Objectivity, Standardization, and Epistemic Injustice in Psychiatry

In “Objectivity, Standardization, and Epistemic Injustice in Psychiatry,” I subscribe to the view that theoretical conceptions of mental health can operate as structural factors that promote epistemically unjust practices in psychiatric clinical settings. I examine how the high value placed on objectivity, conceived in terms of standardized methods and knowledge, may underpin various forms of epistemic injustice toward patients. 

In particular, I argue that it can lead to treating patients as mere informants or, worse, as sources of information, thereby undermining their status as epistemic agents. This state of affairs should be taken seriously because, I argue, the high value placed on objectivity and its standardized conception are theoretical cornerstones of the dominant model of psychiatric practice and research.

Before the development and adoption of the DSM-III in 1980, psychiatry’s disciplinary status was arguably precarious. The likelihood of two psychiatrists agreeing on a diagnosis was little better than chance, and the antipsychiatry movement had raised serious criticisms of its methods and categories. This was unacceptable not only for psychiatry as a discipline but also for patients, who could receive arbitrary diagnoses depending on the individual clinician’s perspective and thus miss out on appropriate treatment.

To establish itself as a branch of medicine, psychiatry needed to rely on objective evidence to support its diagnoses and treatments. Since psychiatric practice relies primarily on patient reports and behaviors, these had to be systematically addressed as its objects of inquiry. 

This required the development of reliable and (at least presumably) valid diagnostic tools — namely, operationalized criteria — and a view of mental symptoms as objects presented by patients and made observable to clinicians through standardized instruments, such as structured interviews and rating scales. 

From this standpoint, being objective in psychiatry means employing these standardized tools. However, by their very nature, such instruments must set aside interpretations — both the patient's and the clinician's — and disregard patients’ idiosyncrasies.

Given such a high value and standardized conception of objectivity, some clinicians may lack either the skills or the will to engage with information that falls outside the standard (and is thus deemed “subjective”), to take up or engage with patients’ conceptual resources and interpretations, and more broadly, to treat patients as epistemic agents seeking self-understanding. 

Others, of course, do have both the skills and the will. But what must be emphasized is the structural dimension of the issue: beyond individual clinicians’ attitudes lies a fundamental conception — that of objectivity — which underpins psychiatric theory and practice, and which systematically hinders engagement with patients as epistemic agents, instead promoting their treatment as mere informants or sources of information.

"[I]f psychiatry is to be an epistemically just discipline,
it must also find ways to engage with patients as epistemic agents."

I am not arguing that psychiatry should abandon the pursuit of objectivity or that generalized knowledge is without value. On the contrary, such knowledge is essential for making predictions about the course of mental conditions and identifying effective treatments. 

My point is that, if psychiatry is to be an epistemically just discipline, it must also find ways to engage with patients as epistemic agents. This would bring not only epistemic benefits but therapeutic ones as well. What is needed, in my view, is a collective theoretical effort comparable to the one that reoriented psychiatry toward standardization. We must now articulate the conditions under which attention to patients’ particularities and perspectives can also be regarded as objective.

Finally, if this analysis is correct, it has implications for the inclusion of patient perspectives in DSM revisions. While their inclusion will be bound to bring epistemic and therapeutic benefits, it falls short of addressing the complex realities of clinical practice. 

Standardized instruments may vary in how well they achieve their theoretical and practical aims — and in the extent to which they promote epistemic and social practices that are just— but they will always be insufficient to fully address patients as unique subjects and as epistemic agents.

Virginia Ballesteros is Assistant Professor in the Department of Philosophy at the University of Valencia. Her research focuses on the philosophy of psychiatry and altered states of consciousness. 

She is particularly interested in how mental disorders and psychiatric treatments are theoretically conceived, and the implications this has — for instance, in matters of epistemic justice, in phenomena such as self-illness ambiguity, or in the adequacy of pharmacological interventions. She has also worked on the philosophy of birth, exploring the epistemic aspects of medical birth care and the metaphysics of the birthing experience.

EPIC Summer School 2026

From July 14th to July 17th, 2026 project EPIC will host a Summer School at Ce.U.B (Centro Residenziale Universitario di Bertinoro) in Bertinoro, Italy. The event is made possible by generous funding by Wellcome, which will also subsidise the delegates' subsistence costs.

Poster of the event

Information about the event will be regularly updated on this page and a detailed programme posted closer to the time. 

The Fortress in Bertinoro

Summer School morning sessions

There will be lectures by the investigators and partners on the project:

• Martino Belvederi Murri (University of Ferrara)
• Matthew Broome (University of Birmingham)
• Lisa Bortolotti (University of Birmingham and University of Ferrara)
• Havi Carel (University of Bristol)
• Rabih Chattat (University of Bologna)
• Luigi Grassi (University of Ferrara)
• Ian J. Kidd (University of Nottingham)
• Elisabetta Lalumera (University of Bologna)
• Michael Larkin (Aston University)
• Rose McCabe (City St. George's University of London) 
• Sheelagh McGuinness (University of Bristol). 

