Contributory injustice in psychiatry

Will psychology ever 'join hands' with disability studies? Opportunities and challenges in working towards structurally competent and disability-affirmative psychotherapy for energy limiting conditions

Despite sustained efforts among critically informed scholars to integrate thinking from disability studies into psychology, the psy disciplines continue to largely neglect the lived experience of disabled people and overlook disability as a form of social inequity and valued culture. In this article, I make a renewed case for integrating thinking from disability studies into psy, in particular within the psychotherapy professions and in the case of 'energy limiting conditions', a grass-roots concept that includes clinically and socially marginalised chronic illness such as Long COVID. Drawing on my experience as a disabled practitioner, and situating this within extant literature on disability and psy, I take an autoethnographic approach to exploring opportunities and challenges in bridging the interdisciplinary divide. I argue that unacknowledged institutional ableism within psy reproduces and is reinforced by physical and attitudinal barriers for disabled practitioners and service users, engendering under-representation of disability in psychotherapy professions and lacunae in disability-affirmative conceptual resources. Additionally, I propose that hermeneutical lacunae are bolstered by documented defensive clinical practices pertaining to disability. After discussing a wealth of opportunities for integration offered by disability studies, and noting the institutional failure within psy to embrace disability-related demographic and epistemic diversity, I question whether ongoing epistemic and social exclusions within the psy disciplines constitute a case of 'willful epistemic ableism'. Drawing on theorising vis-à-vis epistemic injustice and epistemologies of ignorance, I signal a form of systematic, actively maintained and structurally incentivised (motivated) non-knowing that results in collective failure among dominant groups to recognise established hermeneutical resources of the disabled community and allies. I conclude with suggestions of how this form of epistemic injustice might be mitigated.

Spiritually significant hallucinations: a patient-centred approach to tackle epistemic injustice

SUMMARY

This article uses three fictitious case vignettes to raise questions and educate on how clinicians can appropriately approach patients experiencing spiritually significant hallucinations. Religious hallucinations are common but are not pathognomonic of mental illness. They are often intimate experiences for the patient that raise complex questions about psychopathology for clinicians. When assessing a patient with religious hallucinations it is important that clinicians hold at the centre that person's personal experience and create a safe space in which they are listened to and epistemic injustices are avoided. Involvement of chaplaincy services is important not just to support the patient but also to ensure that as clinicians we seek support in understanding the religious nature of these experiences.

What should inpatient psychological therapies be for? Qualitative views of service users on outcomes

BACKGROUND

There is limited research on what, when and how outcomes should be measured in psychological therapy trials in acute mental health inpatient wards.

OBJECTIVES

This study aimed to consider what outcomes service users think are important to measure.

METHODS

This qualitative study explored the views of 14 participants, who had an inpatient admission within the last year, on outcomes of psychological therapies using semistructured interviews. Data were analysed using thematic analysis from a critical realist perspective with both inductive and deductive coding.

RESULTS

The 126 outcomes that were important to participants were mapped onto an established taxonomy of outcomes across different health areas and the socioecological framework to consider the wider context and help summarise the outcomes. Most of the outcomes were mapped to the intrapersonal and interpersonal level. In addition to the outcome mapping, three themes were constructed from the qualitative data: (1) I am not a problem I am a person, (2) Feeling cared for and loved, (3) What does getting better look like.

CONCLUSIONS

Our results highlight the need for patient-reported outcomes which are cocreated with service users, disseminating research and training on preventing dehumanising experiences, enhancing psychological safety and therapeutic relationships and improving access to psychological therapy.

PATIENT OR PUBLIC CONTRIBUTION

The wider People with Personal Experience Involvement Committee at the University of Bath were consulted which included a focus group during the early planning stages. We also collaborated with a person with personal experience, at every stage of the research. This included developing our research question and aims, protocol, participant documents (e.g., information and debrief forms), advertisement and recruitment strategy, interview topic guide, the codes, the final themes and quotes and reviewing the manuscript. People with lived experience of being admitted to an acute mental health inpatient ward participated in our study.

