On a scale of 1 to ten, how sane do you feel?
A little bit about the history of mental health screenings and why you always have to answer the same goddamn questions
Reader, I was weird.
We like to think of ourselves as the experts on our own experience. After all, no one knows us better than ourselves, right? And yet, if you’ve ever been given a self-assessment in a mental health setting - like the survey they give you before you go into therapy or an intake form at a rehab, an institution, or in-patient setting - you may have found yourself staring into the page, unsure what the “right” answer is.
You know the ones. They usually are something like:
On a scale of 1 - 10, with 1 being the worst and 10 being the best, how have you felt this week?
Do you feel uninterested in things that normally interest your? Select “Often,” “Sometimes,” or “Never.”
How much do you wake up every morning and think “Goddamnit it, this again?”
Do you feel down, depressed, or like your will to live has been sapped from your every cell like the moisture leaving a slug that’s recently had a Funyun dropped on it?
I don’t remember the exact questions (though I’ve had to fill them out conservatively a billion times) but I think they go something like that. Anyway!
These assessments always make me feel like I’m at the eye doctor and I’m being asked to choose “one or two” and neither one of them really feels like it’s making anything any clearer. The pen - which I will steal every single time without fail even though I have little need for another shitty Bic - hovers over the page as I ask myself wait, how depressed am I? How much do I enjoy my life? What’s a normal amount of anxiety? Is it normal to worry all the time, or just most of the time?
Recently I had to take one and I wondered where this came from. These assessments are pretty standard, especially for people seeking mental healthcare treatment that they want to have covered by insurance. And if you click through one of the six trillion Instagram ads* for the new, trendy doc shops that promise to make mental health drugs (or like, regular drugs) more accessible, you’ll be greeted with an assessment that decidedly does not feel like it’s interrupting medicine (though it maybe is interrupting privacy and HIPAA laws).
*Sidebar: I recently tried to see what it was like to get a scrip from one of these. I’ve had a prescription for a relatively low dose of a generic ADHD med for like seven years and was curious if I could get my meds cheaper online. When I went through the assessment, I found it to be some of those archaic diagnostic criteria I’d seen in a hot minute. It felt like taking an ADHD assessment in 1992 when the only people who were getting diagnosed were active little boys with spitty mouths and bowl cuts wearing stained pre-buccal-fat-removal Barney t-shirts. The questions were about fidgeting, vague ideas about concentration, and included precisely none of the new criteria that we know to be more accurate in diagnosing women, which I found ironic because it was literally marketed toward women. I failed the assessment and told that I probably did not have ADHD. So modern medicine is going great!
Of course, it makes sense that there would be some kind of boilerplate assessment for people - doctors and therapists can’t know what’s inside our little Easy Bake Ovens if we don’t somehow turn on the tiny, ineffectual bulb. But mental health assessments don’t really seem to keep up with the ever-changing understandings and best practices surrounding symptoms and diagnoses. They seem kind of stuck out of time and I wonder how much they can really help if they mostly just instill in us all a state of panic about getting the answers “wrong”? Because you can bet there’s a “wrong” answer or two, especially if you’re seeking a specific kind of therapy or treatment.
The mental health assessment: A very brief history
The history of our understanding of mental illness is supremely messy. People have known for centuries that the human brain - whether the organ itself or the more conceptual mind - was prone to various diseases, but the modern scientific understanding of mental illness is still relatively new.
In the last century, mental illness was as likely to be diagnosed by a doctor as a barber, or your stepdad or your husband, or some other absolutely non-professional with a loud voice and a lot of confidence). People who were living with mental illness weren’t really involved in their own diagnoses and treatments, either because they were viewed as too feeble or because these diagnoses were a method of social control or because they just weren’t really given the option.
If you were being brought to say, a Kirkbride institute, your doctor (or priest, or local Smart Guy with a long beard or whoever) might have asked you how you felt - but it wasn’t so much a screened as it was more to gauge the way you answered, your overall countenance, and your grasp of (their perceived) reality.
