Bryan Caplan  

Mental Illness and Behaviorism

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In an extended post on economics and mental illness, Tyler remarks:

I disagree with Bryan Caplan's argument that mental illness is a false category; he is making an odd turn toward behaviorism.  That the behavior can be reduced to preferences and constraints does not mean that is the best or only way of understanding the phenomenon (which is not just about behavior).

He misstates my position.  My claim is not that mental illness is a false category, but that "weird behavior stems from illness" rarely fits the facts as well as "weird behavior stems from weird preferences."  And if anyone's being behaviorist, it's orthodox believers in mental illness, who just can't imagine that people do weird things because they genuinely want to do weird things.

I do agree, though, that there are "other ways of understanding the phenomenon" [of mental illness].  But the "other ways" that have insight to offer are ethics and philosophy, not medicine and neurology.  Consider: If people didn't think that alcoholism was bad, would anyone bother to argue that it was an "illness" or stemmed from a "chemical imbalance"?

P.S. The irony of Tyler's hostility to the Szaszian critique of mental illness is that his Create Your Own Economy (now The Age of the Infovore) is essentially a Szaszian interpretation of autism.  If only he had built on this foundation - or even acknowledged the parallels - I think the book would have been much more compelling.


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COMMENTS (13 to date)
Chris Koresko writes:

Consider: If people didn't think that alcoholism was bad, would anyone bother to argue that it was an "illness" or stemmed from a "chemical imbalance"?

If I remember correctly, Greenberg in this EconTalk podcast said that the idea of alcoholism as a disease was invented by a marketing guy to get alcoholics to seek treatment from their doctors rather than turning to others who offered moral support, e.g., clergy.

In fact, there is an extensive discussion on the reality of, and definition of, depression. There was/is a profound lack of definitive detection of a physical or biochemical indicator for most mental illness.

It seems these things are a lot vaguer than many people believe.

Patri Friedman writes:

I am baffled why you would think that neurochemistry is not highly relevant to mental illness. I'm guessing you haven't done drugs, been close to someone with mental illness, or read research about the genetic and neurochemical basis for addiction, because any one of those validates the orthodox view for at least some cases.

I love contrarian views, and I'm sure there are cases and degrees where yours applies (plenty of bogus mental "illnesses"), but mental illness is definitely real in many cases, and definitely neurochemical. I'm more sure of this than an awful lot of things that I'm pretty sure of!

When preferences are strongly driven by neurochemical imbalances, as in bipolar, how is "it's weird preferences" a refutation of "it's illness"? People with seriously messed up brain chemistry don't control their preferences.

Perhaps I don't understand the Szaszian view - what predictions does it make about behavior in the real world that differ from the orthodox view?

Tom West writes:

From a philosophical point of view, I think it's pretty hopeless to define mental illness as anything except deviation from the normal beyond a certain point.

Otherwise you get into endless metaphysical debates about who is the "real" you. There's obviously no clear-cut answer, so we might as well admit we're throwing darts and decide upon some arbitrarily agreed upon answers that we'll use to decide who we offer help to, and who we forcibly "help".

But then, I'm pretty much a consequentialist. If I think a course of action will make a lot of people less unhappy, I'll generally push for it, even if it bends some of my principles.

Hyena writes:

Mr. Friedman,

You're making a category mistake. "Mental illness" is essentially a normative description of a behavioral pattern. Better detailing that behavior pattern does not bring us closer to a normative claim.

Hyena writes:

Prof. Caplan,

We could argue simply that "illness" is subjectively defined by the person experiencing it. In that case, a mental illness is a preference you reject and wish to be rid of.

We could create a continuum extending from mental contaminants to strong behavioral patterns.

Ray writes:

The kinds of major chemical imbalances that render a person incapable of being sentient human beings are rare.

The problem is that most people claiming "mental illness" are suffering from minor chemical imbalances that could be rectified if they simply made better choices.

Years ago I worked as a physical trainer, and dealt with people whose behavior could be fixed to a large degree if they would just put aside certain foods, and take care of themselves. They simply chose not to.

Roger Sweeny writes:

I think Tom West is right. Much of "mental illness" is people wanting to do something--and doing it--while at the same time not wanting to. There just isn't a nice simple preference function here, like Bryan uses in his paper.