The epistemic harms of direct-to-consumer genetic tests

In this paper, I provide an epistemic evaluation of the harms that result from the widespread marketing of direct-to-consumer (DTC) genetic tests. While genetic tests are a valuable accessory diagnostic tool when ordered by a medical practitioner, there are different implications when they are sold directly to consumers. I aim to show that there are both epistemic and non-epistemic harms associated with the widespread commoditization of DTC genetic tests. I argue that the epistemic harms produced by DTC genetic tests have been disregarded in discussions on the topic. Drawing on the notion of contributory epistemic injustices, I highlight two pertinent epistemic harms: (1) a failure to uptake an individual's articulations about their identity and (2) the presiding reductionist framework dismisses useful hermeneutical resources. I then propose ways to mitigate these harms.

Epistemic injustice in the therapeutic relationship in psychiatry

The notion of epistemic injustice was first applied to cases of discrimination against women and people of color but has since come to refer to wider issues related to social justice. This paper applies the concept of epistemic injustice to problems in the therapeutic relationship between psychiatrists and psychiatric patients. To this end, it is necessary to acknowledge psychiatrists as professionals with expertise in treating mental disorders, which impair the patient's rationality, sometimes leading to false beliefs, such as delusions. This paper classifies the characteristic features of the therapeutic relationship in psychiatry into three stages: those of a professional-client relationship, those of a doctor-patient relationship, and those of a psychiatrist-psychiatric patient relationship. Epistemic injustice is prevalent in psychiatric care owing to prejudice against patients with mental disorders. However, it is also predisposed by the roles that psychiatrists play in relation to psychiatric patients. This paper suggests some ameliorative measures based on the analysis.

Epistemic Injustice and Nonmaleficence

Epistemic injustice has undergone a steady growth in the medical ethics literature throughout the last decade as many ethicists have found it to be a powerful tool for describing and assessing morally problematic situations in healthcare. However, surprisingly scarce attention has been devoted to how epistemic injustice relates to physicians' professional duties on a conceptual level. I argue that epistemic injustice, specifically testimonial, collides with physicians' duty of nonmaleficence and should thus be actively fought against in healthcare encounters on the ground of professional conduct. I do so by fleshing out how Fricker's conception of testimonial injustice conflicts with the duty of nonmaleficence as defined in Beauchamp and Childress on theoretical grounds. From there, I argue that testimonial injustice produces two distinct types of harm, epistemic and non-epistemic. Epistemic harms are harms inflicted by the physician to the patient qua knower, whereas non-epistemic harms are inflicted to the patient qua patient. This latter case holds serious clinical implications and represent a failure of the process of due care on the part of the physician. I illustrate this through examples taken from the literature on fibromyalgia syndrome and show how testimonial injustice causes wrongful harm to patients, making it maleficent practice. Finally, I conclude on why nonmaleficence as a principle will not be normatively enough to fully address the problem of epistemic injustice in healthcare but nevertheless may serve as a good starting point in attempting to do so.

"Come and share your story and make everyone cry": complicating service user educator storytelling in mental health professional education

It has become relatively common practice within health professional education to invite people who have used mental health and social care services (or service user educators) to share their stories with health professional learners and students. This paper reports on findings from a postcritical ethnographic study of the practice of service user involvement (SUI), in which we reflexively inquired into conceptualizations of service user educators' knowledge contributions to health professional education in the accounts of both service user- and health professional educators. This research was conducted in response to recent calls for greater scrutiny surrounding the risks, challenges, and complexities inherent in involving service users in health professional education spaces. 'Story/telling' was identified as a pronounced overarching construct in our analysis, which focuses on participants' reports of both the obvious and more subtle tensions and complexities they experience in relation to storytelling as a predominant tool or approach to SUI. Our findings are presented as three distinct, yet overlapping, themes related to these complexities or tensions: (a) performative expectations; (b) the invisible work of storytelling; and (c) broadening conceptualizations of service user educators' knowledge. Our findings and discussion contribute to a growing body of literature which problematizes the uncritical solicitation of service user educators' stories in health professional education and highlights the need for greater consideration of the emotional and epistemic labour expected of those who are invited to share their stories. This paper concludes with generative recommendations and reflexive prompts for health professional educators seeking to engage service user educators in health professional education through the practice of storytelling.

