Epistemic injustice, children and mental illness

Temporal Aspects of Epistemic Injustice: The Case of Patients with Drug Dependence

Scholars usually distinguish between testimonial and hermeneutical epistemic injustice in healthcare. The former arises from negative stereotyping and stigmatization, while the latter occurs when the hermeneutical resources of the dominant community are inadequate for articulating the experience of one's illness. However, the heuristics provided by these two types of epistemic predicaments tend to overlook salient forms of epistemic injustice. In this paper, we prove this argument on the example of the temporality of patients with drug dependence. We identify three temporal dimensions of epistemic injustice affecting drug-dependent patients: the temporal features of their cognitive processes, their individual temporal experience, and the mismatch of social temporality. Notably, the last aspect, which highlights the disparity between the availability of care and its accessibility, does not fit neatly into the categories of testimonial or hermeneutical injustice. (We should note that the International Network of People Who Use Drugs (INPUD) and The Asian Network of People who use Drugs (ANPUD) consider the term "drug addiction" to be associated with disempowerment and negative stereotyping. Instead, they suggest the expression "drug dependence" (INPUD 2020). However, the concept of "drug addiction" is still being used in the current public health, philosophy, and sociology debates that concern the specific field of addiction studies. Replacing the notion of drug addiction with "drug dependence" would not eliminate existing epistemic injustices or allow us to avoid creating new ones, such as those related to ignoring pain claims (O'Brien 2011). Still, for the sake of clarity we will use the notion "drug dependence" when speaking of people while retaining the term "drug addiction" for labelling healthcare practices and the topic for philosophy of healthcare.).

A critical analysis of UK media characterisations of Long Covid in children and young people

Long Covid is the continuation or development of symptoms related to a SARSCoV2 infection. Those with Long Covid may face epistemic injustice, where they are unjustifiably viewed as unreliable evaluators of their own illness experiences. Media articles both reflect and influence perception and subsequently how people regard children and young people (CYP) with Long Covid, and may contribute to epistemic injustice. We aimed to explore how the UK media characterises Long Covid in CYP through examining three key actor groups: parents, healthcare professionals, and CYP with Long Covid, through the lens of epistemic injustice. A systematic search strategy resulted in the inclusion of 103 UK media articles. We used an adapted corpus-assisted Critical Discourse Analysis in tandem with thematic analysis. Specifically, we utilised search terms to locate concordances of key actor groups. In the corpus, parents highlighted minimisation of Long Covid, barriers to care, and experiences of personal attacks. Mothers were presented as also having Long Covid. Fathers were unmentioned. Healthcare professionals emphasised the rarity of Long Covid in CYP, avoided pathologising Long Covid, and overemphasised psychological components. CYP were rarely consulted in media articles but were presented as formerly very able. Manifestations of Long Covid in CYP were validated or invalidated in relation to adults. Media characterisations contributed to epistemic injustice. The disempowering portrayal of parents promotes stigma and barriers to care. Healthcare professionals' narratives often contributed to negative healthcare experiences and enacted testimonial injustice, where CYP and parents' credibility was diminished due to unfair identity prejudice, in their invalidation of Long Covid. Media characterisations reveal and maintain a lack of societal framework for understanding Long Covid in CYP. The findings of this study illustrate the discursive practices employed by journalists that contribute to experiences of epistemic injustice. Based on our findings, we propose recommendations for journalists.

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.

Perspectives of French adolescents with ADHD and child and adolescent psychiatrists regarding methylphenidate use

Many studies have demonstrated the short-term efficacy and tolerability of methylphenidate treatment adolescents with attention deficit hyperactivity disorder (ADHD). Qualitative literature on this matter focused on school outcomes, long-term side effects, family conflicts, personality changes and stigmatization. Yet, no qualitative study has crossed the perspectives of child and adolescent psychiatrists (CAPs) prescribing methylphenidate and adolescents with ADHD. This French qualitative study followed the five stages IPSE-Inductive Process to analyze the Structure of lived Experience-approach. Fifteen adolescents with ADHD and 11 CAPs were interviewed. Data collection by purposive sampling continued until data saturation was reached. Data analysis, based on a descriptive and structuring procedure to determine the structure of lived experience characterized by the central axes of experience, produced two axes: (1) The process of methylphenidate prescription, highlighting how this prescription was motivated from the exterior, experienced as passive by the adolescents and required commitment from the CAPs; and (2) the perceived effects of methylphenidate treatment, in three domains: at school, in relationships and in the sense of self. Findings raised both the issues of the epistemic position and social representation of the adolescents about ADHD and methylphenidate within this specific French context, and the self-awareness and perception of the adolescents with ADHD. We conclude that these two issues need to be regularly addressed by the CAPs prescribing methylphenidate to avoid epistemic injustice and prevent the harmful effects of stigmatization.

Mental Health Experts as Objects of Epistemic Injustice-The Case of Autism Spectrum Condition

This theoretical paper addresses the issue of epistemic injustice with particular reference to autism. Injustice is epistemic when harm is performed without adequate reason and is caused by or related to access to knowledge production and processing, e.g., concerning racial or ethnic minorities or patients. The paper argues that both mental health service users and providers can be subject to epistemic injustice. Cognitive diagnostic errors often appear when complex decisions are made in a limited timeframe. In those situations, the socially dominant ways of thinking about mental disorders and half-automated and operationalized diagnostic paradigms imprint on experts' decision-making processes. Recently, analyses have focused on how power operates in the service user-provider relationship. It was observed that cognitive injustice inflicts on patients through the lack of consideration of their first-person perspectives, denial of epistemic authority, and even epistemic subject status, among others. This paper shifts focus toward health professionals as rarely considered objects of epistemic injustice. Epistemic injustice affects mental health providers by harming their access to and use of knowledge in their professional activities, thus affecting the reliability of their diagnostic assessments.

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.

Effective healthcare communication with children and young people: a systematic review of barriers and facilitators

OBJECTIVE

To identify children and young people's preferences for effective healthcare communication.

DESIGN

A systematic review of qualitative studies was conducted to identify evidence from children and young people on effective healthcare communication. Electronic databases and reference lists of relevant articles were searched to July 2020.

RESULTS

A total of 13 studies were included. Five major themes were identified: medical information (timing, amount, coordination and futures), person not patient (creating relationships, time, nurse involvement, sensitivity), type of communication (creative and interactive, behavioural, talking and listening, written communication), consultations (first impressions, with and without parents, actively promoting involvement, open and honest, age appropriate) and communication with parents (using parental knowledge, support).

CONCLUSIONS

Research in this area remains sparse and consistent implementation is debateable. Children and young people articulate a preference for two-way healthcare communication. General principles for effective communication are identified as well as the need to avoid making assumptions and to tailor approaches to individuals. Establishing and maintaining relationships is essential and requires time and resources. Parents and carers have a positive role in healthcare communication which needs to be balanced with the needs and rights of children. All these factors also apply to children with communication difficulties or from marginalised groups, but additional extra support may be required.

PROSPERO REGISTRATION NUMBER

CRD42019145539.

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.