Self-narratives and medicalization: the effects of psychiatric diagnoses

This post is by Richard Hassall, a qualified clinical psychologist, now retired. After retirement, Richard enrolled at the University of Sheffield to do an MA in philosophy, followed by a PhD which was completed in 2022. At the time of writing, Richard is an affiliate researcher attached to the Department of Philosophy at Sheffield.

Richard Hassall

My area of interest is philosophy of psychiatry, with a particular interest in the nature of psychiatric diagnostic categories and the effect these have on the individuals who receive them. I argue in my PhD thesis that a psychiatric diagnosis may, in some cases, lead the recipient to becoming a victim of epistemic injustice, and specifically of hermeneutical injustice. I argue that this effect can be understood in terms of narrative theory and the self-narratives that individuals construct for themselves.

People gain meaning in their lives through their self-narratives, but such narratives can be changed by the person’s social circumstances and by extraneous events. Receiving a psychiatric diagnosis is one such event in some people’s lives, and it can significantly impact on the recipient’s self-narrative.

The codification of psychiatric diagnoses in disease nosologies, such as the DSM-5 of the American Psychiatric Association, can convey the implication that these represent disease entities of some sort. Patients are often told that their condition is “an illness like any other”. The reductionist methodology characteristic of the biomedical model of diseases can suggest that mental disorders are somehow caused by neurochemical abnormalities in the brain, an idea reinforced by the frequent treatment of such disorders with medication. Consequently, the diagnosis may be understood as a medicalized explanation of the person’s difficulties. However, most such diagnoses are based purely on symptom descriptions and do not explain how the person’s symptoms arose.

The medicalization implicit in psychiatric diagnoses conveys a biomedical narrative which may conflict with or marginalise the recipients’ previous self-narratives at a time when they will be experiencing significant emotional distress. As such, the recipients’ own hermeneutical resources can become marginalised. In other words, their capacity for understanding and expressing their own experiences can be minimised or neglected by clinicians. This can result in them becoming victims of hermeneutical injustice, particularly if they are mistakenly led to believe that their condition is a chronic one, from which full recovery is unlikely to happen.

The biomedical narrative associated with such diagnoses can undermine the recipients’ beliefs about their sense of agency and lead to feelings of hopelessness about recovery. While it is not an inevitable consequence of such diagnoses, there is evidence from testimonies of former service-users that this can happen to some people.

Kathleen Murphy-Hollies joins EPIC

On 1st September 2023, Kathleen Murphy-Hollies will join EPIC as a Research Fellow based in the Philosophy Department at the University of Birmingham. We asked her a few questions to get to know her better.

Kathleen Murphy-Hollies

Hi Kathleen! What are your main research interests?

Hello! My PhD project looks at the impact of self-concepts and self-narratives on our behaviour, and in particular, our ability to embody moral virtues. In confabulation, for example, we assign certain motivations and ascriptions to ourselves which aren’t accurate. 

Confabulations may misconstrue the details of the circumstances and not capture what really drove our behaviour. But despite this, flawed self-ascriptions can drive future behaviour to be in-line with the ascribed motivations, thus improving behaviour and making those idealistic self-ascriptions true over time.

So in general, I’m interested in labelling effects and how perceiving ourselves in a certain way affects how we are. I see this as a very dynamic and social phenomenon, in which we negotiate our self-concepts with others by drawing on their feedback and insights into the nature of our own behaviour. I see these processes also as a perfectly legitimate route to developing virtue and maturing ethical behaviour.

Positive self-concept

Why do you think it is important to study epistemic injustice in healthcare?

In my research, I place a lot of emphasis on the input of the people around us on the formation of our own identities. I think that these social negotiations can go better or worse and that it’s important to get them right. In healthcare interactions, these negotiations with others to attempt to better understand ourselves take place overtly, which also makes explicit how important it is to get right. 

Not giving due credit and weight to the inner experiences and desires of an agent who seeks to understand their behaviour better – the patient, in these cases – is one way in which these negotiations seriously fail to be fruitful. It also, of course, greatly harms the patient and damages the relationship that they have with their healthcare provider, who has a lot of power in this exchange. 

It is important to tackle structural barriers such as belonging to a marginalised social group, which stops people being truly heard when recounting experiences which may be confusing and painful. Addressing these problems will safeguard patient wellbeing and enhance the quality of healthcare.  

What are you working on right now?

At the moment, I am writing about how claims about conspiracy theories may be driven by a desire to express and demonstrate certain treasured self-concepts, rather than by attempts to have accurate explanations of the world. This explains some findings about adoption of conspiracy theories and their bizarre features. 

The social negotiations in this context are set very broadly, across entire cultures, and I’m starting to look at closer, more intimate relationships. In these kinds of relationships, each member has particularly powerful influence on shaping the identity of the other. I hope that this will highlight useful and important dynamics to be aware of in the patient-provider relationship, in order to avoid epistemic injustice there.