Behind the Stigma: the podcast

Today's post is by Seiara Imanova. 

When I began my Master’s in Psychology at King's College London, I quickly realized there was a significant gap between the advancements in mental health research and how that knowledge is communicated to the public. This inspired me to start my podcast, Behind the Stigma, with the goal of bridging the divide between academic discussions in psychology, neuroscience, and mental health, and making them accessible to the general public.

Logo of Behind the Stigma

Although psychology is a science, in the way that it uses empirical research and rigorous methodologies to understand phenomena, its practical applications—especially in clinical work—are often deeply rooted in subjectivity (biases, power dynamics, and social hierarchies etc). This is particularly evident when we examine the lived experiences of individuals, especially those from marginalized groups. These groups are often silenced or undervalued, a concept known as epistemic injustice.

Epistemic injustice refers to how certain individuals or communities have their knowledge and experiences systematically dismissed or ignored. Below are a few episodes where we tackle these critical issues:

Race, Culture & Social Equalities in Mental Health with Hári Sewell

In this episode, Hari Sewell, founder and Director of HS Consultancy, offers insights into the systemic forces driving racial disparities in healthcare. For example, he explains how societal attitudes shape patient outcomes by highlighting the disproportionate detention rates of Black individuals in psychiatric wards compared to their white counterparts. Also, how unconscious biases subtly influence clinical decision-making, affecting everything from patient engagement to the formulation of treatment plans. His insights underscore the urgent need to confront these systemic issues in order to build more just and equitable mental health practices.

Returning to Wholeness: A Story with Psychiatric Nurse Neseret Bemient

In this episode, Neseret Bemient, a former psychiatric nurse in Canada, shares her profound journey toward wholeness and alternative healing. Neseret reflects on her experiences in psychiatric care, revealing how her role often involved navigating a system that frequently dismissed the voices of patients. Diagnosed with medication-induced bipolar disorder, she discusses the ways in which her history and lived experiences as a refugee was an important factor in understanding her wellbeing. Neseret emphasizes the importance of integrating spirituality and holistic approaches into practice, shedding light on the issues within psychiatric care. She urges us to recognize and validate the diverse experiences and knowledge of individuals diagnosed with mental health conditions.

Philosophy of Psychiatry with Lisa Bortolotti 

In this episode, philosopher Lisa Bortolotti delves into the distinctions between delusions and irrational beliefs, as well as exploring implications for agency in youth mental health. She discusses her research examining how young people navigate clinical encounters within mental health settings, highlighting how practitioners often undermine or dismiss young people's contributions due to negative stereotypes, which can lead to epistemic injustice by discrediting their experiences. By advocating for a greater focus on individual agency and integrative approaches, she highlights the necessity of validating diverse experiences in mental health, with practices that validate young people's voices and nurture their sense of agency, ultimately encouraging better mental health outcomes that involve users in decision making. 

Through the podcast, I strive to create a platform for meaningful dialogue around mentalhealth. I believe that by fostering understanding and empathy, we can work together to create a more equitable mental health landscape for all.

Seiara Imanova is a doctoral candidate at the University of Birmingham. Behind the Stigma has explored a range of topics, including AI and mental health, the effects of antidepressant, psychedelics as a therapy, and institutional racism.

Hysteria, Hermeneutical Injustice and Conceptual Engineering

In "Hysteria, Hermeneutical Injustice, and Conceptual Engineering", I look at what Miranda Fricker, in her Epistemic Injustice. Power and the Ethics of Knowing (2007) calls “hermeneutical injustice”, as it arises in the medical context. By drawing on the complex history of hysteria, I argue that the very concept HYSTERIA was used for diagnostic purposes for millennia, before its dismissal with the DSM-III in 1980, due to power structures affected by negative prejudice against women. 

Stereotypical representation of hysteria

I then argue that HYSTERIA fits the central conditions of the concept HERMENEUTICAL INJUSTICE. Yet, reflection on the case of HYSTERIA also signals the need for widening the understanding of the concept HERMENEUTICAL INJUSTICE itself. This is methodologically important for two reasons. First, because instead of considering the medical field merely as an area of application or testing of philosophical ideas, it uses medical data to improve a philosophical notion. Accordingly, I propose that hermeneutical injustice may depend not only on gaps in hermeneutical resources, but also on the presence of faulty ones, such as HYSTERIA. 

