I find this maximalist position that all mental illness is fake to be deeply unpersuasive. I think the crux of this debate is over semantics: what does it mean to say someone is unhealthy or ill? I looked back at the original caplan article and this was how "real" illness is defined:
"How can these conditions be formally modeled? Basic consumer theory makes the answer clear: It shifts your budget constraint inwards....Almost every traditional medical condition one can name can be modeled as an inward shift of one or more budget constraints...Budget constraints shift in for many reasons other than disease. But traditional medical conditions and shrunken budget sets go hand in hand."
"Almost every" eh? So what about traditional medical conditions that can't be modeled as an inward shift on budget constraints? Do they not count either? But why should I accept this definition and does any doctor (the "real" kind) model illness this way? A layman's definition of can be roughly summarized:
"An illness is a condition that affects the body or mind, causing dysfunction, discomfort, or distress. It is a state where an individual's physical or mental condition is impaired or below optimal functioning."
Is this definition vague? Yes.
Does it make it hard to clearly identify when someone is sick or not? Yes, it can.
Does culture and ethics heavily influence what we identify as an illness or not? Sure does.
Ethical judgments are inevitable when determining whether someone is sick and what affordances society gives to sick people. Ask an anti-abortionist their opinion on whether abortion is ever medically justified. How about deaf parents who don't want their deaf kids to get hearing aids because it's "killing" the death community?
The "budget constraint" model would be quite puzzling to use in practice. People claim to be sick when "objective" medical diagnostics finds no evidence of sickness. This doesn't mean there's not a problem, it just means there's no neutral third party validation one can do to prove it. Have you ever had a crippling migraine or debilitating chronic pain? How do you prove that you have it? Well, people have to take your word for it.
Do people lie about chronic pain in order to get prescription meds to get high? Sure. Do I believe there are people with horrible chronic pain that are telling the truth? Yes I do. How do you tell the difference? Well, you need to evaluate on a case by case basis.
I see no difference when evaluating mental illnesses. I’ve had personal experience dealing with loved ones who have had severe mental illness. if you ever interacted with someone who has severe clinical depression, schizophrenia, or bipolar disorder then you know “deep in your bones” that something is deeply wrong. This is very much should i believe your too clever by half argument or my lying eyes.
Ok, but what about adults with an ADHD diagnosis who have a strong desire to take their prescribed adderol/ritalin so that they can concentrate and get their desired work done faster? Wouldn’t that mean they have a preference to have different preferences?
If you have preferences that you prefer you didn’t have, can you really call them your preferences? Seems like a contradiction to use the same word for both.
* "Some are very distressed by how differently their brains work."
Both external coercion and self-diagnosis seem poor tools, and just punishing criminal actions on the one hand or selling people stimulants legally if they want them on the other might be much better. But that doesn't mean that someone who says that he very much wishes he could concentrate as well as his peers is just complaining about his own preferences.
I'm still so confused, sir, by your position on psychology/psychiatry...
On the one hand, you seem to be a fan of CBT and behavioural economics.
On the other hand, you seem to think psychiatrists are a bunch of crooks.
So, you like psychology but hate psychiatry?
It seems the difference: psychiatrists can diagnose conditions and prescribe drugs. It seems that you don't like the diagnosis part because it stigmatizes people and/or gives them an excuse. Is that correct?
Fair enough. But the prescribing part also gives them a way out! If someone wants to like working more and be more accepting of low variety, so they could be more productive and therefore more successful at school or their career wants some help, psychiatrists can prescribe them methylphenidate or hwhat-not.
I long for the day hwhen someone doesn't need a formal diagnosis to access chemicals that help them focus. Maybe they're perfectly normal, but wanna focus BETTER than normal. I would imagine psychiatrists long for this day, too. But in the meantime, isn't getting diagnosed with ADHD and prescribed methylphenidate by a professional psychiatrist a GOOD thing?
Oh, but the ADHD diagnosis also gives them an excuse. A disability that their school/employer has to "accommodate". Fair enough. But shouldn't we look for a key-hole solution? Ban accommodations for such mental "illnesses", not get rid of psychiatry or even the concept of mental illness altogether.
> If alcohol makes people less shy, is that evidence that shyness is a disease?
Once I had a colleague who was quite intelligent ... & stuttered terribly. When properly lit, his stutter disappeared.
Although (pronounced) stuttering is not a disease or mental illness, it is a speech disorder, usually causing some distress to the sufferer. It's hard to see how can it be viewed as a preferred activity (over normal, fluent speech).
