Objectivity, Standardization, and Epistemic Injustice in Psychiatry

In “Objectivity, Standardization, and Epistemic Injustice in Psychiatry,” I subscribe to the view that theoretical conceptions of mental health can operate as structural factors that promote epistemically unjust practices in psychiatric clinical settings. I examine how the high value placed on objectivity, conceived in terms of standardized methods and knowledge, may underpin various forms of epistemic injustice toward patients. 

In particular, I argue that it can lead to treating patients as mere informants or, worse, as sources of information, thereby undermining their status as epistemic agents. This state of affairs should be taken seriously because, I argue, the high value placed on objectivity and its standardized conception are theoretical cornerstones of the dominant model of psychiatric practice and research.

Before the development and adoption of the DSM-III in 1980, psychiatry’s disciplinary status was arguably precarious. The likelihood of two psychiatrists agreeing on a diagnosis was little better than chance, and the antipsychiatry movement had raised serious criticisms of its methods and categories. This was unacceptable not only for psychiatry as a discipline but also for patients, who could receive arbitrary diagnoses depending on the individual clinician’s perspective and thus miss out on appropriate treatment.

To establish itself as a branch of medicine, psychiatry needed to rely on objective evidence to support its diagnoses and treatments. Since psychiatric practice relies primarily on patient reports and behaviors, these had to be systematically addressed as its objects of inquiry. 

This required the development of reliable and (at least presumably) valid diagnostic tools — namely, operationalized criteria — and a view of mental symptoms as objects presented by patients and made observable to clinicians through standardized instruments, such as structured interviews and rating scales. 

From this standpoint, being objective in psychiatry means employing these standardized tools. However, by their very nature, such instruments must set aside interpretations — both the patient's and the clinician's — and disregard patients’ idiosyncrasies.

Given such a high value and standardized conception of objectivity, some clinicians may lack either the skills or the will to engage with information that falls outside the standard (and is thus deemed “subjective”), to take up or engage with patients’ conceptual resources and interpretations, and more broadly, to treat patients as epistemic agents seeking self-understanding. 

Others, of course, do have both the skills and the will. But what must be emphasized is the structural dimension of the issue: beyond individual clinicians’ attitudes lies a fundamental conception — that of objectivity — which underpins psychiatric theory and practice, and which systematically hinders engagement with patients as epistemic agents, instead promoting their treatment as mere informants or sources of information.

"[I]f psychiatry is to be an epistemically just discipline,
it must also find ways to engage with patients as epistemic agents."

I am not arguing that psychiatry should abandon the pursuit of objectivity or that generalized knowledge is without value. On the contrary, such knowledge is essential for making predictions about the course of mental conditions and identifying effective treatments. 

My point is that, if psychiatry is to be an epistemically just discipline, it must also find ways to engage with patients as epistemic agents. This would bring not only epistemic benefits but therapeutic ones as well. What is needed, in my view, is a collective theoretical effort comparable to the one that reoriented psychiatry toward standardization. We must now articulate the conditions under which attention to patients’ particularities and perspectives can also be regarded as objective.

Finally, if this analysis is correct, it has implications for the inclusion of patient perspectives in DSM revisions. While their inclusion will be bound to bring epistemic and therapeutic benefits, it falls short of addressing the complex realities of clinical practice. 

Standardized instruments may vary in how well they achieve their theoretical and practical aims — and in the extent to which they promote epistemic and social practices that are just— but they will always be insufficient to fully address patients as unique subjects and as epistemic agents.

Virginia Ballesteros is Assistant Professor in the Department of Philosophy at the University of Valencia. Her research focuses on the philosophy of psychiatry and altered states of consciousness. 

She is particularly interested in how mental disorders and psychiatric treatments are theoretically conceived, and the implications this has — for instance, in matters of epistemic justice, in phenomena such as self-illness ambiguity, or in the adequacy of pharmacological interventions. She has also worked on the philosophy of birth, exploring the epistemic aspects of medical birth care and the metaphysics of the birthing experience.