Second, once thus improved upon, HERMENEUTICAL INJUSTICE can be used to advocate for other forms of amelioration of concepts, which still embed identity prejudice against certain groups. I claim that it can do so by eschewing the more traditional path taken in current debates on the amelioration of concepts such as WOMAN. These debates risk perpetrating an “essentialist” outlook – let it be grounded in biological “nature” or in socially-acquired “nature” – on what women “really” are (or should be), which is fraught with problems.

By bringing the concept of HERMENEUTICAL INJUSTICE to bear onto this kind of discussion we can bypass that “essentialist” outlook altogether and be more inclusive and open to further applications of WOMAN, if these applications can help people, such as transwomen, to make sense of their experience and if doing so can help remove identity prejudice against them. 

The debate over the concept WOMAN is but one example of the areas in which a reconfigured concept of HERMENEUTICAL INJUSTICE could play a role. In fact, once so reconfigured, HERMENEUTICAL INJUSTICE could also be used to diagnose what is epistemically amiss in the use of those slurs, epithets and pejoratives which likewise embed identity prejudice against certain groups.

In fact, HYSTERIA is a clear example of a harmful concept rooted in identity prejudice against women. Its use undermines women’s ability to understand, express, and reason about their experiences, perpetuating forms of epistemic injustice like testimonial and what I call “rational(ity) injustice”— that is, the injustice of downplaying, diminishing and impeding the development of women’s rational abilities, due to identity prejudice against them. Therefore, I argue that using “hysterical"” and related terms descriptively should be banned.

Still, HYSTERIA could potentially be reclaimed by women, like other harmful concepts rooted in identity prejudice that were initially rejected for their damaging effects but later embraced by marginalized groups to strenghten identity and belonging.

Annalisa Coliva is Professor of Philosophy at University of California Irvine, and Editor in Chief of the Journal for the History of Analytic Philosophy. 

Annalisa's interests are in Epistemology, Philosophy of mind and language, and History of Analytic Philosophy.

Stigma as a Barrier to Self-Understanding

This blogpost is written by Alexander Edlich and Alfred Archer, writing about their recent paper in Social Epistemology entitled 'Rejecting Identities: Stigma and Hermeneutical Injustice'.

To seek, and accept, medical help, it is often necessary to realize that one needs it. Sometimes, however, people refuse to accept they need help, and this disables them from accessing medical resources. This refusal need not be due to stubbornness but can be the result of unjust social factors. In particular, we suggest that stigma can unjustly prevent people from making sense of their situation, including stigmatized illnesses. 

Take, for instance, the American writer Caroline Knapp’s account of her struggle to accept the idea that she was an alcoholic in her memoir Drinking: A Love Story. She describes how at times she was so drunk that she would ‘drive home with one eye shut, to avoid double vision’ (p. 54). 

After being advised by her therapist that she should stop drinking, she decided to attend an Alcoholics Anonymous meeting. Once in the meeting though, she felt a strong revulsion to accepting that she belonged there. As she describes it, she “looked around at the dingy room with the old men sipping coffee from foam cups and I thought, No way. No way in hell I’m doing this. This is not me. I do not belong here’ (pp. 190–191).

For Knapp to accept that she was an alcoholic would mean ‘owning up to flaws and imperfections and depths of confusion I was too ashamed to reveal’. This shame that she felt about her alcoholism was a response to the social stigma attached to it. Even when she had accepted her alcoholism and stopped drinking, Knapp continued to be very careful about which people she would discuss it with ‘for fear of being judged’ (p. 244). 

What prevented Knapp first from accepting and even longer from communicating about her situation was the stigma attached to alcoholism, and thus a social factor burdening those suffering from it. This made it harder for her to seek help.

The cover of Knapp's book

Knapp is far from alone in struggling with this, the stigma attached to alcoholism is a significant barrier to people seeking out medical assistance. This difficulty in accepting one’s addiction is a major problem, given that this acceptance is crucial for overcoming the addiction and also for seeking help in the first place.