You are assuming people are rational and actually take the actions that maximize their utility. That is not true. A big part of mental illness is that it makes people take actions that do not maximize their own utility.
I can make a spreadsheet of goods I can buy and consume, and how much utility they will give me, and produce stats on what to spend my money on to maximize my utility. I do not know things perfectly; if I am comparing two meals I've never actually tried before, I can only guess at which will give more utility. But that spreadsheet will be roughly accurate.
Many alcoholics will correctly predict that consuming alcohol will actually lower their utility, not raise it. Yet they will spend money on alcohol anyway. Why? Your model seems to be they are lying and making excuses for asocial or shameful behavior when they buy alcohol. I disagree, I think it is mental illness/addiction where an irrational portion of the mind overpower the rational portion, and they take action that lowers their utility. I seriously don't get how you can look at an alcoholic whose life falls apart around them due to alcohol consumption and think they're taking the choices that best optimize their utility and that they just have weird utility preferences.
ADHD is similar. I want to sell my labour for money; yet an irrational part of my brain prevents me from actually doing labour. My personal solution to this was to drop out of school and join the military where they will yell at me in the short term if I don't do my work. If I did not have mental illness, it would raise my utility far more to have stayed in school and do easier work that doesn't have people yell at me ever. But part of my brain rebels against my consciousness, so I need to take roundabout routes to raising my utility that aren't the optimal routes a more rational actor would take.
At least alcohol provides transitory pleasure (although even there for a really severe alcoholic it often seems like a pure compulsion with the pleasure a distant memory). Many other mental illnesses are pure hell for the person with the illness as much as for those around them.
Curious what definition of disease Szasz accepts? Given that many adults seek treatment for mental issues, including ADHD, what name should we give those? Is this only challenging when treatment is involuntary?
Psychology is certainly a mix of subjective judgements with a bit of actual science.
I live with two family members who have ADHD and it is not merely a preference. Their minds really do seem to be wired up differently from a typical person, especially when it comes to craving novelty and impulse control. There is a bit of actual science behind understanding those wiring differences.
And I also want to acknowledge that there are probably a lot of people walking around saying they have ADHD just like all the people who say they have gluten sensitivity. However, if you get to know someone who truly has ADHD, it is more than just their personal tastes.
The discussion here is not entirely relevant. The purpose of the classification of ADHD as a mental health disorder is to give individuals access to treatments, as well as a framework to understand their own behavior. The popularity of ADHD as a diagnosis (for both children and adults) is access to highly efficacious pharmaceuticals that are otherwise restricted for mostly political reasons. Undiagnosed ADHD is associated with poor performance in school as well as higher rates of illicit drug use (aka self medication) and higher rates of petty crime. OCD behavior, depression, anxiety, and/or oppositional behavior often occur with it. Most, but not all ADHD cases are believed to be caused by low levels of dopamine in the brain. The term “preference” here is misleading, as most of these outcomes are not preferred by either the patient or the patient’s caretakers (some patients are too young to make treatment decisions themselves).
Bryan does not specifically oppose treatment, though his framing suggests a negative moral judgement on the diagnosis and treatment of ADHD. Treatment of mental health disorders is not different morally than treatment of other physical ailments. I may or may not have a preference for walking, but if I am unable to walk then my ability to function will be impaired. In which case I will seek treatment.
I widely buy the idea that there is a weird over-diagnosis problem in psychiatry, but I find it very strange to boil down the shaking hands and violent mood swings of the alcoholic as he tries to quit cold turkey, as 'a preference for alcohol'. Seems like there's something slightly more complex going on there.
The one thing your analysis misses out is hyper focus. When an activity provides strong stimulus, for whatever reason, I want to keep on doing it. And being productive is by maximising time spent in such activities (that I can hyper focus on)
"Overall, the most natural way to formalize ADHD in economic terms is as a high disutility of work combined with a strong taste for variety"
How do you formalize autism in economic terms?
I find this maximalist position that all mental illness is fake to be deeply unpersuasive. I think the crux of this debate is over semantics: what does it mean to say someone is unhealthy or ill? I looked back at the original caplan article and this was how "real" illness is defined:
"How can these conditions be formally modeled? Basic consumer theory makes the answer clear: It shifts your budget constraint inwards....Almost every traditional medical condition one can name can be modeled as an inward shift of one or more budget constraints...Budget constraints shift in for many reasons other than disease. But traditional medical conditions and shrunken budget sets go hand in hand."