Epistemic injustice and the psychiatrist

BACKGROUND

Psychiatrists depend on their patients for clinical information and are obligated to regard them as trustworthy, except in special circumstances. Nevertheless, some critics of psychiatry have argued that psychiatrists frequently perpetrate epistemic injustice against patients. Epistemic injustice is a moral wrong that involves unfairly discriminating against a person with respect to their ability to know things because of personal characteristics like gender or psychiatric diagnosis.

METHODS

We review the concept of epistemic injustice and several claims that psychiatric practice is epistemically unjust.

RESULTS

While acknowledging the risk of epistemic injustice in psychiatry and other medical fields, we argue that most concerns that psychiatric practice is epistemically unjust are unfounded.

CONCLUSIONS

The concept of epistemic injustice does not add significantly to existing standards of good clinical practice, and that it could produce changes in practice that would be deleterious. Psychiatrists should resist calls for changes to clinical practice based on this type of criticism.

Epistemic injustice amongst clinical and non-clinical voice-hearers: A qualitative thematic analysis study

OBJECTIVES

Research has suggested people who hear voices may be at risk of epistemic injustice. This is a form of discrimination whereby someone is unfairly judged to be an unreliable knower (testimonial injustice) or is unable to contribute to, and therefore access, concepts that make sense of their experience within mainstream society (hermeneutical injustice). Voice-hearing occurs both in people who are mental health service users and in the general population (clinical and non-clinical voice-hearers, respectively). The degree of distress and impairment associated with voices has been shown to relate to how individuals make sense of their experiences and how others respond to their identity as a voice-hearer. The aim of this study was to explore people's experiences of epistemic injustice in relation to voice-hearing and to understand how these may differ between clinical and non-clinical voice-hearers.

DESIGN

A qualitative design was used.

METHOD

Eight clinical and nine non-clinical voice-hearers partook in semi-structured interviews, which were analysed using thematic analysis.

RESULTS

Three pairs of themes related to (i) identity, (ii) relationships and (iii) power and position were constructed across the clinical and non-clinical groups, and two shared themes within both groups were created relating to testimonial and hermeneutical injustice.

CONCLUSION

Both clinical and non-clinical voice-hearers described experiencing epistemic injustice in wider society. The presence of a 'safe haven' (e.g. spiritualist churches) for non-clinical voice-hearers ameliorated the impact of this to some degree, by allowing people to make connections with others with similar experiences within a non-judgemental and accepting community.

Epistemic injustice as a bridge between medical sociology and disability studies

This paper explores the potential of the perspective of epistemic injustice to reconcile medical sociology's attention to the micro level of experience and interpersonal exchange, and disability studies' focus on the macro level of oppressive structures. The first part of the paper provides an overview of the concept of epistemic injustice and its key instances-testimonial, hermeneutical, and contributory injustice. We also consider previous applications of the concept in the fields of health care and disability, and we contextualise our investigation by discussing key features of postsocialism from the perspective of epistemic injustice. In the second part, we explore specific epistemic injustices experienced by people who use disability support by drawing on interviews and focus groups conducted with parents of disabled children in present-day Bulgaria. In our conclusion, we revisit our methodological and theoretical points about the potential of epistemic injustice to facilitate mutually beneficial exchanges between medical sociology and disability studies.

