Deconstructing power imbalance in psychology
Psychology has been a noble profession in some ways, and quite murky in others. While our aspirations have generally been laudable, our actions can be more problematic. Psychology has often taken advantage of restricting, manipulating, and interpreting science to suit ideas of how the people with power believe things should be. Science requires theory. If your theories are biased, your measurements, results, and interpretations will be, too.
Actually, that’s misleading. There is no science without bias. Science necessarily involves asking questions, and asking questions requires a context or framework to ask it in. Who creates that framework? Not science. Scientists do.
The Mental Status Exam
Way back in the history of psychological assessment, before Beck inventories, inkblots, and IQ tests, there was (and, still is) the Mental Status Exam (or MSE, as it’s commonly known). The MSE is not like other exams: there’s no studying, no lectures – for the person being tested, that is. In fact, it’s the type of exam that you may not even know has happened. The MSE is an expert opinion. If you read 19th century psychiatric hospital clinical records, you will find these exams throughout. I’ll describe what these tests are like now in a moment. A good place for information on past practices is the Museum of the Mind at Bethlem Royal Hospital, just outside London, UK. I’m sure there are American resources as well, but this one I’m most familiar with. The main thing to know is that the MSE is mostly observation, interpreted by a trained clinician.
MSE and Power
To understand how the MSE enforces power imbalances, let’s examine how and why it’s used. The MSE was one of the earliest tests, and this placement continues today by being the clinician’s entry point into the relationship. In order to know what to ask, what other assessments to give, and what may be causing this person distress, the clinician first looks and listens. Sounds great, right? And it is. Look at the person’s body language. Listen to the content, tone, and context of the person’s words. Take in information before presuming to deliver it. Graduate school trainers understand that the clinician’s personal biases affect this process. What they have not recognized is that the training’s cultural biases, and biases of the assessment process itself, are also part of our interpretations.
Some trainers don’t even like to acknowledge that psychology, in fact, requires interpretation. I remember a CBT trainer in graduate school who admonished me for using the word interpretation – “Interpretation is what psychoanalysts do. CBT is objective and just looks at observable facts.” However, a fact in one context may be an error in another. Sure, you can stick to fact and say something like, “The right side of their mouth curved down 14 degrees, and the left side at 10 degrees, for a 15sec period of the session when they had paused without having a question to respond to.” Okay… so what? You can see the trade-off. The more factual, the less useful.
Psychology involves context
We need context. Is this a sad frown? Or wistful? Is the person bracing for judgments anticipated to come from the clinician? Is this a common expression for this person, just today, or just this meeting? Did the clinician miss a devious twinkle in their eyes? These are just a few of many potential contexts. Context is crucial if you want to find any meaning in the expression. And the MSE demands this meaning. When writing the MSE, you give interpretations: was the person’s mood depressed, manic, or euthymic (a placid state)? Was their affect full, constricted, blunted, or labile? You can only answer with an interpretation, which is based on personal experience and knowledge of the other person’s experience.
Components of an MSE
Over the decades, a simple interpretation of how put together a person was grew into a lengthy overview. The clinician looks at mood and affect; awareness of who, when, and where they are; alertness; the content of the person’s words; attention and processing of input; sensory inputs. The clinician judges their intelligence, their judgment, their impulse control, and their “insight” into illness. All of these, involve interpretation and bias. But I believe the assessment of insight goes way beyond the rest. Not only is it a thoroughly useless construct, but its main function is to create a power differential. As a result, it’s one that I do not use anymore in my own professional practice.
Insight
What is insight? Essentially, this assessment aims to understand how well the person understands what they are going through. Okay, that sounds important, right? The more you understand about your obstacles, the better positioned you are to tackle them. If I had a time machine, and could jump forward and talk with the future, well-adjusted (for lack of a better word) version of the person I’m treating, then perhaps this could be useful. How well does their perspective now match their perspective when things are working? Sadly, I do not have a time machine. Even worse, that’s not how insight is used. The target is not the person’s perspective. It’s mine. I’m supposed to believe that I know best about how you (yes, you) should understand yourself and your experiences. And if you disagree with my take, well, you lack insight.
You know the joke about how psychologists are always going around analyzing everyone? I dislike that joke, but I have to admit: maybe people would stop telling it if we stopped doing it.
But wait, you say. Haven’t you trained to know what’s going on when things aren’t working? Yes and no. I’ve trained to know how humans learn and grow. How we interact with our environments and each other; how we misalign and hurt each other. I’ve trained to know how to listen. Those are all structures, contexts. What I’m not trained on is content. I have not learned how you specifically have taken what you’ve been through and created meanings. That’s not possible, of course. Even for a friend, it would be an approximation.
Why pretend to know what we don’t?
The only way to explain why insight is in the MSE is to look at what Dr. Sue et al. (2024) call “the four legitimizing pillars” of a white epistemology of psychology. Namely:
- 1) Universalism over relativism: western psychiatry’s perspective on what you’re going through is the perspective
- 2) Individualism over collectivism: your understanding of what you’re going through is solely a product of you, and not connected to cultural norms and biases
- 3) Objectivism over subjectivism: the illness I have ascribed to you is an objective truth and therefore a primary target of treatment; deviations from this truth are subjective, and therefore less legitimate. And,
- 4) Empiricism over experientialism: if you cannot prove your perspective to me, it is not real.
You know the joke about how psychologists are always going around analyzing everyone? I dislike that joke, but I have to admit: maybe people would stop telling it if we stopped doing it.
Let’s divide these pillars in two. Individualism and Empiricism are not wrong; in fact, they are quite important to building wellbeing. You do play a role in what you go through, and a central role in creating a meaningful life for yourself. Also, valid, reliable data is a crucial backbone for expanding knowledge. At the same time, I remember an even earlier scolding, from a middle school science teacher, of any time an answer had a “naked number.” In other words, without its unit label. And she was right: numbers don’t mean anything without context. Psychological empiricism is only as good as our methods of measurement and theories. If you measure my insight with a framework that doesn’t apply to me, you’ll find me wanting.
Psychology, Insight, and Power
The other two pillars, Universalism and Objectivism, are the power enforcers. These ideas take valid individual and empirical perspectives, which are just part of a variety of valid perspectives, and certify them as Truths. People’s personal perspectives are then transformed. If you disagree with the Objective truth of your diagnosis, based on these set of symptoms that are Universal, then you must have a disease. Universalism and Objectivism enforce the Truths already specified. They keep a power imbalance between those who the system deems healthy and those who the system deems sick.
I’d hypothesize that a valid assessment of insight, based on the person’s experiences and culture, would turn out quite differently. You’d find that the person is in the only spot they can be.
If this spot happens to not be where you want it to be: whose is? I’ll let you know when I’ve reached Nirvana.
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