Caplan and the Crank; or Don’t Touch My Meds, You Bastard

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, which resulted 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.

_____________________
* At least as far as I can tell from some cursory research.

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About James Hanley

James Hanley is Associate Professor of Political Science at Adrian College and a Fellow of the Institute for Social Policy and Understanding. The views expressed here do not reflect the views of either organization.
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9 Responses to Caplan and the Crank; or Don’t Touch My Meds, You Bastard

  1. lancifer666 says:

    While I have not been “formally” diagnosed with ADHD I have many of the symptoms. My doctor is not the pushy type and once handed me a pamphlet listing “ten signs you have ADHD”. I thought six sounded like me and my ex-wife said two of the others did as well.

    While you have discussed the meaning of the words disease and illness the last “D” in ADHD stands for disorder. I have never had any treatment for ADHD. I have also been prone to depression in the past, but luckily have not experienced it in the last ten years. I have taken anti-depressants and found them to be numbing at best and some of them had side effects that were worse than the depression! I’m glad that I have been free of that life sapping condition for so long.

    I think Caplan is being too cavalier in dismissing mental illnesses as mere preferences, but I do sometimes wonder if the current medical establishment is trying to force these various “conditions” into pre-set categories that over simplify and perhaps mislabel a range of human mental states as “diseases”.

    Perhaps pharmaceutical treatment for ADHD would alter my mind in ways that would increase my productivity with work related tasks and make me “fit in better” in social situations, but at what cost to my creativity and adventurous spirit? How much of my behavior is due to a “disorder” and how much is due to my personality? (Or as you’re no doubt thinking, just being an asshole.)

    James, as you know by now, I don’t think and act like “most people”. Is that a “disorder” or just who I am? I’m sure that altering my non-standard social behaviors would have financial and social benefits, but at what cost?

    Would I still be me? Would it be someone I even want to be?

    Have you read the materials that accompany your anti-depressants? They say things like “it is believed that…” or “…works, possibly by…”. The truth is that researchers aren’t completely sure how antidepressants work. There’s just a lot we don’t know about how the brain functions.

    In the case of severe depression there is little reason not to take anti-depressants, the condition itself is so bad that some adverse side effects are worth the risk. The only questions are which one and for how long.

    For “disorders” like ADHD it may be a different story. As you said the brain is a bag of chemicals, but it is a very complex bag of chemicals and what is going on in there is who we are. Probably best not to screw with those chemicals unless the benefits out weight the risks and losses.

  2. Jonathan McLeod says:

    Fuck yeah, James.

  3. James Hanley says:

    Lance,

    You’re functional. Your “condition” (assuming that’s a purely descriptive term and has no implicit value connotations) probably makes some things a bit harder to do and other things a bit easier to do. That is, it’s probably like my daughter’s hypermobility, which makes it easier for her than for me to do the butterfly stroke, but has also caused her a lot of pain.

    I think it’s normal to define a “disorder” from a social perspective, but I think it’s probably better to do it from a subjective personal perspective. In one of Oliver Sachs’ books he talked about a guy with, iirc, Tourettes. In some ways it really messed with his life, but it also seemed to help him become a really good drummer, and the meds he took to control it ruined his drumming. So he eventually found a way to manage it pharmaceutically during his regular work week, but go off the meds for the weekend when he was playing.

    For me, being a walking bundle of rage and depression has far more downside than upside. For me, whatever additional creativity comes from it does not remotely compensate for being alienated from the people I love. I remember my uncle, my dad’s brother, bitterly complaining that everyone he’d cared about had left him. And I could see myself becoming the same bitter lonely old man.

    You’re right about the side effects of drugs, obviously. It took a while to find one that worked well for me. The first one did nothing. The second one made me happily unconcerned about anything and astonishingly forgetful–I forgot about appointments, assignments, the backpack I’d set down beside my chair, etc. etc. Of course forgetting everything didn’t really bother me because the drug did a great job of making me feel good, but it was totally unworkable. The third one kept me from being really depressed or temperamental, but robbed me of any real feeling and of sexual desire. The fourth one worked well, with no side effects, and has been working well for a couple decades. One of my biggest fears is that it will stop working, as happened to my sister. That was a hellish time for her.

  4. I might be ADHD and might not. By now there’s so much nurture and adaptation overlaying nature that the question is pretty much moot.