Perspective: Decolonizing postmodernist approaches to mental health discourse toward promoting epistemic justice

Currently, it is possible to observe a slowly (but surely) growing volume of claims seeking to disprove Foucauldian ideas about knowledge and power as overlapping basic theories of epistemic justice. Prompted by these claims, alongside adopting tenets of Critical Race Theory to address injustices inflicted upon people facing mental health challenges, I propose applying decolonizing deconstruction to Foucault's terminology, toward identifying opportunities to enhance epistemic justice, primarily in direct interventions in mental health services.

Staff's experiences of implementing patient-initiated brief admission for adolescents from the perspective of epistemic (in)justice

BACKGROUND

The implementation of Patient-Initiated Brief Admission (PIBA) in child and adolescent psychiatry (CAP) in Sweden is ongoing. This intervention enables adolescents between the ages of 13-17 and with complex mental health problems to initiate a short care period for relief and support rather than the care apparatus being controlling in this process. Offering it is likely to promote epistemic agency, an exchange of knowledge and recovery from mental health problems.

AIM

The aim of this study was to explore staff's perspectives of PIBA for adolescents with complex mental health problems, and what facilitates or hinders its implementation.

METHODS

Twenty seven employees, 21 women and six men, with various professions in CAP were interviewed and the material was analyzed thematically.

RESULTS

Two overall themes emerged: "Staff's Experiences of PIBA" and "Managing Clinical PIBA Work." The results were discussed in relation to the theoretical frameworks of epistemic injustice and Normalization Process Theory (NPT). The main findings indicate that PIBA was generally viewed in a positive way, but that obstacles arose when it was actually put into practice. Findings also point at an overall lack of agency among staff when implementing this new way of working, at the same time as the need to adapt PIBA from an adult psychiatric intervention to one for adolescents in CAP is addressed.

CONCLUSION

This article offers insights into the views of psychiatric staff regarding the implementation of PIBA. If staff wish to support epistemic agency and recovery among adolescents, their agency may be an important aspect in the continued implementation. Furthermore, in order for PIBA to become normalized in a sustainable way, we suggest that the continued implementation should be characterized by a youth-friendly framework.

[Testimonial injustice against people with mental disorders in health care. A conceptual and ethical analysis]

Menschen mit psychischer Erkrankung sterben statistisch gesehen früher als die Allgemeinbevölkerung. Ein Grund hierfür ist, dass sie eine schlechtere somatische Gesundheitsversorgung erhalten. Wir argumentieren, dass ableistische Netzwerke sozialer Bedeutung zu einer Abwertung der epistemischen Kompetenz von Menschen mit psychischer Erkrankung führen. Diese Abwertung kann mit dem Konzept der testimonialen Ungerechtigkeit erfasst werden. Testimoniale Ungerechtigkeit bezeichnet das ungerechtfertigte Herabstufen der Glaubwürdigkeit einer*s Sprecher*in aufgrund eines Vorurteils gegen ihre*seine soziale Identität. Wir analysieren ethische und epistemische Folgen testimonialer Ungerechtigkeit als wichtige Ursachen der schlechteren Gesundheitsversorgung von Menschen mit psychischer Erkrankung. Testimoniale Ungerechtigkeit kann zu medizinischen Behandlungsfehlern führen und für Betroffene schwerwiegende gesundheitliche Folgen nach sich ziehen. Zudem kann sie zu einem Vertrauensverlust von Menschen mit psychischer Erkrankung in das Gesundheitssystem führen. Daher trägt testimoniale Ungerechtigkeit zur strukturellen Diskriminierung von Menschen mit psychischer Erkrankung bei. Vor diesem Hintergrund diskutieren wir, wie die somatische Gesundheitsversorgung unter ethischen Gesichtspunkten verbessert werden kann.

