A Feedback Loop between Testimonial and Hermeneutical Injustice

‘Epistemic injustice’ picks out a distinctive kind of harm inflicted upon somebody in their capacity as a knower. Miranda Fricker (2007) famously distinguished two subtypes of epistemic injustice, i.e. testimonial injustice and hermeneutical injustice. 

Testimonial injustice is primarily a matter of credibility deficit. Paradigmatically, a speaker incurs testimonial injustice when they are given less credibility than they deserve due to identity prejudice in the hearer. Hermeneutical injustice is, by contrast, a matter of unintelligibility. 

A speaker incurs hermeneutical injustice when, owing to the substantive exclusion of one’s reference social group from the production of collective hermeneutical resources, there are no shared concepts they can make use of to understand their own experiences and/or make those experiences intelligible to others. 

Harassment

In an article published in Rivista di filosofia, we provide an opinionated survey of the major debates surrounding epistemic injustice, and argue that testimonial injustice and hermeneutical injustice reinforce each other in a feedback loop that hasn’t been fully unpacked so far -- but see Medina (2012), McKinnon (2017), and Lagewaard (2020). Here we offer a glimpse of this loop, starting from how testimonial injustice may feed off hermeneutical injustice.

As already mentioned, hermeneutical injustice typically stems from what Fricker (2007: 152) calls hermeneutical marginalization, i.e. (i) the systematic exclusion of certain groups from, or (ii) their merely formal inclusion in, meaning-making practices. Oppressed groups have historically been denied equal hermeneutical participation in both senses (i) and (ii), and this can be partly (although not exclusively) explained by appealing to the operations of testimonial injustice. When a group is negatively stereotyped in certain domains, it is no wonder that its members tend not to be asked to participate in communicative practices and hermeneutical activities related to those domains. This tendency gives rise to preemptive testimonial injustice (Fricker 2007: 130). 

We claim that preemptive testimonial injustice may fuel hermeneutical marginalization in sense (i): the long exclusion of women from institutional sources of collective meanings such as higher education and academia may be partly explained in this way. More standard forms of testimonial injustice, where a speaker’s testimony is heard but not given due weight, may contribute to hermeneutical marginalization in sense (ii).

As we all well know, women had to fight an unfinished battle after getting access to academia in order for their voices to be given equal hearing and weight – owing, in part, to the persistence of biases affecting women’s epistemic standing.

To close the loop, hermeneutical injustice must feed off testimonial injustice. We maintain that this is perfectly plausible. Consider Carmita Wood’s case (Fricker 2007: 149-50). Living in a time when the concept of sexual harassment had not yet been crafted, Wood was unable to fully make sense of what she was going through, and a fortiori to communicate it clearly to others. Wood was a victim of hermeneutical injustice. But this is not it. We argue that, because of this, she was also very likely a victim of testimonial injustices. 

After all, there is a strong chance that some hearers assigned a credibility deficit to her due to the inevitably unfit concepts she made use of (e.g. flirting) when telling them about her experience and state of anxiety. If this in fact happened, what would otherwise have been received as testimony against discriminatory treatment, ended up sounding, at least to some hearers, as a confused outburst. 

The hermeneutical injustice perpetrated against Wood ‘spilled over’, making her testimony not only scarcely intelligible but also less credible than it would otherwise have been. Importantly, these instances of testimonial injustice may not have had their roots in prejudice against (people like) Carmita but may be entirely explained by the hermeneutical injustice women were suffering at the time.

Laura Caponetto (University of Milan, Cambridge University) is a philosopher specialising in philosophy of language, feminist philosophy, and social philosophy. Laura is the author of "Undoing things with words", published in Synthese in 2020. 

Tommaso Piazza (University of Pavia) is a philosopher specialising in epistemology and the philosophy of language. Tommaso is the author of "The Value of Truth and the Normativity of Evidence", published in Synthese in 2021.

Epistemic Injustice in Diagnosis

In this post Lisa Bortolotti interviews Anke Bueter (principal investigator) and Thor Hennelund Nielsen (post-doctoral researcher) on their exciting project, “Epistemic Injustice in Diagnosis” (January 2024 – December 2025) funded by a Starting Grant of the Aarhus University Research Foundation. 

Aarhus University, credit Lars Kruse / AU Foto

Lisa: How did you become interested in this project?