While medical professionals are aware of the importance of reducing the stigma attached to medical conditions like addiction, the impact of stigma on self-understanding is not only practical, but, we argue, also creates a particular type of hermeneutical injustice: those whose experiences are stigmatized are unjustly made to reject helpful descriptions of their situation.

Hermeneutical injustice is the label philosophers use, coined by Miranda Fricker, to describe cases where the social practices of knowing, learning, and communicating are unjust so that persons in particular social positions are deprived of the means to make sense of their experiences. In paradigmatic cases, this occurs because dominant discourses do not include concepts that are needed to make sense of the experiences of marginally situated agents.  

For example, Fricker argues that before the development of the concept ‘sexual harassment’ people who experienced unwanted sexual attention in the workplace were not able to properly name their experiences. In this case, they were unfairly prevented from fully understanding the situation they were in because they lacked the concepts needed to articulate what it is they were experiencing, which, consequently, also disabled them from sharing their experiences. 

The stigma related to addiction (and other stigmatized experiences, like homosexuality or suffering intimate partner violence) also unfairly prevents people from making sense of their experiences but does so in a subtly different way. Here the conceptual resources are available to people. The concept of an alcoholic or an addict was available to Knapp and once she accepted that it applied to her, she was able to access the resources she needed to manage her addiction, including a supportive community of people struggling with the same problem. 

What prevented Knapp from accessing these resources was not the absence of a concept but the stigma that was attached to it. Knapp denied herself access to the hermeneutic resources that go with the label ‘alcoholic’ because of the stigma attached to this identity, which led her to refuse to accept that the label applied to her. In this way, stigma can unjustly cause people to reject helpful descriptions of their situation or identity.

To come to terms with a condition like addiction and to seek help about it, it is important to understand one’s situation and to accept it. Some people refuse such acceptance, and they can suffer gravely from it. This is a problem for medical practice, but, importantly, it can also be a problem of justice: to offer help, but also to treat people justly, we must make sure that stigma does not stand in the way of self-understanding.

Alexander Edlich completed his PhD at Ludwig-Maximilians-Universität Munich in 2023, where he then was a postdoctoral researcher. He works on moral responsibility (specifically blame, protest, and apology), the philosophy of emotions, and feminist and LGBTQ ethics.

Alfred Archer is Associate Professor of Philosophy at Tilburg University. He is interested in ethics, social philosophy, philosophy of sport, and moral psychology. He is the co-author of Honouring and Admiring the Immoral: An Ethical Guide (Routledge 2021), Why It’s OK to be a Sports Fan (Routledge 2024) and Extravagance and Misery: The Emotional Regime of Market Societies (OUP 2024).

Epistemic Isolation in Psychiatric Healthcare

This blog is based on an article by Dr Lucienne Spencer which was published last month in the journal Social Epistemology.

Kidd and Carel’s concept of ‘epistemic isolation’ occurs in ‘situations where a person or group lacks the knowledge of, or means of access to, particular information’ (Kidd and Carel 2017, 183–184). Such epistemic isolation can be found in psychiatric healthcare, where treatment plans and even diagnoses can be withheld from the patient (Spencer, 2024).

Goldstein distinguishes between epistemic isolation as an epistemic injustice or as an epistemic disadvantage (Goldstein 2022). Not all epistemic harms are necessarily epistemic injustices, but rather ‘circumstantial epistemic bad luck’ (Fricker 2007, 152). While Fricker limits ‘epistemic bad luck’ to the product of ‘hermeneutical disadvantage’, Goldstein broadens this notion to ‘Epistemic Disadvantage’, which occurs when a person or group is excluded from knowledge in a warranted way, even if it results in intellectual or moral harm.

A thinking head

Goldstein argues epistemic isolation is an epistemic disadvantage when it meets the following criteria:

1. ‘Harms are non-deliberate, arising in circumstances of bad luck’.
2. ‘Speakers lack precision or mastery of concepts to effectively communicate their experience’.
3. ‘Affected participants are justifiably excluded or subordinated from the practice that could make the concept known’. (Goldstein 2022, 1870–1871)

Here, I examine Goldstein’s criteria in relation to epistemic isolation in psychiatric healthcare.  

