So I’m here just to discuss a little bit about how these issues of epistemic injustice
might emerge, specifically in a psychiatric context, based on some research that I’ve
done over the past year or so.
So first of all there’s probably one core paper that’s out there at the moment that
discuses epistemic injustice, specifically in psychiatry, and this one core paper was
written by Paul Crichton, Havi Carel, and Ian James Kidd, published in the BJPsy in
2016 and in this they focused almost entirely on what Kathy was discussing over there as
testimonial injustice.
Specifically they try and argue three things; firstly that psychiatric service users are
particularly acutely at risk of testimonial injustice, particularly with interactions
with medical staff.
This is in addition to an acute vulnerability that already happens in other kinds of sematic
illness.
Secondly, medical professionals can enjoy undue credibility inflation.
They point out that this might lead to a similar sort of injustice, even in cases where patient
testimony is given due weight.
I think people may disagree about these things but this is the point that they make sometimes.
Thirdly, that they identify two broad kinds of factors that will contribute to these injustices.
Firstly global prejudices about the mentally [0:01:38] one, including things like many
things that are in fact symptomatic, for example substance abuse or addiction are actually
cases of personal vice.
Secondly, specific prejudices about people with specific diagnosis, for example, that
schizophrenic patients are intrinsically or meaningfully violent.
Both of these kinds of factors can contribute to undue credibility deflation in psychiatric
encounter.
And they make a recommendation on the basis of all of this and they suggest that medical
staff should develop certain kinds of virtues, and by virtue I just mean a disposition to
behave in a particular kind of way in interactions with patients, specifically they should listen
to and respect patient viewpoints in order to counteract any tendency towards injustice.
So they should actively seek out to give more credibility to patient testimony than they
would do naturally.
That’s the idea.
So all of that seems somewhat sensible to me.
I’m not a medical professional but all that seems relatively sensible.
Certainly a lot of research in the service user literature and work by service user political
movements seem to suggest that at least these risks really do happen, these harms really
do occur.
But when I first read this paper I think I had two main questions that really stood out
for me.
Firstly it’s quite common to think of stigma or prejudice in terms of social structure
as well as individual interactions.
So we might think that some of these problems go beyond any particular kind of interaction.
If we do think that, is that the case in psychiatry?
And does that suggest that we need structural remedies rather than just individual remedies,
rather than just pinning all this stuff on medical staff and saying ‘you must develop
your virtues’.
Are there other things that need to be done to enable that to happen, or being entirely
separate from that.
And secondly, and relatedly, this paper focuses on testimonial injustice but it also mentions
hermeneutical injustice which is another form of epistemic injustice that Kathy introduced
to you.
But the question remains, are service users vulnerable to other forms of epistemic injustice
as well?
And if so, what might analyses that make use of these concepts reveal, either about ways
in which you could reform the psychiatric profession or, alternatively, just getting
greater insight into patient experience of the psychiatric profession.
So, after a little while I think I’ve got some very tentative answers to both those
questions that I’m going to try and spend the rest of my time trying to share those
answers with you.
So in answer to the first question – so I say tentative answers up there so I don’t
have to be tentative from here on in; just take it that there’s tentatively sort of
built into everything that I say!
So the answer is yes and yes.
So there are all sorts of systematic or structural failings that might lead to epistemic injustice
between psychiatric patients – psychiatric service users, sorry – and clinicians.
So firstly, service users often lack access to what we might call socially acceptable
markers of credibility.
So we have to make judgements about people’s credibility all the time.
We might think that there’s nothing vicious about that, it’s just a matter of fact about
living in a busy, noisy world where we have to interact with people all the time and come
to believe things on the basis of what other people tell us much of the time.
There are ways in which we identify which people are credible and which people aren’t.
You might think there’s nothing ethically wrong about most of that, or at least some
of it, the ways we do that.
But the problem is that the markers that we use aren’t justly distributed across the
population.
People who are underprivileged in various ways, including psychiatric service users
which often cuts across the lines of class, economics, race, sexuality, gender and so
forth, may lack access to the kinds of credibility that we give to people.