"Almost every" eh? So what about traditional medical conditions that can't be modeled as an inward shift on budget constraints? Do they not count either? But why should I accept this definition and does any doctor (the "real" kind) model illness this way? A layman's definition of can be roughly summarized:
"An illness is a condition that affects the body or mind, causing dysfunction, discomfort, or distress. It is a state where an individual's physical or mental condition is impaired or below optimal functioning."
Is this definition vague? Yes.
Does it make it hard to clearly identify when someone is sick or not? Yes, it can.
Does culture and ethics heavily influence what we identify as an illness or not? Sure does.
Ethical judgments are inevitable when determining whether someone is sick and what affordances society gives to sick people. Ask an anti-abortionist their opinion on whether abortion is ever medically justified. How about deaf parents who don't want their deaf kids to get hearing aids because it's "killing" the death community?
The "budget constraint" model would be quite puzzling to use in practice. People claim to be sick when "objective" medical diagnostics finds no evidence of sickness. This doesn't mean there's not a problem, it just means there's no neutral third party validation one can do to prove it. Have you ever had a crippling migraine or debilitating chronic pain? How do you prove that you have it? Well, people have to take your word for it.
Do people lie about chronic pain in order to get prescription meds to get high? Sure. Do I believe there are people with horrible chronic pain that are telling the truth? Yes I do. How do you tell the difference? Well, you need to evaluate on a case by case basis.
I see no difference when evaluating mental illnesses. I’ve had personal experience dealing with loved ones who have had severe mental illness. if you ever interacted with someone who has severe clinical depression, schizophrenia, or bipolar disorder then you know “deep in your bones” that something is deeply wrong. This is very much should i believe your too clever by half argument or my lying eyes.
Ok, but what about adults with an ADHD diagnosis who have a strong desire to take their prescribed adderol/ritalin so that they can concentrate and get their desired work done faster? Wouldn’t that mean they have a preference to have different preferences?
If you have preferences that you prefer you didn’t have, can you really call them your preferences? Seems like a contradiction to use the same word for both.
It’s an interesting perspective on preferences and how they relate to ADHD medication. Thanks for sharing your thoughts.
Exactly. The homo æconomicus doesn't exist, because we're not one person, we're many.
The following statements can coexist:
* "The mental health field is baloney. "
* "Not every brain functions identically."
* "Some are very distressed by how differently their brains work."
Both external coercion and self-diagnosis seem poor tools, and just punishing criminal actions on the one hand or selling people stimulants legally if they want them on the other might be much better. But that doesn't mean that someone who says that he very much wishes he could concentrate as well as his peers is just complaining about his own preferences.
I'm still so confused, sir, by your position on psychology/psychiatry...
On the one hand, you seem to be a fan of CBT and behavioural economics.
On the other hand, you seem to think psychiatrists are a bunch of crooks.
So, you like psychology but hate psychiatry?
It seems the difference: psychiatrists can diagnose conditions and prescribe drugs. It seems that you don't like the diagnosis part because it stigmatizes people and/or gives them an excuse. Is that correct?
Fair enough. But the prescribing part also gives them a way out! If someone wants to like working more and be more accepting of low variety, so they could be more productive and therefore more successful at school or their career wants some help, psychiatrists can prescribe them methylphenidate or hwhat-not.
I long for the day hwhen someone doesn't need a formal diagnosis to access chemicals that help them focus. Maybe they're perfectly normal, but wanna focus BETTER than normal. I would imagine psychiatrists long for this day, too. But in the meantime, isn't getting diagnosed with ADHD and prescribed methylphenidate by a professional psychiatrist a GOOD thing?
Oh, but the ADHD diagnosis also gives them an excuse. A disability that their school/employer has to "accommodate". Fair enough. But shouldn't we look for a key-hole solution? Ban accommodations for such mental "illnesses", not get rid of psychiatry or even the concept of mental illness altogether.
It's mostly smart that he doesn't read the comments, but it's a shame in this case. He might have chosen to respond to it.
A good chunk of “adhd” is just people’s desire to turn teenage boys into girls and have them sit quietly and do the very unnatural “work” of school
As with many if not most mental illnesses, adults diagnosed with ADHD, or at least those who talk about it online, seem to be mostly female.
Females may be more willing than males to "share" their inner feelings with others. You seem to acknowledge that possibility.