Anke: This project brings together my research interests in feminist epistemology and the philosophy of medicine and psychiatry.  It focuses specifically on diagnosis, as diagnosis is both a prerequisite of successful medical treatments and susceptible to pathocentric epistemic injustices. I wanted to further explore this area after working on the phenomenon of diagnostic overshadowing, in which a previous psychiatric diagnosis leads to diagnostic delays or missed diagnoses regarding somatic diseases (Bueter 2023).

Thor: Diagnostic practices in both somatic medicine and psychiatry – their internal reasonings and capacities to change peoples’ lives for better or worse – have always interested me academically and personally. I’ve been very fortunate that this project allows me to fulfil this interest through investigating the topic of overdiagnosis.

Lisa: What are your objectives and why do you think it is important to achieve them?

Anke: My primary interest lies in avoidable diagnostic errors, which are estimated to affect 10-20% of all medical cases. The project seeks to rethink diagnosis as an (ideally) collaborative epistemic process and to explore how epistemic injustices can hinder this process. For example, I am currently examining gender biases in psychiatric diagnostic criteria, as well as the important role of trust between patients and clinicians.

Thor: Studies within the field have tended to focus on either epistemic injustices of/leading to under- or misdiagnosis but haven’t paid particularly close attention to overdiagnosis, though the epistemic harms of the latter may be equally serious. I want to show that overdiagnosis is not just a problem in terms of iatrogenic harms or lost opportunity costs but also because it fundamentally affects the overdiagnosed patient’s ability to understand themselves and be understood by others.

Lisa: Does your project involve interdisciplinary or crossdisciplinary work? If so, what disciplines are involved?

Thor: The issue of overdiagnosis is crossdisciplinary at heart. The problem itself derives from medicine but is often studied through sociological methods and additionally calls for philosophical scrutiny to elucidate the concepts themselves and the injustices they may create.

Lisa: What do you expect will be the impact of your project, within philosophy and beyond it?

Anke: A better understanding of how epistemic injustice affects diagnosis, and of the mechanisms behind these issues, is a crucial first step toward mitigation. Beyond contributing to the philosophical discussion, we aim to raise awareness among the public and medical professionals about the need for epistemic justice in health care.

Thor: The ambition is to put overdiagnosis on the map within the epistemic injustice in healthcare discussion, and, conversely, open the concept of epistemic injustice to the medical debate on overdiagnosis. Hopefully this contributes to reducing the epistemic harms of overdiagnosis in the “real world” in the long run.

Anke Bueter is Associate Professor of Philosophy in the School of Culture and Society, Aarhus University. Anke is the author of Feminist Philosophy of Science (Cambridge University Press, 2024).

Thor Hennelund Nielsen is postdoctoral researcher in the School of Culture and Society, Aarhus University. Thor is the author of "The Dynamics of Disease: Toward a Processual Theory of Health", an article published in the Journal of Medicine and Philosophy in 2024.

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. 

Narrative Deference

This blog post is a write-up of a paper by project postdoc Ellie Byrne which was published in Topoi in September as part of a special issue entitled Scaffolding Bad: Varieties of Situated Cognitive Harm edited by David Spurrett, Giovanna Colombetti and John Sutton. 

When I worked on the project Grief: A Study of Human Emotional Experience (PI Matthew Ratcliffe) at York, we obtained hundreds of first-person testimonies from grieving people about their experiences. I think regularly about some of the things people wrote, but there’s one in particular I keep coming back to: “My childhood is now only remembered by me. I’m an only child. So that time seems completely inaccessible.” (#208)

To me, this quote drew attention to the extent to which having other people available to corroborate our memories influences how we understand ourselves. We do this all the time and all throughout our lives: we might ask our parents to corroborate some significant childhood experience of ours, or ask a sibling to confirm that we’ve remembered something correctly. Later in life, we may ask a friend to corroborate how we remember coping with a breakup or our partner to remind us of a certain order of events in a particularly busy period.

We also enlist others to fill in the gaps for things we do not remember well. We might not really remember much at all about these experiences; perhaps just diffuse ‘feelings’ associated with certain events. In such cases, we might end up pretty reliant on our friends, family and partners to tell us what happened, how we felt about what happened and how those feelings have shaped who we are today.

According to the philosopher Richard Heersmink, autobiographical memories are the building blocks of our autobiographical self-narratives. Heersmink, situating some of his work within the field of ‘distributed cognition’, has emphasised that since our memories are distributed between people, it makes sense to say that our self-narratives are too. In my paper, I followed Heersmink in drawing attention to the extent to which we can rely on others for our autobiographical self-narratives, and the ways that this can be both good and bad for us. My paper introduces a concept which I call ‘narrative deference’, defined as the phenomenon whereby one is more dependent upon another person for central aspects of one’s autobiographical self-narrative than on oneself.