Topics for lectures will encompass perspectives from philosophy, psychology, psychiatry, history, legal scholarship, clinical practice, and lived experience:

• the ineffability of illness
• AI-enhanced healthcare and epistemic injustice
• phenomenological approaches to epistemic injustice in medicine
• the role of dignity and person-centred care in an epistemic just healthcare
• the importance of clinical communication for good and epistemically just medicine
• moral responsibility and epistemic injustice
• legal and clinical approaches to epistemic injustice
• the centrality of agency in youth mental health
• co-design and co-production as ameliorative strategies
• epistemic injustice in dementia, schizophrenia, and depression.

One of the meeting rooms at the venue

Summer School afternoon sessions

EPIC researchers Jodie Russell, Kathleen Murphy-Hollies, Dan Degerman, Fred Cooper, Ellie Byrne, Alice Monypenny and Michael Bresalier will also participate, leading reading groups and discussion sessions on recent journal articles and book chapters.

 

Topics for discussion will include: 

• uptake of delusional beliefs
• vaccine hesitancy and epistemic injustice
• silence and testimonial smothering
• loneliness
• affective injustice
• phenomenology and intersectionality.

Apply!

If you are interested in joining us, there is a form you can fill to apply. The deadline for applications is 1st March 2026 and the outcome will be made known to applicants by 2nd April 2026.

The project EPIC team is looking forward to seeing you in Bertinoro!

What is Epistemic Loneliness?

In today's post  Ramón Alvarado discusses the notion of epistemic loneliness.

representation of loneliness

Often, we think of loneliness as a matter of social isolation. If we had someone— anyone— by our side, we would feel less lonely. Sometimes, we acknowledge that there is an extra component to this companionship. If we, or other lonely person, had not just any other person but a significant other, then we would be less lonely. And yet, we often feel lonely in crowds, in loving relationships, and even amongst friends and family. If this is the case, then there must be something else to certain instances of loneliness that is not addressed merely by the presence of others or even significant others.

In recent work, some philosophers of loneliness have suggested that what it is missing in such instances is a kind of recognition. For some, this comes from a mutual, evolutionarily convenient recognition of kinship. For others, it is a recognition of intellectual and character complexities that constitute your uniqueness. However, just as we saw above and as many highly recognized individuals can attest, being recognized is sometimes the reason why one may feel intellectually lonely. So there must be something else in some instances of loneliness where being in company of others, significant others, or being recognized does not suffice.

For example, many times we feel lonely because we are not “understood”. But this isn’t just us lacking someone we can impart knowledge to or someone that recognizes how smart and unique we are. Rather, we yearn for a conversation partner that can hold their own, someone that will not just challenge our beliefs but that can also help us build new ones. In short, sometimes what we yearn for and do not or cannot have is an epistemic partner—a willing and able interlocutor with whom we can share, exchange, and construct new knowledge. These are instances of epistemic loneliness.

Sometimes we feel lonely because we do not something others do.

While it is easy to think of extreme cases in which this happens— say the lonely genius or the trauma survivor— notice that epistemic loneliness is far more common in our everyday life. Most of us have felt it at least temporarily— teenagers, parents, romantic partners, introverts, academics, uneducated people, etc. In these instances, the loneliness arises because we know something that others didn’t but also because we do not know something others do. This is a very particular yet common instance of loneliness.

Understanding different kinds of loneliness allows us to better understand the different dimensions of this growing and worrying global phenomena. It can also elucidate the kinds of resources most apt to address or assuage it. Understanding epistemic loneliness in particular can help us make sense of the instances in which our loved ones and those we care for seem to lack something other than mere companionship. 

We are epistemic creatures. The acquisition, exchange, and creation of knowledge is at the center of our understanding of ourselves and our place in the world and amongst others. We should know and acknowledge this.

Ramón Alvarado is an Assistant Professor of  Philosophy at the University of Oregon. 

Ramón is interested in the philosophical implications of the design, development and deployment of computational methods and technologies in science and society. 

Ramón recently published a paper in Synthese on epistemic loneliness.

Epistemic Trust Injustice and Distrust in Public Health: Amelioration Strategies

In today's post, Elena Popa summarises a talk she gave as part of the pre-conference workshop “Epistemic Injustice in Healthcare” at the Nova University Lisbon. You can see the list of speakers here.

