Is Mental Illness Merely a Social Construct?

Caplan on socially disapproved preferences

Bryan Caplan writes,

I take the Szaszian view that most so-called “mental illnesses” are not illnesses at all, but socially disapproved preferences.

Later, he writes,

If any incentive in the universe makes you stop, you must have been able to stop all along. Incentives matter implies voluntariness implies preference implies non-disease.

I want to suggest a distinction between “incentive” and “treatment.” An incentive is a reward or punishment. A treatment is a an attempt to change how one reacts to situations, using a medication, counseling, cognitive behavioral therapy, a substance abuse program, or something along those lines.

For what most of us call mental illness or what Caplan wants to call socially disapproved preferences, either an incentive or a treatment might prove effective at changing behavior. I think that it is important to allow for treatment as a separate concept from an incentive.

Let us work with some examples.

First,

Samuel Brinton, who is nonbinary and uses they/them pronouns, was given a 180-day suspended jail sentence for lifting a woman’s suitcase from Las Vegas‘ Harry Reid International Airport in July 2022, according to court records obtained by Fox 5.

I take it that it is unlikely that Mr. Brinton stole the suitcase out of need. It is more likely a symptom of mental illness socially disapproved preferences.

I can imagine giving Mr. Brinton a strong incentive not to steal a suitcase, and that could work. I can also Mr. Brinton undergoing psychiatric treatment to try to change his propensity to steal suitcases, and that might work.

Second, suppose that a child cannot seem to focus. In school, his inability to stay on task adversely affects his performance and that of his classmates.

I can imagine giving the child a strong incentive to stay on task. I can also imagine giving him adderall to treat his ADHD. I have seen parents try all sorts of incentive systems, including charts and treats. They had much more success with adderall.

Third, the late Jordan Neely was acting out socially disapproved preferences on a subway when he was subdued by other passengers, ending with his death. Perhaps strong incentives could have deterred him from yelling and making violent threats. But it seems that his behavior under treatment had been better.

Caplan’s position appears to deny the significance of what I am calling treatment. Even if treatment can sometimes (not necessarily always) be effective, his criteria do not allow one to apply the term “illness.” Instead, only if there is no chance whatsoever that any incentive will work might we label behavior mental illness rather than socially disapproved preferences.

I do not think that the game Caplan is playing with definitions is going to persuade someone who disagrees with him. Using the label “socially disapproved preferences” does not eliminate the real issues involved. In practical terms, two types of claims are important.

1. What most people call mental illness and what Caplan calls socially disapproved preferences can sometimes be altered by using treatment.

2. Other people have the right to impose treatment on someone. They might use strong incentives or threats for this purpose.

My examples illustrate why I believe that (1) is true. For (2), we are talking about a philosophical issue, particularly for libertarians.

In the case of the luggage thief, I don’t think that a libertarian should let that socially disapproved preference to take other people’s stuff go unchecked. I think we have a right to try to stop his behavior. Do we have the right to send him to prison? If so, then how do we not have the right to insist that he obtain treatment?

In the case of ADHD, I do not believe that anyone other than the child’s parents should actually force the child to go on medication. But I think you have to allow a school to tell parents that the child cannot continue to attend without obtaining treatment. That means that I am condoning a form of social coercion.

In the case of Jordan Neely, I believe that everyone would be better off if the state had succeeded in coercing him to remain in treatment. You have to be a really hardcore deontological libertarian to believe otherwise.

Caplan has a sufficiently restrictive definition of mental illness to make it seem as though it is merely “socially disapproved preferences.” But he cannot define away the question of whether someone with “socially disapproved preferences” should undergo treatment. There remains the philosophically fraught issue of the extent to which others are entitled to force such treatment on such an individual.

Substacks references above:

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The Szaszian Fork: Another Reply to Scott Alexander on Mental Illness