The patient was, unlike today, decidedly not viewed as the expert on their current condition.
In the middle of the century, though, two things changed - the first was that mental illness became an actual issue that advocates and practitioners rallied behind and the second is that people got really into personality tests.
The first real personality test was developed as a way to pre-screen soldiers heading out to fight during World War I. During and after the war, the rates of “shell shock” i.e. post-traumatic stress were so high that local public health and government officials were left unsure of how to manage all of these damaged men. Instead of doing the normal, rational thing and like, offering soldiers great supports and also many getting rid of the draft, there was an idea that men could be screened before they went into battle and ensure that recruiting efforts were “rigidly excluding insane, feebleminded, psychopathic and neuropathic individuals from the forces which are to be sent to France and exposed to the terrific stress of modern war.”
Yes, because only the feebleminded would be deeply disturbed by bloody warfare, starvation, lice, and having your feet eaten away at by rats in trenches.
Anyway, this test kind of kicked off a much bigger movement to assess people based on their own insight (though the actual impact was negligible and of course the United States never really did figure out how to help people who are impacted by battle). After this questionnaire was deployed, many more followed in its footsteps - and not just for soldiers. Personality tests in the workplace became popular in the 1920s. From a 2008 research paper out of Bowling Green:
In an early assessment, Elwood (1927) utilized the Colgate Mental Hygiene Tests to determine whether psychoneuroticism could aid in the selection of careers for nurses. Peck (1936) used the Thurstone Personality Schedule to investigate the adjustment difficulties of women teachers, and concluded that “one third of the women teachers are definitely maladjusted, and one-sixth need psychiatric advice, as judged by the Thurstone Personality Schedule. Only one fifth can be classified as well-adjusted” (p. 414).
Neat! This doesn’t sound at all patriarchal or like something that the men of medicine and psychiatry might weaponize against the women who were currently gaining new and unprecedented rights in the workplace and at home!
These assessments were seen as potentially valuable in clinical space, especially during the 1940s push toward more standardized evaluations of mental health. The initial version of the DSM, published after World War II, was touted as being one of the first official manual to include information about mental health and illness in a clinical setting. It was heavily influenced by a psychiatrist named Adolph Meyer, who really liked to observe and survey patients, though there wasn’t an actual assessment in the book.
At this time, researchers and therapists began creating their own assessment tools, as there wasn’t a gold standard. There still isn’t - there are hundreds of mental health assessment evaluations available, each with their own benefits and drawbacks. There are a few that are used more frequently than others - the Minnesota Multiphasic Personality Inventory (MMPI-2), created in 1989, the Patient Health Questionnaire-9 (PHQ-9) from 1999, and the Hamilton Depression Rating Scale (HAM-D), which was written in the late 1950s (!!!) - but they’re pretty much all kind of the same. And many share the same huge, glaring issue: They’re old and they were invented by crusty white people.
Some actual questions from a WHO assessment. These questions are from 1994 and are still in use today.
Consistent inconsistency
Of the hundreds of assessment tools - which again, might be used to guide your treatment or to ensure your insurance actually foots the bill for your meds - pretty much all of them rely on people to self-assess to some degree or another. And that’s something that we’re really quite bad at!
In a survey of self-assessments of all sorts, researchers - including David Dunning of the Dunning-Kruger effect - found that “the act of self-assessment is an intrinsically difficult task.” From that paper:
In general, people's self-views hold only a tenuous to modest relationship with their actual behavior and performance. The correlation between self-ratings of skill and actual performance in many domains is moderate to meager—indeed, at times, other people's predictions of a person's outcomes prove more accurate than that person's self-predictions. In addition, people overrate themselves. On average, people say that they are “above average” in skill (a conclusion that defies statistical possibility), overestimate the likelihood that they will engage in desirable behaviors and achieve favorable outcomes, furnish overly optimistic estimates of when they will complete future projects, and reach judgments with too much confidence. Several psychological processes conspire to produce flawed self-assessments.