Trust plays a key role in public health. The success of guidelines and recommendations requires a trusting relation between the scientists making claims about the efficiency of interventions, policymakers and members of the public. Even on the best available evidence and policy design, public health interventions can fail if the levels of trust are insufficient. 

The example of vaccine uptake is particularly illustrative: distrust is an important driver of vaccine hesitancy and if such attitudes are present among a significant part of the population, this can undermine the aim of achieving sufficient levels of immunity within a population to prevent further infection. Similarly, guidelines regarding lifestyle, diet or other kinds of medical advice are less likely to be heeded in a context of distrust.

While there are several sources of distrust, my interest will be on the connection between distrust and epistemic injustice and the challenges it brings to public health and health sciences more broadly. The link between distrust and injustice has been pointed out in political context. As the scientific establishment also functions within a socio-political context such patterns of injustice and oppression can also spill over in scientific practice. 

This, in turn, yields warranted distrust in members of groups that have suffered oppression. Examples include unethical practices in medical research that have affected members discriminated on ethno-racial grounds or the neglect of women when investigating particular health conditions, such as heart disease or illnesses that do not have a clear link to fertility.

While the connection between injustice and distrust embodies a multitude of factors, including material and social ones, there is an important epistemic dimension to highlight. Particularly, if oppressed groups have good reasons to distrust scientific institutions or healthcare providers, these groups are also harmed in their capacity as knowers. 

The term ‘epistemic trust injustice’ thus refers to cases where the conditions that ground public trust in experts, or enable public access to scientific knowledge, are not met for members of oppressed groups. This kind of epistemic injustice is particularly harmful for the members of oppressed groups because it further limits access to needed health services or relevant medical knowledge. Furthermore, from a population-level perspective, the resulting distrust can exacerbate existing health disparities, making it more difficult to act so as to improve overall health.

How can this type of epistemic injustice be ameliorated? One thing to clarify is that solutions looking particularly at health research and healthcare also require improvements in social justice in the background. That is to say, scientific and healthcare institutions are moving away from or, ideally, completely eliminating, historically oppressive practices that have given rise to distrust. 

Assuming this background, more specific solutions involve acknowledging and highlighting structural factors leading up to health disparities, providing health professionals with skills to spot them when working with patients and engage in advocacy, and incorporating input from patients with relevant backgrounds.

First, taking a more population-focused approach in public health, particularly around social determinants of health and upstream causes of illness, would emphasize issues such as poverty, experiences of discrimination or oppression, lack of access to education or decent living conditions. Not only are all of these relevant for health outcomes, but they are more likely to affect vulnerable segments of the population, thus drawing attention to issues experienced by discriminated groups rather than focusing on the needs of better off groups that can access healthcare or expensive treatments with more ease. 

Furthermore, as these problems are more effectively approached through population-based interventions, this perspective is also likely to address health disparities as they do not require conditions that are unlikely to be met among oppressed groups. Through its explicit incorporation of problems likely to affect previously oppressed or excluded groups, this approach may also increase trust with time.

Second, medical and public health practitioners can play an important role in this perspective, as they can recognize patterns of epistemic trust injustice when interacting with patients. As opposed to placing the responsibility on the patients to acquire more knowledge about, e.g., vaccination or asking for blind trust from patients, which is common, health practitioners could acknowledge the problems faced by their patients and advocate for addressing them at the level of society or the health system. The skill of structural competence can enable this shift in practice.

Nevertheless, leaving the solutions to scientists and healthcare professionals is insufficient. Input is further needed by those most likely to be affected by how public health science and health policy are conducted. This can be done, for instance, though patient activism or activism from groups whose health problems have been neglected. Input from such groups can generate epistemic resistance, challenging existing frameworks and producing epistemic resources better suited for spelling out the health needs of oppressed groups.

A final point to stress is that these proposals for ameliorating epistemic trust injustice are not without pitfalls. They are all entangled with further political dynamics; it is possible that some solutions can be hijacked to tip the balance in favor of more influential groups. In order to counter that, a further condition, together with the move towards a more just society, is the closer integration of the goals and activity of experts with those of the patients and the public at large. Thus, ameliorating epistemic trust injustice in healthcare contexts can be done by orienting practices in healthcare towards the needs of oppressed groups within a background where wider steps are taken towards more social justice and integrated health goals.

Elena Popa is Ramón y Cajal fellow at the University of Seville working on a project conceptualizing causality in connection to social determinants of health funded by the Spanish Ministry of Science, Innovation, and Universities and the State Research Agency. Her research focuses on causality and causal reasoning and values in science, with special emphasis on cultural and social issues in medicine, particularly psychiatry and public health. Her published work includes articles in journals such as Synthese, Studies in History and Philosophy of Science: Part C, and Topoi and book chapters with publishers such as Oxford University Press and Cambridge University Press.