Written by Nur’ Ain Zainal
This paper aims to explicate how individuals who suffer from mental illness are victims of testimonial and hermeneutical injustices, and are thereby harmed in their capacity to provide knowledge and form knowledge of their own experiences. These harms are considered unjust because they are both unfair and discriminatory, owing largely to the lack of social power that mentally ill individuals are afforded in epistemic dialogue — especially compared to physically able and disabled groups of people. Henceforth, this paper will assume that mentally ill individuals occupy a particular social identity, where a social identity consists of the ways in which society is divided along intersections of race, class, gender, sexuality, ability and so forth. This social group which mentally ill individuals occupy is marginalised and discriminated against within the community of knowledge-creators, thereby resulting in these epistemic harms.
This paper will first limit the scope of epistemic injustice towards mentally ill individuals with psychiatry, and emphasise the significance of this context. Secondly, I will explain and define testimonial and hermeneutical injustice. I will then show how and why mentally ill individuals are victims of these epistemic injustices. I will also outline several ways we may combat these injustices, and examine how effective they may be.
1. 1 The Significance of Epistemic Injustice in Psychiatry
This paper will limit the discussion of epistemic injustice to that which occurs within psychiatry, and the psychiatric treatment that mentally ill individuals receive. This is not to say that mentally ill individuals do not experience epistemic injustice outside of psychiatric treatment. However, it is crucial to note that this examination as it pertains to psychiatric treatment is a much more significant problem in light of the fact that mentally ill individuals often rely on psychiatrists and specialists to help and treat them. This highlights an important underlying dynamic where the patient’s health, judgment and even freedom is often controlled and facilitated by his/her psychiatrist, be it implicitly or explicitly so. It essentially reveals that often, both parties operate under the assumption that the mentally ill individual ought to listen and obey the direction and judgment of his/her psychiatrist(s) regardless of their own opinions or feelings on the matter. This unambiguous dynamic of asymmetrical power must be taken into consideration, as it amplifies the severity to which false, prejudicial and harmful conclusions will affect the lives of mentally ill individuals if they are not faced and rectified. If treatment of psychiatry is to be well-intentioned, and aimed at helping rather than harming, these embedded problems must be addressed and rectified.
2 Testimonial Injustice towards Mentally Ill Persons
Epistemic Injustice is a targeted operation, be it consciously or unconsciously directed. Often when it is directed by an individual, system or group, it is often at the advantage of that responsible party and at the expense of the targeted group. Where it concerns mentally ill individuals as a social group, the operation of this epistemic injustice is primarily caused by an operation of identity power. Here, identity power refers to a social power that includes the operation of imaginative social coordination (Fricker, 2007). This operation of imagination refers to the usage of socially constructed perceptions of particular social identities, such as stereotypes.
When an individual testifies, and delivers knowledge to a hearer, a hearer often relies on heuristic aids in making judgments on an individual’s credibility (Fricker, 2007). Stereotypes are specifically used as heuristic aids in making spontaneous judgments of credibility. When these stereotypes consist of prejudicial associations between the social group and negative associations, they will lead to a credibility deficit of the speaker. Testimonial Injustice hence occurs when a speaker receives an unfair deficit of credibility from a hearer caused by prejudice by the speaker (Fricker, 2007). Because of this, testimonial injustice thereby undermines a speaker’s capacity as a knower by resulting in their testimony and knowledge being rejected, dismissed, neglected or downplayed. When mentally ill individuals are victims of testimonial injustice, it undermines their capacity as knowers and contributors to the epistemic discipline and knowledge-creation in psychiatry that is needed to treat and diagnose them. When it is exercised on a large-scale by a community of psychiatrists, it can lead to harmful measures and practices accepted into the practice, and when it is is exercised on an individual basis, it can worsen a patient’s treatment and lead to ineffective or harmful treatment.
What then, are the stereotypes associated with being mentally ill? These individuals are often deemed “cognitively impaired or emotionally compromised”, “existentially unstable”, unable to think straight, or “psychologically dominated by their illness in a way that warps their capacity to accurate describe and report their experiences” (Crichton et al, 2017). Essentially then, the strong emotions of their psychological illnesses are perceived to have distorted their judgment. Because of this, mentally ill individuals suffer from a credibility deficit where their testimonies are often presumed to be irrelevant, unreliable or confused (ibid) despite the good intentions of psychiatrists.