Epistemic injustice in psychiatric practice: epistemic duties and the phenomenological approach

Epistemic injustice is a kind of injustice that arises when one's capacity as an epistemic subject (eg, a knower, a reasoner) is wrongfully denied. In recent years it has been argued that psychiatric patients are often harmed in their capacity as knowers and suffer from various forms of epistemic injustice that they encounter in psychiatric services. Acknowledging that epistemic injustice is a multifaceted problem in psychiatry calls for an adequate response. In this paper I argue that, given that psychiatric patients deserve epistemic respect and have a certain epistemic privilege, healthcare professionals have a pro tanto epistemic duty to attend to and/or solicit reports of patients' first-person experiences in order to prevent epistemic losses. I discuss the nature and scope of this epistemic duty and point to one interesting consequence. In order to prevent epistemic losses, healthcare professionals may need to provide some patients with resources and tools for expressing their experiences and first-person knowledge, such as those that have been developed within the phenomenological approach. I discuss the risk of secondary testimonial and hermeneutical injustice that the practice of relying on such external tools might pose and survey some ways to mitigate it.

The value of doing philosophy in mental health contexts

People experiencing mental distress and illness are frequently on the receiving end of stigma, epistemic injustice, and social isolation. A range of strategies are required to alleviate the subsequent marginalisation. We ran a series 'philosophy of mind' workshops, in partnership with a third-sector mental health organisation with the aim of using philosophical techniques to challenge mental health stigma and build resources for self-understanding and advocacy. Participants were those with lived experience of mental distress, or unusual beliefs and experiences; mental health advocates; and mental health service providers (such as counsellors, psychologists and psychiatrists). We draw on a shared perspective as a participant and facilitator of the workshop series to assess their impact. We discuss the following benefits: (i) the opportunity for structured discussion of experiences and models; (ii) dialogue across different mental health backgrounds; (iii) the potential to reduce self-stigma and to increase self-understanding and advocacy; and (iv) the potential to alleviate (some) epistemic injustice. We invite researchers and mental health practitioners to consider further opportunities to investigate the potential benefits of philosophy groups in mental health settings to establish whether they generalise.

Recovery Mentors as continuing professional development trainers for better recognition of the epistemic value of the experiential knowledge and improved access to recovery-oriented practices

Objectives

To lay the groundwork for the arrival of Recovery Mentors (RMs) in some of its multidisciplinary teams, a Continuing Professional Development (CPD) conference was organized in a large public agency in the province of Quebec, Canada. The aim was to come up collectively with recommendations to improve access to recovery-oriented care and services for this vulnerable population by recognizing the epistemic value of their lived experience.

Methods

A series of workshops were organized among health professionals to reflect on their practice and to discuss the role of RMs for improving epistemic equity and recognition of the experiential knowledge. In preparation for these workshops participants completed the Recovery Self-Assessment (RSA). The RSA is a 32-item questionnaire designed to gauge the degree to which programs implement recovery-oriented practices, which should notably include RMs in multidisciplinary teams (five-point Likert scale: 1= strongly disagree ; 5 = strongly agree). The interactive workshops were hosted by RMs as trainers who first shared their lived experience and understanding of recovery.

Results

Eighty-height of the 105 participants completed the RSA. The highest score on the RSA was for the item Staff believe in the ability of program participants to recover (mean = 4.2/5). The lowest score was for the item People in recovery are encouraged to attend agency advisory boards and management meetings (mean = 2.2/5). Based on the average inter-item correlation, a reliability test confirmed an excellent internal consistency for the French RSA scale, with a Cronbach's Alpha of .9. Means and standard deviation for each item of the RSA questionnaires were calculated. The results did not differ by participant characteristics. Results to the RSA and results from the workshops that were co-hosted by RMs were reported in the plenary session and further discussed. The workshops, the RSA and the whole CPD conference raised awareness among health professionals about stigmatizing attitudes and epistemic inequity in actual service provision.

Conclusion

RMs could be invited to actively participate and attend advisory boards and management meetings more frequently and on a more regular basis for ongoing quality improvement towards better access to recovery-oriented practices. This CPD conference has shown the acceptability and feasibility of including RMs as trainers for better recognition of the epistemic value of the experiential knowledge of recovery. They can help health professionals to recognize and better appreciate service users as knowers and potential contributors to knowledge.