Bryan Caplan  

The Szaszian Gestalt Shift: An Illustration

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The LA Times recently ran a front-page story on Tiffany Sitton, a 23-year-old schizophrenic girl. Its official position, of course, is that Sitton is a victim of a disease. But the details of the story paint a different - and rather Szaszian - picture.

If you read the story, you'll notice that this "victim" is strikingly self-motivated. Sitton's hallucinations and delusions strangely fail to affect her ability to do the things she really wants to do - like obtain narcotics:

After Tiffany got out of juvie, she ran away, hitchhiking to Los Angeles, where she lived on the streets, eating uncooked ramen noodles and using any street drug she could find.
Even in treatment, Sitton figured out how to get high:
The new roommate, Tiffany eventually confessed, was "cheeking" her pills -- taking them from nurses but spitting them out later. She'd been handing them over to Tiffany, who ground them up and snorted them, sending her brain back into a tailspin.
In fact, she mastered skills beyond a lot of Boy Scouts:
If her caretakers wouldn't give her a match to light a cigarette, she knew how to use a gum wrapper and a light socket to set fire to a tampon.
The article notes, of course, that drug abuse is common among schizophrenics:
Like many schizophrenics, she had also been a serious drug abuser: heroin, Vicodin, by her account just about anything that came along.
If schizophrenia were "just another illness," this would be an amazing - and strange - correlation. If, however, schizophrenia is a linguistic excuse for bad behavior, largely focused on relatives who won't exercise their exit option, it makes perfect sense. But you don't have to take my word for it. Here's what Sitton herself has to say
"It's like part of me wants to be sick. So I do bad things," she said on a recent afternoon. "I know I do bad things."
If you've read (not seen!) A Beautiful Mind, you'll find Sitton's self-analysis eerily familiar. As John Nash explained his own recovery:
Actually, it can be analogous to the role of willpower in effective dieting: If one makes an effort to "rationalize" one's thinking one can simply recognize and reject the irrational hypotheses of delusional thinking. (Nasar 1998, p.354)
The article dwells heavily on the suffering of the Tiffany Sitton's mother. As a parent, I feel for her. But I have to think that she'd feel better if she recognized her daughter as a perpetrator of extreme emotional abuse, instead of a victim of a mysterious illness.


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COMMENTS (17 to date)
Patrick writes:

This particular person may or may not be an emotional abuser operating under the cover of a diagnosis of schizophrenia. Regardless, there are striking refutations of the Szaszian hypothesis. There is a form of schizophrenia which can be cured, instantly and completely, by kidney dialysis. This was discovered completely by accident in a patient who had undergone years of ineffective therapy. In such a case, personal choice is utterly irrelevant.

Nathan Benedict writes:

Any citation for that Patrick? I googled this, and the first hit I found stated "Once a darling of the psychiatric newspapers, kidney dialysis for schizophrenia is now a professional embarrassment."

dearieme writes:

You may be right, but I've twice had to work with people later diagnosed as schizophrenic and I (layman) thought the condition very real. Particularly after my experience with the first one let me diagnose the second one myself.

Jim writes:

Bryan, I'm assuming you've met quite a lot of people described as schizophrenic. I mean, you must have, otherwise generalising from absolutely no experience of the issue would be crass and ignorant, right?

Matt C writes:

You have argued along these lines before and I am still not clear on what your position is.

To take the case of the girl in the story, do you think she really had no delusions--when she said there were spiders under her skin or "heard voices", she was consciously telling lies to get sympathy?

Or do you think that she really had the delusions but could have resisted them if she had tried harder? Or something else?

Lee writes:

@Patrick, I have only read one of Szasz's books, but I do not see how the case you cite challenges his views. Here is a nice short summary of Szasz from Dominic Murphy's excellent book Psychiatry in the Scientific Image (p 25):

Szasz thinks that the only respectable notion of disease is that of damage to bodily structures, and putative mental disorders are not the result of tissue damage. In reply, psychiatrists often agree with the first point but insist that mental disorders will eventually receive an explanation in terms of brain abnormalities. Szasz's response is that if something is a brain disease then it's physical, not mental: he appears, in fact, to be an eliminativist about the mental.

Also, Bryan: One of your earlier posts on Szasz inspired me to read up on the mental illness skeptics more generally. This is a fascinating topic. Some analytic philosophers have dealt with the subject more carefully and less polemically than Szasz, though. I highly recommend Neil Pickering's The Metaphor of Mental Illness and some of Ian Hacking's writings on transient human self-understandings (Multiple personality, e.g.).

The book I quoted by Murphy is good too. Although he is no "constructivist" about mental illness, it is amazing how much even he concedes about the fundamentally normative concepts of human flourishing that determine our psychiatric categories (p 98):

If we can make the two-stage picture work, we can arrive at an objective answer about whether someone is or is not dysfunctional, and then deliberate about how to regard the dysfunction. On this view, "mental disorder" is a concept like "pest," "weed," or "vermin." Weeds and vermin are not natural kinds, but they are made up of natural kinds that can be explained empirically. Furthermore, whether something counts as a weed or a vermin depends on human interests in a way that allows the class to grow over time, or vary across projects. Foxes are vermin if you're a farmer, but other people think of them differently. As we develop new habits of life, species come to be pests because they interfere with the new habits. Some insects prey on vines: we care about vines because their fruit is essential to civilized life, so those insects are pests. Other insects are not pests because they prey on species we do not care about. But, if we discovered a medicinal use for a plant that humanity never had previously husbanded or exploited, the insects that inhibited out use of the new plant would become pests. Concepts that are sensitive to human interests in this way are open-ended--things may drop into them (or drop out of them) as human interests change over time. Folk thinking does not determine in advance whether a species is a pest, not does it make scientific investigation of a species of pest into a normative endeavor.
Tony writes:

Bryan,

Your piece reminds me of the classic essay Daniel Patrick Moynihan wrote close to 15 years ago entitled, "How We've Become Accustomed to Alarming Levels of Crime and Destructive Behavior." As you may recall, in the report he coined the term "defining deviancy down" in an effort to bring to light the alarming rate of deviant behavior social scientists specifically, and post-war American culture generally, had come to tolerate.