Many mentally ill individuals, including myself, would be the first to acknowledge that these stereotypes are not completely unfounded. However, it is equally obvious that each individual’s experience with their mental illness is uniquely different, and most mentally ill individuals will fall into the shades of grey between that are not accounted for by stereotypes. Furthermore, mentally ill individuals have exclusive access to their own experiences that others are not privy to. Operating on Fricker’s assumption that stereotypes cannot be avoided in a heuristic practice, stereotypes ought to take a backseat to the unique psychological profile of each and every patient. This however, is not the reality, and often, stereotypes dominate a patient’s treatment process and the psychiatric practice in general. Below, I will outline several real-life examples and the resulting harmful results as such.
3 Hermeneutical Injustice towards Mentally Ill Persons
Hermeneutical Injustice occurs when an individual is unable to understand a significant area of his/ her social experience due to “prejudicial flaws in shared resources for social interpretation” (Fricker, 2007). This definition presupposes the notion that a marginalised individual’s understanding depends on a collective social understanding that is “structured” by groups that occupy more social power. Hermeneutical Injustice is an insidious problem in that it effectively hinders self-understanding — constraining and harming his/her capacity as a knower— by virtue of some form of social unfairness and asymmetrical disadvantage that prevents self- experience from coalescing into self-knowledge. The operation of hermeneutical injustice can hence occur by various ways; for example, by a lack of being able to participate in epistemic dialogue, by being deprived of the words to understand such experiences, by having to obey or align one’s thinking with the dominating consensus, or by being deprived of legitimacy over their own experiences in any epistemically meaningful way. All these ways however, essentially point to a lack of social power or powerlessness in an epistemic dialogue dominated by a group of knowers.
4 Examples of Testimonial Injustice and Hermeneutical Injustice
Let me preface this briefly by stating that I myself am clinically diagnosed of being mentally ill. My own experience of psychiatric treatment has provided me with numerous examples of being a victim of epistemic injustice. For example, when my attending psychiatrist was on leave, I was scheduled to be seen by a different doctor. This doctor dismissed my request to be put on a different medication because as I explained, the current medication I was on was not effective and in fact, I was feeling worse. She said that her decision was based on the fact that I appeared to be doing well; she pointed to my t-shirt and jeans, and the make-up on my face. I explained to her that I had come directly from class, and that I was unable to attend school for a week prior due to my depression. This did not matter; the visual evidence of my current state was deemed more reliable. A week later, I broke down in therapy and explained that I was lost as to how I could be seen as progressing when the suicidal thoughts had been amplifying, and there was nothing to be done about it because no one was listening. “Am I actually okay? How can I feel so wrong about me?” I asked. My therapist immediately scheduled a visit with my original psychiatrist, who was back from leave. He apologised, listened to me and granted my request.
Above is an example of both testimonial and hermeneutical injustice. Where my testimony of my own mental condition and state was dismissed in favour of the stereotype that genuinely mentally depressed individuals would ‘look worse off’, I was the recipient of testimonial injustice. The result of this was that I experienced profound doubt of my own experience, in that I questioned my own knowledge of my welfare — I was well aware that psychiatrists have a wealth of knowledge and experience that I did not have, and I was well aware that the doctor had authority and good intentions. Seeing her believe in such a stereotype made me have good cause to believe in it about myself. Consequently, my internal epistemic struggle and loss of certainty over my own experience is an example of hermeneutical injustice.
Another example that strikes keenly is taken from a TED talk delivered by Associate Dean and Professor Elyn Saks, in which she details how she and many schizophrenic patients are victims of testimonial injustice. In Psychiatry, the practice of mechanically restraining patients is common practice, of which she herself has experienced. This is despite the fact that in America, one to three people every week die in restraints, often from choking on their vomit, suffocation and heart attacks. She notes the horror of the experience as “degrading, painful and frightening”, and how she firmly believes that force is not an effective treatment. Despite this, testimonies of schizophrenic individuals are not taken into legitimate consideration. In a stunning example of such, she recalls how her law professor (who did not know of her illness) told her, “Elyn, you don’t really understand: These people are psychotic. They’re different from me and you. They wouldn’t experience restraints as we would.” Elyn proceeds to say that she didn’t have the courage to tell him the truth of her own illness, and that schizophrenics “don’t like to be strapped down to a bed and left to suffer for hours any more than he would”. She even notes how until recently, restraints were seen as helping psychiatric patients feel safe. “I’ve never met a psychiatric patient who agreed with that view”, she says succinctly (Saks, 2012). This example is a clear example of the widespread testimonial injustice that occurs in psychiatry which results in harmful practices. Schizophrenics are deemed to be unreliable, too violent or volatile, and experiencing things differently from how “normal” persons would. Because of this, they are subjected to inhumane treatment ‘for their own good’.