Criteria 1

For Fricker, epistemic injustice is necessarily non-deliberative. The epistemic injustices she conceives of are ‘discriminatory but ingenuous misjudgement’ rather than ‘deliberate manipulation’ (Fricker 2017, 54). Therefore, unintentional epistemic harm is not unique to epistemic disadvantage.

As Goldstein observes, epistemic injustice must be motivated by an identity prejudice. To refer to epistemic isolation in psychiatric healthcare as an instance of ‘bad luck’ would be to assume that it is merely circumstantial that the clinician does not have time to meet the patient’s epistemic needs: to ensure they understand their treatment and diagnosis. However, this so-called ‘bad luck’ is driven by what Fricker calls an ‘institutional epistemic vice’ in the healthcare system (Fricker 2021).

Institutional epistemic vice is a culpable lapse in the institution’s epistemic ethos (Fricker 2021, 101). Fricker imagines a school with good epistemic commitments but has developed ‘sloppy information sharing’ (Fricker 2021, 100). Similarly, the psychiatric healthcare system has a good ethos, yet flawed information-sharing practices and an institutional attitude that deprioritises the epistemic needs of the patient. This epistemic isolation emerges from a structural identity prejudice that is not located in the clinician but, rather, in the bones of the institution.

Criteria 2

Here, we need to determine if an inability to effectively communicate emerges from a ‘lack of mastery’ or from hermeneutical injustice. A ‘lack of precision or mastery of concepts’ may simply be a lack of mastery in the imposed interpretive framework. One may have a good capacity for communicating one’s experience in one’s own words, beyond a clinical framework; however, such communication is not understood or taken seriously.

Instead, we can ask whether there is a just division in epistemic labour between experts and non-experts. Goldstein follows Goldman in defining an expert as those with a ‘superior quantity or level of knowledge in some domain and an ability to generate new knowledge in that domain’ (Goldman 2001, 91). Clinicians, indeed, have developed skills in their field and act as generators of knowledge. However, those with psychiatric illness hold a unique form of experiential knowledge and expertise.

Illness ‘gives us experiences that we would not otherwise have had and that we cannot know what it is like to have until we undergo them’ (Carel et al. 2016, 1152). Therefore, if we take the ‘domain’ to be the psychiatric illness under evaluation, psychiatric patients cannot be said to lack a ‘superior quantity or level of knowledge’ or ‘an ability to generate new knowledge’. If the patient is treated as a non-expert from the outset, and knowledge is withheld, they are deprived of the opportunity to ‘master the concepts to effectively communicate their experience’. Instead, ignorance is imposed upon the patient from the offset.

Criteria 3

Clinical institutions could attempt to justify withholding information through the ‘non-maleficence principle’, the idea that revealing a diagnosis or treatment plan will cause harm to the patient. Alternatively, it could be argued that the deprioritisation of the patient’s epistemic needs is justified due to limits on time and resources. However, withholding information from a patient often causes the patient more harm than good (Spencer, 2024).

Most significantly, institutionalised epistemic isolation places the patient at a ‘cognitive disadvantage’. As such, they are inhibited not only from contributing to the pool of knowledge regarding their illness but also from making sense of their illness themselves. Although the diagnosis may be withheld due to the fear of stigmatisation, it is the stigmatisation that causes harm, not the diagnosis itself. This stigmatisation is only exacerbated by a culture of silence around the diagnosis.

Goldstein provides a valuable development of epistemic isolation, and I share her concern for overstretching the term epistemic injustice beyond the unjust. I show that epistemic isolation in psychiatric healthcare is not such a case of epistemic disadvantage.

Lucienne Spencer

Lucienne is a a Postdoctoral Researcher in Mental Health Ethics located within the Neuroscience, Ethics and Society (NEUROSEC) Team in the Department of Psychiatry, University of Oxford. Her research primarily focuses on phenomenology, epistemic injustice and the philosophy of psychiatry.