May 24, 2021, 05:57AM

Clinical Psychology is Definitely Not a Science

Perhaps we should think of psychology as one of the arts or humanities.

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Psychology's pretensions to science have always been problematic. Freud claimed that the Id was a scientific discovery, and the Oedipus Complex. Jung thought the same about "archetypes" and "the collective unconscious." Those theories were interesting and fun. It may even be that they were useful therapeutically and helped people feel better, though I doubt that. But they were far from anything that could plausibly be regarded as a science. Rather, they're literary tropes or flourishes: big myths or little metaphors. You aren't going to find that Id in an MRI, and we haven't yet developed instruments capable of detecting the collective unconscious, floating around us like an ethereal weather system.

We've had a century of psychology since Freud and Jung, but it hasn't gotten any more scientific. Nothing could be more obvious, which makes the persistence of the pretension puzzling. If psychology is supposed to be a science, it's a ridiculous flop.

Psychology, that is, needs therapy. Begin with the basic ontology: when psychologists talk about "disorders" (the preferred term now, as opposed to illnesses or diseases), what are they talking about? Here's a problem: they've really got no idea, and in many cases what they’re talking about can't possibly be the kinds of things psychologists think they are. Psychologists have certain talents, and if they’ve dedicated themselves to reducing human suffering, that’s admirable (if they were, or are, actually reducing human suffering, that would be, or is, even more admirable). But they are, demonstrably, not capable of clear reflection on the basic conceptual underpinnings of their discipline.

Let's talk about the Diagnostic and Statistical Manual, 5th ed (DSM-5), the standard reference work for diagnosing psychological disorders in all their myriad permutations. The book characterizes one broad category of disorders as "neurodevelopmental." The 20-odd variously overlapping difficulties enumerated include "Language Disorder," which is to be distinguished, for example, from "Social (Pragmatic) Communications Disorder," "Unspecified Language Disorder" and other deficits. Each is amorphous in multiple dimensions, each is a matter of degree, and each overlaps with the others.

It's a mess, and figuring out whether your kid has Pragmatic Communications Disorder or, rather, Unspecified Language Disorder is not only impossible by the criteria given in the DSM, it's useless in figuring out what to do about the apparent problem. It's definitely nothing like distinguishing diabetes from hepatitis, for example. You could diagnose the latter by lab tests, by directly measuring physical facts. Psychology is operating in an entirely different field with entirely different methods.

Now, the detailed impressionistic eclectic incoherent mess given in the DSM's detailed characterizations of various conditions possibly constitute a fixable problem: perhaps the APA could hire a logician or something to clean them up or get them into a coherent relation to one another. But the basic conceptual difficulties, or I might say the basic fabrications, run a lot deeper and structure the entire discipline.

Consider, for example, the criteria for diagnosing Attention Deficit/Hyperactivity Disorder (ADHD). Typically among DSM disorders, it's described in terms of a mass of various behaviors and internal mental processes. The DSM criteria don’tdistinguish those who have ADHD from those who don't in any clear way, even though it seems to give a little checklist. "The" "disorder" ends up being defined disjunctively and only by symptoms: a person with ADHD acts like this, or like that, or like the other, to a certain unspecified degree of intensity.

But consider the fact that ADHD, like dozens of other alleged problems is characterized as a neurodevelopmental disorder."ADHD" as a concept didn’t emerge from neurological research. It emerged from school behavior problems. It’s not reliably detectible by scanning or measuring neurotransmitter activity. That it is a neurological disorder is not, evidently, a result emerging from research, and I think it's unlikely or impossible that the alleged neurological condition can be detected physiologically. So why would you stipulate that it exists at the outset? Whatever that is, it's not any sort of science.

The claim that ADHD and all the rest are neurological disorders is a hope, an assumption, a hypothesis. Psychology and neuroscience are very far from discovering brain conditions corresponding to the sprawling impressionistic overlapping folksy diagnoses available in the DSM. The claim that these disorders are neurological is a claim by psychology to scientific status. But it's entirely disingenuous, and brain research had nothing to do with the definition of ADHD, which is only characterized in terms of behavioral problems.

Apologizing in advance, I’m going to do a little philosophy. Every time any person fidgets or their attention wanders, there are presumably things going on in the brain. That is, every fidget and every daydream that any person has at any particular time has some sort of nervous-system correlate. I think we’re physical organisms, in other words, and it's true that physical organisms can be described, even fully described, by science. So, anyone who displays any of the many symptoms associated by the DSM with ADHD at some particular moment is in some sort of neurological condition that partly explains why they display that symptom. Philosophers might say that each token psychological state of a particular person at a particular time is identical to a physical condition of their brain at that time.

But the claim that the DSM makes so blandly and with no justification for ADHD and all the rest is much stronger. It claims there’s a general kind of neurological condition that’s shared by all the people who display some of the following symptoms to a certain degree of intensity. Philosophers call this sort of view "type identity": on a type identity theory, it seems that there ought to be a neurological structure or sequence common to everyone experiences love, for example, or anger, or everyone who adds 2 and 2 and gets 4. This is to be true, but in any case it’s an empirical hypothesis that could only be sustained by a very detailed research program.