There is an incredible amount of faith that patients put in the judgments and decisions of their psychiatrists, and the intentions of these psychiatrists might truly be in good faith. But these examples highlight how epistemic injustice can harm the patient not just as knowers, making them doubt their own self-knowledge, but also in threatening one’s health and life in the process. If I had had a worse week, if Elyn Saks had been strapped down too tight, both our lives could have been at severe risk. This points to the grave importance to which epistemic injustice towards mentally ill individuals ought to be weeded out from psychiatry. However, both these examples contain a kernel of hope; not all psychiatrists dismiss patient’s experiences and knowledge, and psychiatry as a practice has been progressing away from deeply troubled and harmful preconceptions.
5 How may we Combat these Problems?
Firstly, students of Psychiatry ought to be taught to believe what their patients tell them unless there is good reason not to (Crichton, 2017). This effectively ensures that each psychiatrist places the unique psychological experience of each patient as a priority, and dissuades them from relying too much on the stereotypes that exist on mentally ill patients — a vast majority of which are negative and harmful. Furthermore, it ensures that psychiatrists obtain a better understanding of the experiences of their patient that does not epistemically harm them. In turn, by doing so, they are able to teach patients more about their illness and what they should be looking out for, providing them with much needed vocabulary and frameworks of understanding that the patient may not have prior. The patient’s mental health ought to be seen as a collaborative effort, for if the patient cannot understand his own mental state, it hinders the psychiatrist’s own understanding of the patient. Both patient and psychiatrist must work together, and this is facilitated by learning on both parties.
Another solution may be to integrate the (inherently subjective) perspectives of mentally ill persons into medicine and psychiatry, such as by emphasising the role of “Schwartz rounds” that are gaining more traction in the United Kingdom (Crichton, 2017). Schwartz Rounds are exercises where healthcare staff are encouraged to share their experiences of the emotional and social aspects of psychiatry, and are aimed to improve the doctor’s feelings of empathy and compassion toward patients (Farr, 2017). By facilitating empathy and encouraging a personalised workspace, doctors may find it easier and rely less on stereotypes and prejudices in diagnosing and treating mentally ill patients, and are more likely to think about the consequences of their treatment to a patient’s thinking and self-knowledge. Furthermore, it may aid in revising and rethinking current harmful practices toward mental health patients in psychiatry over time. New research has found that Schwartz Rounds a resulting in promising benefits for the mental health community in this respect (ibid).
Lastly, I believe a more comprehensive education about mental illness within education institutions and workplaces would help diminish the prominence of stereotypes and false beliefs within society, and aid in creating a more understanding and supportive environment for individuals who may be experiencing mental health problems but have never fit into a particular stereotype. Mental health is a highly personalised experience, and by diminishing an automatic negative response towards mental illness, we may be able to open the dialogue to more people in need and give them the needed space and acceptance to reflect, seek treatment, and love themselves.
6 Conclusion: A Positive Outlook
Epistemic injustice towards mentally ill individuals occurs throughout society, but it also is profoundly experienced in psychiatry. The steps I have provided above may aid in diminishing these occurrences, and the recent progress in society and psychiatry are promising in light of them, such as the universities holding mental health talks on Mental Health Awareness Week, and Psychiatry emphasising Schwartz Rounds and teaching students to believe in their patients in recent years. This points to a slow, but existing progress that will hopefully aid in mental health treatment and self- acceptance for mentally ill individuals in years to come.
Crichton, P. et al (2017) Epistemic injustice in psychiatry. BJ Psych Bulletin. The Royal College of Psychiatrists. UK. Retrieved from: http://pb.rcpsych.org/content/early/2016/08/18/pb.bp. 115.050682
Farr, M. and Barker, R. (2017) Can staff be supported to deliver compassionate care through implementing Schwartz Rounds in community and mental health services? Qualitative Health Research, University of Bath. UK. Retrieved from: https://www.pointofcarefoundation.org.uk/evidence/can-staff-supported-deliver-compassionate-care-implementing-schwartz-rounds- community-mental-health-services/
Fricker, Miranda (2007) Epistemic Injustice: Power and the Ethics of Knowing. University Press Scholarship Online. Retrieved from: http://www.oxfordscholarship.com/view/10.1093/acprof:oso/9780198237907.001.0001/acprof-9780198237907
Saks, Elyn (2012) A Tale of Mental Illness — From The Inside. Retrieved from: https:// www.ted.com/talks/elyn_saks_seeing_mental_illness