> If alcohol makes people less shy, is that evidence that shyness is a disease?
Once I had a colleague who was quite intelligent ... & stuttered terribly. When properly lit, his stutter disappeared.
Although (pronounced) stuttering is not a disease or mental illness, it is a speech disorder, usually causing some distress to the sufferer. It's hard to see how can it be viewed as a preferred activity (over normal, fluent speech).
You are assuming people are rational and actually take the actions that maximize their utility. That is not true. A big part of mental illness is that it makes people take actions that do not maximize their own utility.
I can make a spreadsheet of goods I can buy and consume, and how much utility they will give me, and produce stats on what to spend my money on to maximize my utility. I do not know things perfectly; if I am comparing two meals I've never actually tried before, I can only guess at which will give more utility. But that spreadsheet will be roughly accurate.
Many alcoholics will correctly predict that consuming alcohol will actually lower their utility, not raise it. Yet they will spend money on alcohol anyway. Why? Your model seems to be they are lying and making excuses for asocial or shameful behavior when they buy alcohol. I disagree, I think it is mental illness/addiction where an irrational portion of the mind overpower the rational portion, and they take action that lowers their utility. I seriously don't get how you can look at an alcoholic whose life falls apart around them due to alcohol consumption and think they're taking the choices that best optimize their utility and that they just have weird utility preferences.
ADHD is similar. I want to sell my labour for money; yet an irrational part of my brain prevents me from actually doing labour. My personal solution to this was to drop out of school and join the military where they will yell at me in the short term if I don't do my work. If I did not have mental illness, it would raise my utility far more to have stayed in school and do easier work that doesn't have people yell at me ever. But part of my brain rebels against my consciousness, so I need to take roundabout routes to raising my utility that aren't the optimal routes a more rational actor would take.
At least alcohol provides transitory pleasure (although even there for a really severe alcoholic it often seems like a pure compulsion with the pleasure a distant memory). Many other mental illnesses are pure hell for the person with the illness as much as for those around them.
I think what you were saying is that I have
Curious what definition of disease Szasz accepts? Given that many adults seek treatment for mental issues, including ADHD, what name should we give those? Is this only challenging when treatment is involuntary?
Psychology is certainly a mix of subjective judgements with a bit of actual science.
I live with two family members who have ADHD and it is not merely a preference. Their minds really do seem to be wired up differently from a typical person, especially when it comes to craving novelty and impulse control. There is a bit of actual science behind understanding those wiring differences.
And I also want to acknowledge that there are probably a lot of people walking around saying they have ADHD just like all the people who say they have gluten sensitivity. However, if you get to know someone who truly has ADHD, it is more than just their personal tastes.
If we allowed people to take Adderall/Antidepressants/etc. without a prescription, maybe we wouldn't need to medicalize the reasons people take them.
The discussion here is not entirely relevant. The purpose of the classification of ADHD as a mental health disorder is to give individuals access to treatments, as well as a framework to understand their own behavior. The popularity of ADHD as a diagnosis (for both children and adults) is access to highly efficacious pharmaceuticals that are otherwise restricted for mostly political reasons. Undiagnosed ADHD is associated with poor performance in school as well as higher rates of illicit drug use (aka self medication) and higher rates of petty crime. OCD behavior, depression, anxiety, and/or oppositional behavior often occur with it. Most, but not all ADHD cases are believed to be caused by low levels of dopamine in the brain. The term “preference” here is misleading, as most of these outcomes are not preferred by either the patient or the patient’s caretakers (some patients are too young to make treatment decisions themselves).
Bryan does not specifically oppose treatment, though his framing suggests a negative moral judgement on the diagnosis and treatment of ADHD. Treatment of mental health disorders is not different morally than treatment of other physical ailments. I may or may not have a preference for walking, but if I am unable to walk then my ability to function will be impaired. In which case I will seek treatment.
I widely buy the idea that there is a weird over-diagnosis problem in psychiatry, but I find it very strange to boil down the shaking hands and violent mood swings of the alcoholic as he tries to quit cold turkey, as 'a preference for alcohol'. Seems like there's something slightly more complex going on there.
The one thing your analysis misses out is hyper focus. When an activity provides strong stimulus, for whatever reason, I want to keep on doing it. And being productive is by maximising time spent in such activities (that I can hyper focus on)
Is PTSD a “real” disease or best conceptualised as a cluster of preferences?