Love is one thing, however, and ADHD is something else. A person with ADHD displays at least six of nine varieties of inattention (frequently, to an intense degree, since we all display all of them on a given day). For example: "often loses things (keys, eyeglasses, mobile telephones)." Also, the ADHD sufferer displays at least six of nine varieties of "impulsivity" ("unable to play quietly," for example). Also, several symptoms must’ve emerged before age 12, and be displayed in various settings. Also, the symptoms must not be better explained by another of the many disorders to which the DSM makes them potentially relevant (that is, with which ADHD overlaps).

Whatever I just described, it can’t possibly be a single sort of brain structure that all the ADHD people display. There’s no reason to think that it is, first of all: no research supporting the claim that I can find. And the massive disjunction of possible symptoms on which the definition is based make it implausible to look for any particular brainish correlate that all the disordered people might have in common. Looking for the common brain state that explains Betty's fidgeting or being "driven like a motor" and the fact that Veronica has misplaced her phone again: it just doesn't eyeball promising.

Anyway, the diagnosis doesn't make use of neurology at all, and the claim that this is a neurological disorder is completely speculative and unlikely to be true. The reference to neurology is merely a claim to authority, an assertion of scientific status, a grab at prestige that can’t possibly be maintained.

Psychology isn’t any sort of science. On the other hand, we're not going to be able to stop trying to figure out who we are and why we act as we do, so psychology can’t be entirely abandoned. And even in its terrible conceptual confusion it sometimes helps people. Perhaps we should think of psychology as one of the arts or humanities. Interpreting someone's identity and behavior is more like interpreting the Renaissance or a novel than like dissecting a brain. It's more like painting a portrait than detecting a cancer.

Psychology might persist, but not as a science. If you want it to be a science, you'll have to do much better on the conceptual level. Until you do, pipe down.

—Follow Crispin Sartwell on Twitter: @CrispinSartwell


  • . Dr. Sartwell would benefit from reading the book the he criticizes. He casually mentions that the term "mental disorder" is now preferred to talk of mental disorders as "illnesses" or "diseases". However, Instead of examining the definition of mental disorder provided in the DSM-5, or the philosophical and theoretical literature the decision was based upon, he attributes the preference to philosophical confusion. In fact, there has been a robust interdisciplinary debate for many years about the status of mental disorder and its ontological status. It is a major topic in the philosophy of psychiatry, a subdiscipline that Dr. Sartwell appears ignorant of. (It is worth noting, in passing, that Dr. Sartwell's apologetic philosophical excursion into type-token identity reveals either his ignorance of how complex the theory is and the extent to which it has been criticized within the philosophical community, or his willingness to rely on questionable claims .) Dr. Sartwell's apparent difficulties with reading his source material, the DSM-5, becomes even more problematic when he shifts to discussing "Neurodevelopmental Disorders" and ADHD. He very clearly did not read the summary or definition of the category before taking the time to criticize it. I cannot tell from Dr. Sartwell's writing precisely what he means by neurological. However, I am confident in asserting that nowhere does the DSM-5 make the claim that Neurodevelopmental Disorders are neurological in the way he asserts. With respect to his claims about Attention-Deficit/Hyperactivity Disorder (ADHD), Dr. Sartwell's claims are an embarrassment. Without going into unnecessary details, he misunderstands the diagnostic criteria that he does report and neglects to include essential elements. The first criteria for a diagnosis of ADHD (there are many) is Criteria A. It requires "A persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterized by (1) and/or (2)". Notice the "and/or". Individuals may be diagnosed with ADHD based on the presence of only inattentive symptoms, only hyperactive-impulsive symptoms, or both. Dr. Sartwell's summary indicates that both categories of symptoms must be present. The numbers (1) and (2) in Criteria A refer, respectively, to criteria for identifying whether the threshold for inattentive and hyperactive-impulsive symptoms are met. The criteria for "Inattention" is that "Six (or more) of the following symptoms have persisted for at least six months TO A DEGREE THAT IS INCONSISTENT WITH DEVELOPMENTAL LEVEL and that negatively impacts directly on social and academic/occupational activities. Similar limiting language is included in the criteria for "hyperactivity-impulsivity". Dr. Sartwell is absolutely correct that most of the behaviors listed as symptoms are relatively ordinary human behaviors. However, the frequency with which people do the behaviors varies dramatically by developmental level. There are objective measures age-normed on the general population that are used in assessing whether the listed behaviors fall within the norm. There are also similar measures used to assess functional impairment. Not all clinicians use such tools, but that is a separate issue. It is not surprising Dr. Sartwell is ignorant of the tools used in formal psychological assessment since he is not trained as a psychologist, and apparently did not bother to research the subject. This lack of training is at the core of his difficulty. The DSM-5 is the equivalent of a dictionary. If he had reviewed its history (or read the introduction), he would have realized that the Diagnostic and Statistical Manuals were developed to provide clinicians with a common language to communicate. The meaning of various terms, the techniques and criteria for establishing diagnoses, those are determined by community practices that govern how the criteria are applied. If Dr. Sartwell had taken a charitable stance, he would have recognized that reading (or, more accurately, misreading snippets of) the DSM-5 does not make one able to diagnose any more than reading a textbook on surgery prepares the reader to perform surgery. Dr. Sartwell indicates that there is no evidence of "a single sort of brain structure that all the ADHD people display". This would be relevant, except that neither ADHD or any other mental disorder are defined in terms of common brain structures. (Besides, the idea that all members of a category do not necessarily share a single property should not be a novel concept to a philosopher.) The characteristics shared by individuals with ADHD are difficulties with executive functioning, working memory, behavioral inhibition, set shifting, etc., all concepts familiar to anyone working in cognitive psychology or neuroscience. These concepts are meaningful and have a very well-established basis in research. The symptoms Dr. Sartwell challenges are considered consequences of underlying deficits. If enough of the symptoms are present, it is reasonable to infer the underlying deficit. The argument from observable symptoms to an underlying cause is a pattern of reasoning found all across the medical and scientific disciplines. It is near the end that Dr. Sartwell's returns to one of his fundamental errors. He asserts, "Anyway, the diagnosis doesn't make use of neurology at all, and the claim that this is a neurological disorder is completely speculative and unlikely to be true". Despite its rhetorical bite, Dr. Sartwell's conclusion is aimed at a straw person. He is the only one that has asserted ADHD is a neurological disorder. What is saddest about Dr. Sartwell's argument is that so many of his mistakes could have been avoided if he had bothered to read more than a paragraph.

