The Scope of Epistemic Injustice in Psychiatry

In this post, Themistoklis Pantazakos and Sarah Arnaud argue that the concept of testimonial epistemic injustice has been too broadly used in psychiatry, leading to confusion and doubts about its usefulness. They suggest that once the concept is properly focused on phenomenology, these issues are largely resolved.

In broad terms, to do an epistemic injustice is to harm somebody in their capacity as a knower (Fricker, 2007). The concept has taken the world of philosophy of psychiatry by storm, with a surge of academic articles and presentations over the past decade. However, many fundamental aspects of the concept remain unclear. For instance, it is often ambiguous what type of knowledge mental health service users contribute, or why and when psychiatrists should listen to them. “Listening to the voice of the marginalized (service users)” has become a common go-to phrase for finding a remedy to epistemic injustice, however it remains too vague. Overall, there is a pressing need for accounts that clarify the mechanisms and specifics of epistemic injustice with an eye to making it clinically useful.

In our recent article in Philosophical Psychology, we address these questions, beginning with a recent debate in philosophy of psychiatry, focusing specifically on the testimonial strand of epistemic injustice, which involves the information provided by service users. Kious et al. (2023) recently argued that the concept of testimonial epistemic injustice is at best superfluous and at worst detrimental to psychiatric conduct, presenting two key arguments for this. Firstly, that uncritically believing everything a service user says would undermine the critical skepticism necessary for effective psychiatric practice. Secondly, that the careful consideration of information provided by service users is already covered by existing psychiatric guidelines. Unsurprisingly, friends of the epistemic injustice concept responded swiftly and intensely (Aftab, 2023; Kidd et al., 2023).

Kious et al. discuss various psychiatric incidents to support their position, arguing that these cases, often cited as examples of testimonial epistemic injustice, do not involve moral missteps by the attending psychiatrists. Their opponents claim the opposite. Disagreeing with both, we contend that these incidents, regardless of their general moral aspects, are unsuitable for demonstrating testimonial epistemic injustice in psychiatry. To do this, we first clarify that the primary mission of psychiatry is to help service users cope better, i.e., to improve what it is like to be them. We then argue that psychiatrists should not listen to service users indiscriminately or merely for the sake of participation. Instead, they should listen when service users speak about their area of expertise, which regards foremostly what it is like to be them. The cases discussed by Kious et al. and their opponents concern issues outside the natural expertise of service users, who therefore may not be the primary epistemic sources in these contexts.

Generalizing this approach, we propose that the concept of testimonial injustice in psychiatry should be centered on phenomenology, or the study of the lived experience of service users. This conceptualization allows for what Kious et al. call “a degree of healthy skepticism”, which we agree is crucial in psychiatry. Moreover, it highlights an epistemic dimension that is overlooked in psychiatric practice guidelines, thereby clarifying the novelty and the necessity of the epistemic injustice concept for the field. We conclude by examining historical cases in psychiatry, including schizophrenia and autism, to demonstrate that this form of epistemic injustice, which we term phenomenological epistemic injustice, has been prevalent in the profession.

Themistoklis Pantazakos

Sarah Arnaud