Some years back I met a guy who eagerly billed himself as “the angriest mayor in America.” He was coming to speak to some of our students. He eagerly told me that he hated economists, except this one economist, a guy who unlike all the other economists told it like it really is. He then proceeded to spin some bullshit that, of course, nearly every economist rejects. But he’d found that one guy with an Econ PhD who confirmed his economic beliefs, and that was the evidence he needed to support his claim that he was right and almost all economists were wrong.

Bryan Caplan would surely shake his head in amused or weary acknowledgement of the mayor’s foolishness. And yet Caplan has done the same, in choosing Thomas Szasz as his go-to psychologist. Szasz argued that the mental illness/disease model was wrong, and that “there is no such thing as ‘mental illness’” (source). Although rejected (at least in his more extreme pronouncements) by the majority of the psych profession,* Szasz confirms for Caplan what Caplan wants to be true about psychology. That is, Caplan wants to treat these issues as merely one of preferences.

In its literal meaning of “discomfort,” disease (not at ease) is certainly an apt term for certain mental states. Of course that’s not what we really mean by disease these days, but what we actually mean by the term is, well, apparently there is no consensus on what the term means. We can’t confidently exclude mental states from the category of disease if we can’t even define the term clearly. But this is exactly what Szasz did, because he “refused to define disease because such a definition is inevitably value-loaded” (source). I struggle to imagine Caplan approving such sloppiness in his own field of economics.

But the standard definitions in use tend to say something like

1. An interruption, cessation, or disorder of a body, system, or organ structure or function. …

From that perspective, to say there is no mental disease is to say that there are no states of the mind in which it can be considered disordered in its functioning. But the mind is certainly an organ of the body, and its function can undoubtedly be interrupted, and not just by physical injury. John Nash’s schizophrenia, for example, disordered his mind, interrupting its functioning, and deprived him of years of productive work.

Illness is even harder to identify clearly, because it is distinguished from disease, and generally defined as an internal state, the subjective experience of the individual.

“Illness … is a feeling, an experience of unhealth which is entirely personal, interior to the person of the patient. Often it accompanies disease, but the disease may be undeclared, as in the early stages of cancer or tuberculosis or diabetes. Sometimes illness exists where no disease can be found.

Following that definition, Szasz and Caplan are denying that the individual’s subjective internal experience of suffering has any reality.

Instead, Caplan views these states as merely preferences.

[A] large fraction of what is called mental illness is nothing other than unusual preferences – fully compatible with basic consumer theory. Alcoholism is the most transparent example: in economic terms, it amounts to an unusually strong preference for alcohol over other goods. But the same holds in numerous other cases. To take a more recent addition to the list of mental disorders, it is natural to conceptualize Attention Deficit Hyperactivity Disorder (ADHD) as an exceptionally high disutility of labor, combined with a strong taste for variety.

One has to wonder if Caplan has bothered to ask many alcoholics and folks with ADHD what their preferences are. He might just fall back on the idea of revealed preferences, which is generally useful. But let’s consider John Nash. His effort to dominate his schizophrenia stemmed from his recognition that certain people he saw were not real, but illusions. He learned to ignore them, but he couldn’t get rid of them. Caplan’s approach suggests we should see Nash’s situation as a preference to have ignorable illusory people distracting him than to not have them there at all. We could, I suppose, say that his preferences changed from wanting to pay attention to them to wanting to not pay attention to them, but I don’t think that’s how Nash himself described it.

Or take me. I am bipolar, which causes me to at times be suicidally depressed, and at other times to have a hair-trigger temper that has terrified my wife and my daughters. If those are my preferences, then why do I voluntarily take medication to control them? A revealed preferences approach shows that my preference is to avoid those things, by taking appropriate actions, not that I actually have a preference to yell at my kid or a preference to think about methods of suicide.

It frequently happens that a medication that has been effective suddenly stops working for a person, and their bipolar symptoms return. The only difference in that case is that the person is suddenly taking a placebo, and unknowingly, of course. Can we plausibly say in such a case that the person’s preferences changed, that in some meaningful way “the person,” as opposed to “the chemical makeup of the person’s biological brain” has chosen a different set of preferences?