For example, we tend to, for instance, treat people who are clearly well dressed and have
paid attention to their personal hygiene, probably treat them as generally more credible
than people who are dishevelled.
That’s something that could easily be lost if you are in a group of a particularly nasty
psychiatric issues.
There’s nothing in general necessarily – maybe you think there is something wrong with that
particular example – but there’s nothing necessarily wrong about using these markers
of credibility but they’re not shared widely enough and so when we use those, when people
use those in the clinical encounter we’re going to perpetuate a certain kind of injustice,
despite the fact that individually we’re not necessarily doing anything wrong.
Secondly, service users might also lack access to the kinds of epistemic resources that are
necessary to make sense of their experience.
So people need certain kinds of language – technical language in particular.
They might need certain concepts, so certain ways of thinking about these things.
They might need access to research to understand the condition.
They need access to methodology, sort of like ways they can come to know things themselves
about their own condition.
They need all of this to fully interpret and understand their own experience.
This is just a general point about how we come to know things about ourselves and about
the world, but because of the way that the psychiatric information tends to be produced
and disseminated, a lot of service users will lack access to those kinds of resources specifically
relating to their experience, their condition and so forth.
Again, this isn’t the responsibility of any single person to communicate.
Obviously a primary clinician should try and communicate as much as possible but this isn’t
the fault of that, this is a much broader problem in how we produce, how we sort of
come to know things about psychiatry and how we disseminate that information to the wider
population.
Those two things.
And finally even when service users collectively, particularly in service user movements, are
able to develop these resource themselves, often in ways that are quite different to
the psychiatric profession more broadly, their attempts to communicate these insights to
clinicians and service providers are often undervalued.
So even when they have access to the right sorts of resources to make sense of their
experience, there’s no guarantee that those resources will be shared with someone who’s
responsible for their care and that can lead to all kinds of misunderstandings in communication.
And once again this isn’t necessarily an individual failing of anybody, it’s a way
in which these resources are distributed and in which the ability of people to make those
contributions, how that works.
So I think all of that suggests a need for a general overhaul of what sorts of epistemic
resources and concepts are shared between service users and medical staff, as well as
a kind of epistemic level between service users and medical staff.
Obviously I’m not necessarily advocating for anything specific here but these sorts
of reasons speak in favour of those kinds of measures.
And then very quickly, so the answer to question two doesn’t quite make sense because I phrased
the second question differently at one point.
So instead of ‘yes’ and ‘quite a lot in both respects’, remove ‘in both respects’,
‘yes and quite a lot’ is the answer to question two.
So let’s take an example of – just one example, there are lots of other kinds but
let’s take the example of testimonial smother that Kathy talked about earlier.
So I won’t recap too much of what Kathy said but what I will say is that another important
aspect to testimonial smothering is that the testimony involved is risky.
So there is a chance of harm if that testimony is misinterpreted.
Maybe even if that testimony isn’t misinterpreted it’s the sort of thing that creates risk
either for the people themselves or for people they love or care about.
And if they don’t feel that people can handle that risky testimony properly they very often
silence themselves.
Now it’s hard to identify specific cases of testimonial smothering definitively because
obviously testimonial smothering is marked by an absence of testimony.
So it’s very hard to know when testimony is absent because of testimonial smothering,
and when testimony is simply absent for other reasons.
But we can at least identify that there’s certain kinds of conditions that exist in
psychiatry.
So testimony is indeed risky and it’s risky in part because of the powers that psychiatric
professionals have over service users, whether they use these powers appropriately or not.
So, the powers of detention, the powers of enforcing treatment, powers of giving or refusing
care, all of these different kinds of risks are present when you’re trying to testify
about your own symptoms or your own experiences, especially in recent history and crisis care.
And so I think that suggest that we need to re-evaluate not just how medical staff use
the powers granted to them, I think that might be important as well, but what the powers
are themselves because the mere presence of that power even when used appropriately makes
the testimony of the service user potentially more risky than it needs to be and on that
point, I have hit time, I’ve gone over time, sorry about that.
I will stop there