As I started to present this idea at conferences and workshops, there was a consistent theme in Q&A discussions: each time, multiple people in the audience had thought of contexts in which this phenomenon is harmful. This led me to think about the phenomenon in terms of another one of my research interests: affective injustice.

Affective injustice scholar Shiloh Whitney connects affective injustice to a distinctively affective form of gaslighting, the phenomena whereby casting doubt on someone is the means through which they are made to doubt themselves: “in gaslighting, the way others respond to me begins to impair an aspect of my relationship to myself. In particular, the noncooperative response I receive from some second person(s) when I express my experiences to them begins to impair some aspect of my ability to make sense of my own experience to myself in the first person” (Whitney 2023, pp.31–32). 

Understood this way, we can see how the affective influence others have on us can be used to undermine our self-trust over time such that our autobiographical self-narrative possibilities are restricted. While gaslighting is primarily discussed in the context of romantic relationships, it is being increasingly recognised how gaslighting can also occur in healthcare settings.

In a variety of contexts, an ill person might narratively defer to another because it presents itself as the best immediate option. Perhaps narratively deferring to my parents allows me to maintain a coherent or desirable autobiographical self-narrative. Perhaps deferring to my doctor allows me to make sense of an otherwise overwhelming and confusing situation. Perhaps deferring to my partner prevents conflict and maintains my bond with the person who cares for me. This deference can surely help me to secure lots of things that are good for me, but my most fundamental sense of self is also made vulnerable by it.

I think there is a lot of interesting and important future work to be done in exploring how this phenomenon operates in both epistemic and affective injustices in healthcare.

Eleanor Byrne

Eleanor is a postdoctoral research fellow at the University of Birmingham and part of Project EPIC. She specialises in affective and existential dimensions of illness experiences, particularly Functional Neurological Disorders. She has worked on grief in illness and experiences of post-viral fatigue such as Long Covid. She is currently developing a project on phenomenology and functional seizures. 

Communicating Ineffable Experiences

On the occasion of the Research & Development (R&D) Conference 2024 on October 15th, Jodie Russell, postdoctoral researcher on project EPIC, presented her work on ineffable experiences and the phenomenology of language to the Herefordshire and Worcestershire Health and Care NHS Trust.

In this post, Jodie summarises the key points in her talk.

Ineffability

Language as gesture

I want to make the case that it is possible for people who don’t themselves experience mental disorder to understand the experiences of those who do, even when these individuals struggle to communicate their experiences. This recognition is important as it may help us overcome some epistemic injustices as a result of assuming some experiences are un-understandable and therefore not worth trying to understand.

To make my case, I argue that we should take a phenomenological approach to language, drawing on French philosopher Maurice Merleau-Ponty for this purpose. On the phenomenological view, language is much more than the words on the page or the sounds that come out of our mouths; for Merleau-Ponty, language is a gesture at the world, which our whole body is involved in. When we speak, we are 'geared' towards the world in a particular way.

For example, when I talk about my cat Fluffy sitting on the mat, I’m gesturing toward Fluffy with my words, in the same way that I might point at Fluffy with my finger. My statement also indicates Fluffy’s ‘presence’; my statement turns us towards Fluffy in our shared world. At my mention, you might look for her or anticipate her to appear, for example, even if she’s actually just hopped out the cat flap.

A cat

The horizon of ideas

My language also implies certain things about me, the world I live in and the nature of Fluffy. For example, I live in a world where cats are domesticated. Her name also tells you that she’s a cat with a significant coat (hence her name) who is well known to me. Language, in the way that it points to aspects of the world, also implies further ideas beyond what we merely see; this is what Hayden Kee (2020) refers to as the ‘horizon’ of ideas.

Importantly, we are aware of other ideas implied by our language in virtue of being part of a shared world. As members of a linguistic community, we all contribute to a stock of shared meanings by both introducing new meanings, changing the old meanings, or reinforcing the old meanings. Which kinds of contribution we make depends on the context (my old saying maybe new to your ears, and thus I may contribute something new – in one way - to our personal pool of shared meanings). Nevertheless, we are, I claim, inherently embedded in a linguistic community and thus our language is (almost) inescapable from this pool of shared meanings.

