Epistemic injustice in the therapeutic relationship in psychiatry

Today’s post is by Eisuke Sakakibara, who is currently a lecturer at the University of Tokyo Hospital. He is a clinical psychiatrist as well as a researcher in the field of philosophy of psychiatry. Since 2013, he has been leading a study group in Tokyo, aptly named Philosophy of Psychiatry and Psychology. 

His recent publication, “Epistemic injustice in the therapeutic relationship in psychiatry,” published in Theoretical Medicine and Bioethics, discusses the effects of epistemic injustice on the interactions between psychiatrists and their patients.

I first heard of the concept of epistemic injustice in 2019 in San Francisco. From that moment on, I intuitively knew that it is a concept suitable to highlight practical and ethical issues of communication that arise between psychiatrists and psychiatric patients. I have decided to further my research.

The psychiatrist-psychiatric patient relationship is a type of doctor-patient relationship, and furthermore, the doctor-patient relationship is a type of professional-client relationship. I have made a distinction between problems that arise specifically between psychiatrists and psychiatric patients, problems that arise within the broader doctor-patient relationship, and problems that can arise generally in the professional-client relationship. Although there are no clear boundaries to what is called professional work, in addition to the classic three professions of physician, lawyer, and clergy, one could add psychologist, pharmacist, accountant, etc. to the list of professionals.

Professionals’ work involves helping clients solve problems through paid consultation. This problem-solving process requires an “epistemic collaboration,” a shared understanding and exploration of the problem, between the professional and the client. However, a professional’s high level of expertise and their close-knit relationships with peers can sometimes hinder this collaborative process. They might unintentionally dismiss certain issues important to the client as irrelevant from a professional perspective.

Eisuke Sakakibara

The doctor-patient relationship is unique among professional-client relationships in that it seeks to solve the client's bodily problems. Thus, the client experiences the duality of being both the problem solver and the problem itself—both informant and source of information. This is where the epistemic injustice inherent in medicine can arise, since in today’s medicine, objective findings from the patient's body, such as CT scans and blood tests, tend to be more prioritized than the patient’s verbal complaints.

Finally, psychiatry deals with illnesses that may impair the patient’s rational capacities, which further creates additional difficulties in epistemic collaboration. If a patient is delusional, the psychiatrist may have to accept the patient’s utterances not as testimonials, but as sources of information that reflect the patient’s illness.

The paper identifies a variety of epistemic injustice that occurs between psychiatrist-psychiatric patients from these three perspectives and proposes possible remedies.