Take someone who is "an alcoholic" who says, without any intention to lie, "I don't want to drink." One could say there are actually two sub-people here, the one who wants to drink and the one who doesn't. As I recall, Tom Schelling has some papers using this idea.

Similarly, one can speak of different "modules" or sets of synapses in the brain, one of which pushes the body to drink and one of which pushes against drinking. Indeed, many psychologists will say that there is no unitary "real you." There are ever-changing "yous" that result from the interaction of many, many groups of brain cells (though each person has limits to how different the various hes and shes can be).

Michelle Dawson writes:

CYOE is science-based, while being critical of approaches to autism that are not science-based.

In other words, CYOE has nothing to do with Szasz. Not that anyone should have to say so.

Evan writes:
Take someone who is "an alcoholic" who says, without any intention to lie, "I don't want to drink." One could say there are actually two sub-people here, the one who wants to drink and the one who doesn't. As I recall, Tom Schelling has some papers using this idea.

There are people like that. However, there are also people that Bryan describes, who behave oddly because they genuinely want to with all of their being (I occasionally find myself one of them).

In addition, even in the "two subpeople" cases, there is still a nonscientific, moral component of the argument. While the existence of subpeople is a scientific issue which subperson is right is a moral issue. Why is the subperson who wants to drink automatically wrong? Why is the subperson who doesn't want to drink given preference? It is because we've made a moral judgement about mental illness that exists separate from science.

Roger Sweeny writes:
In addition, even in the "two subpeople" cases, there is still a nonscientific, moral component of the argument. While the existence of subpeople is a scientific issue which subperson is right is a moral issue. Why is the subperson who wants to drink automatically wrong? Why is the subperson who doesn't want to drink given preference? It is because we've made a moral judgement about mental illness that exists separate from science.

Definitely. One of the pivots of Bryan's article is the story of how the American Psychological Association turned "homosexuality" from a mental disorder to part of the diversity we celebrate because of a change in moral judgment. It was fairly easy to say that gay people who didn't want to be gay were just reflecting bigoted societal attitudes and the difficulty of being gay in a straight society.

But there is more than societal bigotry when it comes to heavy drinking or ADHD. Many people who drink a lot and say they don't want to are concerned about the money and time that they lose and the things they do when they're drunk, things that may have serious negative consequences for their lives and that they regret later. There is also often a fear that the unitary "I" is not in control, that something unwanted makes "I" do things that "I" don't really want to do.

Many people with ADHD have the same feeling. Some are happy to take medication because it makes them feel more "in control" and they are more productive. Some, on the other hand, resist taking medication--either because of side effects or the fact that they enjoy the hyperness (or because they consider it part of "who I am"). And a third group takes the medication sometimes and doesn't sometimes because sometimes the strongest part of their brain wants to and sometimes not.

Ray writes:

Bryan,

Suppose I am a psychiatrist and someone comes to me to say that he is having trouble in his life because he is feeling down and a few other factors.

Now, in order to help him, I need to figure out what might help. And in order to do that I have to study him and others who are similar. That is how medicine works. But in order to do that I need to create a classification system. What should I call that system, if not a classification of mental illness?

Maybe a classification of general life problems? But that's too broad.

Roger Sweeny writes:

To the extent that "general life problems" can be helped by chemicals that only doctors have access to, and those chemicals can legally only be used to "treat an illness," then I suppose you have to call those problems "mental illness."

If insurance will only pay you for help if that help is to deal with an illness, then I suppose you have to call those problems "mental illness."

Absent legal and reimbursement constraints, there might well be a classification of general life problems. Actually, I suspect there would be many, with areas of agreement and disagreement.

Tracy W writes:

My grandma by all accounts spent 10 years convinced that her husband was trying to kill her. Her husband was a forensic scientist with ample access to lethal chemicals. She suffered no physical effects, stopped believing this when prescribed lithium, and eventually outlived him by 20 years. How is that a case of weird preferences?

I know the "there's no such thing as mental illness, it's all just differing preferences" and I can't disprove the view, but also, confronted with real life cases, I can't believe in that. And plus, we know that every other physical organ in the body can stop working, or work badly, eg eyes, why not the brain?

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