Horizon

Sharing a linguistic community 

Individuals with ineffable disorder experiences are part of the linguistic community too; they may lack words for their experiences because there simply is no way to describe them in our community. But that doesn’t make their experiences totally incommunicable, I argue. We may just have to understand communication as being broader than words (someone may indicate with their body how they feel, and it is up to us to take up this meaning and try to integrate in into our horizon of ideas).

We must also acknowledge that describing an experience as ineffable is still, itself, communicating some of the experience. We may then need to tease apart the implications of that for other areas of the individual’s life (how they feel they live with an experience that can’t describe, e.g., as a mother, a friend or a working professional) to work around the areas that are more difficult to express.

Understanding individuals with mental disorder to be a part of our linguistic community, of which we are all inherently embedded, is key, I think, to overcoming some of the communicative issues that can arise when someone lacks words for a complex experience, and to gaining valuable insight into what it is like for them to live with said experiences.

Epistemic injustice and diagnostic approaches to mental ill-health

Epistemic injustice is evident in a plethora of contexts, some institutional, for which the discourse of hermeneutical injustice offers a helpful frame by way of its negotiation of meaning. Examples could include different treatments administered by healthcare institutions that unfortunately limit a patient’s voice and visibility. Other instances are well-trodden in the literature and media, and remain ever present, including gender and race issues, as presented by wide-ranging movements like Black Lives Matter and #MeToo.

A megaphone

Some examples of epistemic injustice are close to home and, sometimes, in the home. Relationships that once thrived can fracture when under sufficient pressure, whether between intimates, blood relations or in-laws, or something more general like the bonds between friends and other associates. In the throes of such breaks, testimonial injustice might be at work, concerned as this is with semiotic ruptures in spoken utterances that displace kindly intentions and good will. 

Where relational intimacy intersects with discourses that organise bonding experiences, for example, some kinds of religion and politics, the distinctions between hermeneutical and testimonial injustices are difficult to identify. The cliché that what is today’s deviance becomes tomorrow’s norm is continually challenged by the vicissitudes of lived experience that make possible the very identification of deviancy and normativity. The making of necessary interventions is, in this regard, highly problematic and, when it occurs in its zenith form, an achievement.

In 2021 my Master by Research dissertation, which explored some of these questions, was accepted in the University of Wales Trinity Saint David. My thesis, titled Diagnosis, misdiagnosis, and becoming better: An investigation into epistemic injustice and mental health, focused on diagnostic issues in the treatment of mental ill-health. Its main focus was to contextualise observations sometimes termed “empirical” by considering some of the existential contexts that experients of mental health treatment might find themselves in.

It is naturally the case that in an acute state, the solutions common to the biomedical model of mental ill-health are readily reached for. If a person suffers a psychotic breakdown then administering an antipsychotic drug could be a profoundly helpful and practical way of relieving distress. But there are many social domains that circumscribe, penetrate and, in turn, shape an individual’s diverse experiences of society. As well as religion, family, politics and the State, they could also include the stories we tell that frame those very societal categories. Psychoanalysis, literature, film and sociology are a handful of subject-disciplines that present telling-truth and telling-detail by offering “ways forward and out” of profoundly difficult moments in the life-course. My belief is that any line of enquiry that enables an experient to learn constructively and “re-find their feet”, so-to-speak, is both directive and instructive.

Antipsychotic medication

Concerned as it is with the mind as an aspect of embodiment that is organising as much as organised my research explores modes of being-and-becoming. In this regard, I am interested in two broad areas of exploration: first the clinical tools that enable a growth mind-set, whether employed by experients or physicians. Second, I lay out some of the general principles that might categorise those tools as philosophically resonant. They could be of a testimonial variety by highlighting signs and symbolic structures generative of psychosocial capacitation. 

Other, hermeneutical kinds may point to the diverse social movements that can lead an experient out of different forms of fog and miasma commonplace in contested diagnoses and misdiagnoses. In showing the presence and gravity of an epistemic injustice, there is laid the groundwork for a theoretical space where the experient can incrementally attain functionality. They may find ways of learning that which they themselves need vitally such that self-understanding becomes a real possibility. They might even encounter levels of personal, interpersonal and social responsivity expressive of epistemic justice and accountability.

Martyn Sampson

Martyn Sampson is an independent researcher of the philosophy of psychiatry and mental health. He is presently working on an extended project on stigma and phenomenology in regard to different psychiatric conditions.

Project EPIC on World Mental Health Day 2024

On the occasion of World Mental Health Day (#WMHD2024), we asked project EPIC team members to share a quote and a resource relevant to their work on epistemic injustice in healthcare.