Caplan takes the easy path, rather than daring to make a hard case, by choosing ADHD. There is widespread agreement that too many kids are diagnosed as ADHD, resulting in the normal activeness of young kids, especially boys, being medicalized. In that sense, while Caplan seems to see himself as taking a bold stance, he is to some extent actually tucking himself safely into popular opinion.

But is his position even true for ADHD? That is, Caplan appears to actually deny the existence of ADHD, rather than seeing it as over-diagnosed. His bold stance is in describing ADHD as merely a “high disutility of labor, combined with a strong taste for variety,” rather than an inability to focus and exercise considered judgement before acting. Before accepting his position, though, I’d like to hear from folks who were diagnosed with ADHD, and get their perspective on whether they just had a preference for variety and no work or whether they wished they could have focused better.

We have a friend whose teenage son is a competitive swimmer and hyperactive (meaning the term only in comparison to most other kids his age). He recently started taking medication and has been able to focus better, and his swimming has improved considerably. Caplan’s approach requires us to believe that his actual preference was to not be able to concentrate for the length of a 200 yard swim, and that if his preference changed, then he just needed to exert more willpower to make it happen, no medicine necessary.

Or as a commenter on Caplan’s post snarked,

I’ve always thought Alzheimer’s just amounted to a strong dispreference for forming memories.

Caplan pretends–and I use that word deliberately–that he is trying to destigmatize ADHD and other mental states.

labels like ADHD medicalize people’s choices – partly to stigmatize, but mostly to excuse.

He forgets, or deliberately rejects, the word “explain,” and the ultimate effect is to stigmatize. His use of the word “excuse” is stigmatizing in itself. His assumption that ADHD people just lack willpower, although politely stated as recognition that it’s harder for them than for some other people, is also stigmatizing, because it suggests a personal failing for which they are making excuses.

This subject hits very close to home for me, because there is a contingent of anti-pharma folks out there, inspired by Szaz, who are encouraging people with mental illnesses–people with internal mental states which cause them to feel unhealthy–to avoid pharmaceuticals. While there is little doubt, I think, that pharmaceuticals are over-prescribed, and while there is, I am certain, too little recognition that there are no magic bullet medications and that there are some real dangers associated with some medications, people who advocate general avoidance of medications are asking people to take an even greater risk. Without medications I possibly would already be dead. If alive, there’s a good chance I would not be able to hold down a steady job, and would be living in poverty. If this were 80 years ago, I might, like my grandfather die in a mental institution. The same is true for my sister, who has had trouble with medications suddenly ceasing to be effective, and who barely manages to function at times despite taking medication. To think that all she has to do to be happier in life is to change her preferences, and just stop preferring to be so fucking miserable!

The brain is, after all, a big bag of chemicals, as is the rest of the body, and so there’s no reason to think the functioning of that bag of chemicals can’t be disordered, can’t end up functioning in a way that is harmful to the person’s interests and preferences. Nobody claims that a diabetic has a preference for not producing insulin or for not using it effectively to manage sugar levels. And yet Caplan is implicitly arguing that I have a preference for my brain producing or handling chemicals in a way that causes me to be so deeply unhappy that I think about ending it all to avoid the pain.

I don’t take medicating lightly. Given that my bipolarity is genetic–my sister and I are at a minimum the third generation–and that I see similar symptoms in my daughter, I expect she will eventually need medication. In fact I think she needs medication now, but I am very reluctant to medicate an adolescent, because the brain chemistry is different and the brain is still developing. As a parent, I’m torn between harming her through action and harming her through inaction. There’s more complexity in this than the anti-med folks realize.

But this is the perspective that Caplan bolsters, because he’s enamored of a crank in a discipline that is not his specialty, who not coincidentally happens to reinforce Caplan’s own preferences.

Caplan’s an oustanding economist, and I benefit from reading his essays. I highly recommend his book, The Myth of the Rational Voter. But he’s out of his depth here. I suspect that he has no experience with the problems many other people face, and there’s a distasteful intellectual hubris in assuming he can diagnose all of them, sweepingly, from afar.
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* At least as far as I can tell from some cursory research.