    My sons? Very different story. One example that really brought the matter home to me was when one of them was trying to do arithmetic homework in (IIRC second) grade. He would start a problem, get partway in it, lose track of what he was trying to do, reset, loop. He knew how, he wanted to do it, and couldn’t keep focused for more than twenty seconds straight. He wanted to do that homework so badly it left him in tears.

    A few decades later he has degrees in physics and electrical engineering, minors in math, etc. He also takes stimulants that make it possible for him to pay attention — and would dearly love to stop but trials show that would be a Really Bad Idea.

    So when someone tries to tell me it’s “expressed preferences” I tend to get just a bit short.

  5. lancifer666 says:

    James,

    I’m glad you found one that works for you. While my depression was never diagnosed as “bipolar” I would have some of the same symptoms you describe; I would become very agitated and angry for a period of time and then slide into a deep depression that would last for weeks. It took a huge toll on my first marriage. Luckily for me, and Kidist, I have not felt myself returning to those dark times.

    As far as being “functional” I am sure that my lack of organization and the ability to finish tasks I have started (usually because I have been distracted into starting a completely new and equally demanding task) has kept me from completing my long term goals or even formulating a coherent set of long term goals. I see people in the math and physics department that I know are less talented than I am achieving their goals and making much more money than I do (not that I measure success in terms of money) and I wonder if my resistance to seeking treatment for ADHD was a good idea.

    D.C. Sessions,

    It’s great that you were perceptive and attentive enough to catch your sons ADHD and have it treated. I was a precocious kid, but I couldn’t force myself to sit for an hour and do my homework. My parents noticed the problem but I managed to do well in school despite the inability to sit and study for long periods of time so they didn’t worry too much about it. Also, it was over thirty years ago and I don’t think there was much known about ADHD at the time.

  6. Ross says:

    I think you over-read Bryan’s use of the economic term “preference”. It’s not the same as “enjoy”. It’s simply a term that indicates there is a distinction between whether the alcoholic “chooses” to drink and whether the cirrhotic “chooses” to develop portosystemic venous shunting. The former actually requires a choice by the alcoholic. The latter is a pathophysiologic consequence of liver fibrosis, and will occur independent of the will of the cirrhotic.

    The claim that X is an unusual preference does not mean one enjoys it any more than the “preference” of a prisoner to not actively engage in escape means he “prefers” to be in prison. But we wouldn’t deny the prisoner COULD, if he really wanted, make stronger efforts to escape. Neither Bryan nor Szasz ever argue that because ADHD isn’t a “disease” (or, more neutrally, is more productively viewed as not best studied using the disease model) that ADHD is no big deal, or that people who have ADHD aren’t suffering or have only themselves to blame. Being unable to balance one’s checkbook causes suffering and is not a disease, and it would be churlish to say someone who has difficulty learning how to do it has only themselves to blame.

    Now, if you believe that there is no such thing as free will, that people are not free agents, and that diseases are best viewed as anything that makes people feel bad, Bryan and Szasz’s critique is lost on you. But it does not follow that they haven’t thought carefully about the topic or that they are uncaring, or (in Szasz’s case, a practicing psychiatrist for many decades) that they’ve never met anyone who had these “diseases”.

    I’ve said more than I intended. Nothing above is meant with ill feeling and I’m sure you’d rather not have the problems associated with ADHD. I’ve said my piece, so I won’t respond further. Thanks for allowing me to comment on your blog.

  7. James Hanley says:

    Ross,

    Caplan strips the “prefer” out of preferences, making the concept incoherent.

  8. Kim says:

    lancifer — bipolar folks aren’t put on anti-depressants.

    James,
    I was diagnosed with ADD as a child (you’ll notice you don’t hear much about that diagnosis anymore…). I was subsequently and deliberately dosed with a formulation of Ritalin specifically designed to suppress my sexuality (which, while it might have resulted in some attention-seeking that certain people found troublesome, was not in fact disclosed to either myself or my parents. Likely the doctor decided that “make the problem go away” was easier than a frank discussion with my father).

    My experience has little to do with you — and the people I know who you’d probably describe as “high functioning bipolar people who don’t take medication.”

    People like Caplan are overstating a simple “Maybe we don’t need to medicate Everything” into “Everything is Happy and Good” — no, even if you don’t get any medication, it is still useful to explore coping mechanisms — and to do that, you have to be willing to say “It’s a little bit weird that I have this persistent urge to lick my hand like a cat or bark like a dog at everyone I see” [medically induced Tourettes sucks]

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