Jodie Russell

Jodie is a researcher working at the University of Birmingham on one of EPIC case studies. Jodie is the author of "Problems for Enactive Psychiatry as a Practical Framework", published open access in Philosophical Psychology, highlighting the limitations of enactivism in reducing the harm and suffering experienced by individuals diagnosed with mental disorders.

 

Lisa Bortolotti

Lisa is an investigator in project EPIC, based at the University of Birmingham. Lisa has co-authored with Kathleen Murphy-Hollies a paper entitled "Why We Should Be Curious about Each Other", published open access in Philosophies, arguing that curiosity a good antidote to epistemic injustice. Lisa also edited and contributed a chapter to the forthcoming open access book on Epistemic Justice in Mental Healthcare (Palgrave Pivot).

Dan Degerman

Dan is a researcher on project EPIC, based at the University of Bristol. Dan's research explores the idea that it might not always be good to talk about one's mental health. If you want to know more, you can read Dan's article written for the Conversation.

Havi Carel

Havi is project EPIC principal investigator, based at the University of Bristol. Havi's work focuses on the experience of illness and she pioneered the application of the notion of epistemic injustice to healthcare. Watch this video where she introduces project EPIC.

Rabih Chattat

Rabih is a project EPIC partner, based at the University of Bologna. Rabih's work focuses on psychosocial interventions in dementia and the clinical psychology of ageing. He recently wrote a post for the EPIC blog on good living and social health as applied to dementia. Rabih also contributed a chapter on these themes to the forthcoming open access book on Epistemic Justice in Mental Healthcare (Palgrave Pivot).

Jude Williams

Jude is the project manager for EPIC at the University of Birmingham. Jodie volunteers for the Choir with No Name, the choir that gives homeless people a voice. If you want to know more about what the Choir is about and what impact it has, please read this.

Matthew Broome

Matthew is an investigator on EPIC and directs the Institute of Mental Health at the University of Birmingham. He recently co-authored a paper with Lucienne Spencer on epistemic injustice and claims of suicidality that can be found here. Together with Michael Larkin, Lisa Bortolotti, and Rose McCabe, Matthew contributed a chapter on youth mental health to the forthcoming open access book on Epistemic Justice in Mental Healthcare (Palgrave Pivot).

Eleanor Byrne

Eleanor is a researcher on project EPIC, based at the University of Birmingham. Eleanor works in the philosophy of medicine, on conditions that impact on the mental and physical capacities of those affected. In this podcast, she discusses an area at the intersection of philosophy and psychotherapy, focusing on experiences of fatigue.

Elisabetta Lalumera

Elisabetta is an EPIC project partner based at the University of Bologna. Elisabetta works in the philosophy of medicine. You can read this blog post where she talks about how to achieve epistemic justice in the biomedical paradigm. Elisabetta also contributed a chapter on digital health technologies to the forthcoming open access book on Epistemic Justice in Mental Healthcare (Palgrave Pivot).

Rose McCabe

Rose is an EPIC project partner based at City University, London. Rose specialises in research on clinical communication and contributes to the design of interventions to improve the capacity of professionals to listen to people who seek support for their mental health. See an example here. Together with Michael Larkin, Lisa Bortolotti, and Matthew Broome, Rose contributed a chapter on youth mental health to the forthcoming open access book on Epistemic Justice in Mental Healthcare (Palgrave Pivot).

Lara Calabrese

Lara is interested in ways of explaining and ameliorating the stigmatisation of people with dementia. She is a researcher at the University of Bologna, and is going to collect the data for one of EPIC case studies. 

Luigi Grassi

Luigi is an EPIC project partner, working at the University of Ferrara. Luigi recently shared some of this research interests in dignity and stigma in end of life care on the EPIC blog. Luigi also contributed a chapter on these themes to the forthcoming open access book on Epistemic Justice in Mental Healthcare (Palgrave Pivot)

Kathleen Murphy-Hollies

Kathleen is a researcher at the University of Birmingham. Kathleen has worked with some entomologists to better understand delusions of parasitosis, when people come to believe that their bodies have been infested by insects. To know more about this fascinating condition and the challenges it poses, go here.

Martino Belvederi Murri

Martino is an EPIC project partner, working at the University of Ferrara. Martino recently shared of his research interests in demoralisation and testimonial injustice in an acute psychiatric ward on the EPIC blog. Martino also contributed a chapter on these themes to the forthcoming open access book on Epistemic Justice in Mental Healthcare (Palgrave Pivot).