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  • You're looking squarely at the DSM-5 and claiming that it does not assert that ADHD is a neurological disorder? That really is a more subtle reading.

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  • PS The whole "executive function" type picture is just ridiculous: half-assed Descartes or Kant slapped onto brains.

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  • It pictures human mental life as a hierarchical political system. Y'all are so entirely and so completely unconscious of what you're doing and why. Let's diagnose!

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  • Having a common vocab is of questionable value if the words fail to signify.

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  • I’m disappointed by your responses. I’ve read some of your academic work and expected more from you. You very obviously have not seriously engaged with this literature. - The conclusion that the DSM-5 does not claim ADHD is a neurological disorder is not a subtle reading. It is a reading that takes the text at its face value. Neurodevelopmental does not mean “neurological.” The closest you get to neurological claims would be the Neurocognitive Disorders, but even then the distinction is clear. At a clinical level, the distinction is also clear. Neuropsychologists assess neurodevelopmental and neurocognitive disorders and neurologists assess neurological disorders. (If I am incorrect, please point me to what you are referring to in the text (and how you interpret that consistently with the definition of the category that beings the relevant section.) - I can hardly make sense of your comment framing executive function as “half-assed” Descartes or Kant. I’m also lost as to the role you seem to attribute to executive functions and the unconscious. The unconscious, at least not in the Freudian sense you seem to refer to, is not a concept you find in cognitive science. If you are working from a Freudian framework, conceptualizing the mind as a hierarchical political system does not make much sense because the conscious does not control the unconscious in the way you suggest. If you are using a cognitive science framework, which is the framework that the concept of executive functioning applies, then the analogy to a political system makes no sense. All I can imagine is that you didn’t bother to look up the meaning of “executive functioning” and went with your instinctual interpretation given the word “executive”. - The one point I would agree with you is that cognitive psychology and cognitive science assume a Cartesian framework and that is problematic. - Your last comment is the most confusing. A common vocabulary would be problematic indeed if the words failed to signify. However, the words clearly signify and have meaning relative to lots of social and legal practices. I suspect you meant to say that the vocab is of questionable value if the words fail to refer. However reference, as you well know, is not a simple concept. Besides, it would bring us back to your assumption that ADHD is intended to refer to a specific neurological condition in the brain rather than concepts used in cognitive science that address the interaction with the brain, world, and culture. Incidentally, the relationship between ADHD and the brain is multi factorial and only partially understood, but we do have some understanding. For example, one of the reasons for the current increase in diagnosis of ADHD is the fact that babies are being born more premature than in the past and are surviving due to advances in medical science. This is relevant because the prefrontal areas are the last to develop and the most vulnerable to injury. There is a direct correlation between infant prematurity and the likelihood of ADHD. The current thinking is that this is because underdeveloped blood vessels burst and there is micro damage to the prefrontal cortex.

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  • This is a well thought-out essay making valid points.

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  • Well, to show that prematurity is correlated with ADHD, you'd have to have some notion of what ADHD is. An aspiration for the discipline.

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  • Interesting recent piece suggests renaming it: https://www.scientificamerican.com/article/we-need-to-rename-adhd/

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