.
Sociologically, I think something is probably a disease when it is an obstacle for satisfying the values of either the person with the condition or of society at large.
For homosexuality, we decided as a society that we should reorganize such that gays have a place within society, and a lot of people's values shifted, and so being gay is no longer considered a disease.
For Down Syndrome, we're still sorting out what we value, and even the people with the condition probably vary from being frustrated by their limitations to being completely content with the way they are.
For let's say a panic disorder basically no one values the condition of randomly suffering and freaking out, and panic attacks get in the way of quite a lot of things that people and society do value, so we consider it a disease non-controversially. If we believed as a society that people in a state of panic were getting closer to God or something like that, we probably would have a different opinion.
I am wondering if anyone knows whether David Smail is part of the anti-psychiatry "movement".
ADHD is just going to be an easy target for a long time. In the last hundred years the society has changed in terms of how much attention needs to be paid to activities, particular ones you get paid for. Sometimes the needs are intense, and people who had some difficulty adapting to the slower pace in other eras (even within memory) are now thriving. But this doesn't stretch indefinitely. A fourth-grade teacher from the 1950s might have to adjust her metrics a bit, and everyone might start looking at various professions with different eyes, but the ability to focus on a task and see it through ain't that different. This mild ambiguity in our era allows clever people to create fun anecdotes in their attempt to prove that it is all hogwash. But they are just fools with large vocabularies.
I was a psychiatric social worker in an institutional setting for forty years, and you have heard most of the arguments by the end of year one.
You may have mentioned in your writing, but I will mention now. Szasz never treated a schizophrenic patient and may never have met one. At this point I have to wonder what people are hiding.
This is interesting, but can you please address how this might apply to something like obesity? Is that the result of someone having constant suffering unless they eat (like Prader-Willi) and constant suffering if they try to exercise? Or is it the result of someone clearly and rationally choosing to overeat and not exercise fully aware of the tradeoffs? Is it a little of each? Is it different for different people? Should we just politely assume that it's the Prader-Willi-esque explanation for everybody? Is that even more polite than assigning them agency? Should we just give everyone semaglutide and stop talking about it?
One additional point is pain as a warning for future damage. I once kept working despite increasing pain — until I literally couldn't any more (finally passing the constraint test). I had reached the point where I would drop coffee cups etc because of damage done by continuing. The preceding pain was screaming at me STOP DOING THIS RIGHT NOW, but I kept going, stupidly, in part because I though of the pain as just an experience and not as a warning that I was in the process of destroying myself.
And people do this all the time. Some tear muscles at the gym because they ignore the pain, others burn out, and so on. They CAN keep going so they DO keep going — until they can't. You can even die by ignoring pain. It's clearly not just an experience or a preference.