His thesis was sweeping and quite breathtaking: "Over the past generation ... the amount of deviant behavior in American society has increased beyond the levels the community can 'afford to recognize' and that, accordingly, we have been re-defining deviancy so as to exempt much conduct previously stigmatized, and also quietly raising the 'normal' level in categories where behavior is now abnormal by any earlier standard."

I don't think he was wrong then and I don't think he's wrong now. While many libertarians may choose to eschew his penchant for this type of moral absolutism, your criticism of Ms. Sitton's "schizophrenia" seems to me a clear example of defining deviancy down.

Troy Camplin writes:

Can't speak for anyone else, but my cycles of depression and self-destructive behaviors stopped when I decided to stop them. It turns out chocolate is a wonderful way to medicate mild bipolar disorder -- especially if you combine it with the will power to be well.

Dain writes:

Tony,

I'm not sure Bryan is excusing the behavior of Ms. Sitton as atypical yet defensible, but instead simply questioning the degree to which her actions can be considered outside of her control. Indeed one could take the Szaszian POV to bolster the need to punish her for her actions. (Though I wouldn't.)

Morgan writes:

Am I reading this correctly? Are you really disputing the reality of schizophrenia? Is there anything of which you are ignorant of that you aren't willing to comment on?

Schizophrenia is a horrible, horrible condition as anyone who has ever lived with someone with this disease can tell you.

Perhaps an economist might be careful not to draw conclusions from an anecdote which may or might not be a false positive.

In any case, I can see your attraction to Szasz. He is another person who starts with a theory and then bends, disputes and denies reality as necessary to keep his theory intact.

Why are economists so often ridiculed? Because many refuse to see the world right in front of their eyes.

Troy Camplin writes:

I wouldn't dismiss Szasz so quickly. His concerns came about precisely because he saw how "mental illness" was being used in the USSR to control the people, and how people used it to excuse (and avoid punishment for) their behaviors. Perhaps he goes too far -- but I think too we also go too far in this country to excuse bad behaviors, claiming that people can't help it for reasons of mental illness, their childhoods, etc. Most cases of ADHD in the U.S. are misdiagnoses to sell Ritalin -- and the evidence on what causes ADHD, slower brain development, suggests that Ritalin is useless for treating the "disease." Many people with "mental illnesses" drive themselves crazy. Many other cases are responses to what they perceive to be a meaningless world (thanks postmodern leftists!). We need more Szasz as a corrective to the overdiagnosis of mental illness in this country. I could have used a Szasz there for a while to tell me to grow up and get over myself. I did it without him, but it did take me a few years.

Morgan writes:

No doubt there are many false positives diagnosed for whatever reasons. But when it is real, and in my friend's case it is all too real, it is a horrible, catastrophic condition which pretty much destroys a person's life.

Considering the crippling side-effects of the medicines used to treat schizophrenia, I have a hard time understanding anyone theorizing that people are doing it for the medication. It destroys your ability to focus, makes you fat and bloated, doesn't get you high, only miserable, but at least the demons stop talking to you.

Troy Camplin writes:

They may not be doing it for the schizophrenia medication, but other mental disorders let you get ahold of much more interesting drugs. Also, there was the argument, at least in this one case, that it was being used as an excuse to excuse drug use of other kinds. And what do we make of the Nash example, where he chose whether or not he was going to be ruled by his sickness? Does Nash really have more willpower than anyone else with it?

Ben Kalafut writes:

I see even upmarket libertarians can get sucked in by rubbish if it flatters their prejudices.

Let's play Spot Caplan's Error. This one it easy: the conclusion that if a schizophrenic also manifests the behavior of a drug addict, she Must Not *really* Be Schizophrenic.

Sitton's mother may feel better if she doltishly thought her daughter was feigning her mental illness. But it wouldn't add to her understanding of what's going on. Foolish of you to think a schizophrenic's symptoms ought to preclude her from obtaining narcotics like any other addict.

Not only has schizophrenia been shown to have a strong biochemical component; abnormal brain activity is visible on modern imaging instruments.

As is the case with Arnold's posts about global warming, perhaps you ought to do your homework before taking a position against a strong scientific consensus in a field that's not your own. I presume that, as a member of the GMU faculty, you have online access to technical journals. Read up on recent work on the etiology of schizophrenia. You'll find that the position that schizophrenics are malingerers, feigning their symptoms to manipulate, is untenable.

Morgan writes:

Correct me if I'm wrong, but our dear Mr. Nash claimed all sorts of things which weren't true. He was crazy.

Scott Scheule writes:

So, Bryan, that stuff about it being good to defer to experts in their respective fields, you meant only when those experts agree with you, right?

Patri Friedman writes:

Like Morgan says, mental illness may be overdiagnosed, but that does not mean it is not real. I have observed mental illness firsthand (bipolar), and I can personally assure you that it is a real, physical, chemical, non-voluntary phenomenon.

If you are trying to claim that all schizophrenia is just an excuse, well, this is the first time you've ever said anything that I thought was genuinely stupid. But hey, that still leaves you batting 99% or so :).

Still, your post bothers me because not only is it stupid, but I feel as though you are belittling an affliction that cause incredible pain and suffering to both victims and their families. And again, an affliction that I am 100% positive does, in many cases, result from physical abnormalities of the brain.

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