Now, this may not matter too much if you’re just like, filling out a questionnaire for your boss. But in the shrink’s office, as you try to do the little song-n-dance required to get your meds refilled, your own terrible understanding of your situation could mean leave your doctor unable to help you.
Consider people who are in unsafe home environments, or those who don’t realize their living situation is dangerous due to some mental health crisis, like hoarding. Or folks who rate themselves as generally managing OK when in fact they are drowning, but they’ve only ever been drowning.
And, depending on how or when tests are administered, there might actually be differences in the findings. A survey of mental health self-assessments performed in 2020 noted that “tools designed to assess the same disorder(s) showed considerable inconsistency in the symptoms that they were considering.” Additionally, the authors noted, “two experimental studies assessing patients with the same clinical diagnosis, but using different tools to assess symptom severity, may deliver different results because they are assessing a different set of symptoms.”
This is partially due to the wide range in the questions each asked and how they focused - were they asking the person to rate themselves compared to others, or were they asked to recount specific impacts?
“[The survey of] ADHD was dominated by questions relating to behavioral symptoms (51%) while only 13% focused on emotion related symptoms. Others such as OCD, ASD, eating disorder, and schizophrenia were distributed more uniformly across multiple themes. Assessments for OCD, PTSD and anxiety more commonly asked about the triggers associated with a symptom, while assessments of depression, bipolar, ASD, schizophrenia, addiction, and ADHD rarely asked questions of this type. Assessments of addiction and ADHD more commonly asked about the consequences of a symptom, but this was more rarely assessed for other disorders. Symptom treatments were most commonly asked about during assessments of addiction.”
Those are pretty high stakes - and if your doctor isn’t aware of all of your cooccurring issues, they may give you a test that shows results which are accurate but not useful for your specific issues and, as a result, treat you in a way that isn’t helpful.
Additionally, we have to consider the sources of these tests. Just like standardized tests in school can further racial gaps, these kinds of behavioral self-assessments might lack cultural competency.
“Translation, which is often necessary, leaves room for confusion. In some instances, important mental health–related concepts lack true equivalents in languages other than English, opening the way to misunderstanding of complaints,” writes Dr. Lonnie R. Snowden. “When faced with standardized assessment procedures, for example, some Asian Americans approach the very task of responding with tendencies different from those assumed by developers of the procedures.”
Assessing the assessments
In my research on these assessments, I had a hard time actually finding any agreeing research that these are a useful diagnostic tool. Some assessments, which are used to figure out whether or not people are in danger (Kaiser always asks if you have access to a gun which I honestly do appreciate), can help prevent future bad outcomes and prompt hard conversations in talk therapy.
But in a vacuum - like if you’re just given one of these tests online to help determine whether or not you should get ADHD meds shipped to you - they often seem like a waste of time at best. Especially since, as I’ve learned, most of them are extremely old and don’t necessarily reflect the issues people have today?
Like, I’d love to see an assessment that asks “do you often waste time dopamine-minining on TikTok when you should be working?” or “what’s more depressing: The fact that the planet is on fire or that fact that you, personally, have been made to feel like this is an individual failing?”
Ok those are too specific, but you know what I mean. Like bitch yeah, everyone is tired all the time. And yes we’ve all lost interest in SOME things because there are other things that are taking up our time and attention.
I’m just not sure that you can figure out what someone’s experiencing when you’re asking them questions meant for their grandmother.
But then, I’m not a professional. I’m just someone who would love to spend less time circling “very much” or “not really” every time I try to get my meds adjusted.
Oh also! If you like my writing on mental health stuff, you should see what I’m publishing on Medium, especially about ADHD stuff. Here’s a link.
xoxo HBO