Episodicity, Mental Illness and Epistemic Injustice

In today's post, Dr Sally Latham summarises for us a chapter in her recently defended PhD thesis on narratives of the self, mental illness and epistemic injustice:

Self-narratives, especially in illness, have become a social expectation. However the assumption that being narrative is the normal, psychologically healthy human condition, and regarding non-narrative experience as somehow deficient, risks epistemic injustice.

I identify several forms of philosophical narrativism, the position that self-narratives are necessary for some individual good. One of these positions is metaphysical narrativism, the view that having self-narratives is necessary for an individual to have personal identity (for example see Antony Rudd and Marya Schechtman). I argue that metaphysical narrativism underpins the psychological position that not being narrative is symptomatic of mental illness.

Episodic Experience 

Galen Strawson first introduced the concept of episodicity, when rejecting what he calls Psychological Narrativity, which is the empirical claim ‘that human beings typically see or live or experience their lives as a narrative or story of some sort, or at least as a collection of stories’.

Strawson makes a distinction between an episodic and diachronic sense of self. A diachronic self-experience is an experience of oneself as ‘something that has relatively long-term diachronic continuity, something that persists over a long stretch of time, perhaps for life’. An episodic, in contrast ‘has little or no sense that the self that one is was there in the (further) past and will be there in the (further) future, although one is perfectly well aware that one has long-term continuity considered as a whole human being.’ Strawson counts himself amongst episodics, and claims others include Bob Dylan, Iris Murdoch and AJ Ayer. Importantly, as episodics lack an extended sense of self, they will not be narrative, meaning they will not experience events narratively, or understand them as part of an extended life-story.

The existence of non-pathological episodics with personal identity, as Strawson claims he has, undermines metaphysical narrativism.

Counterargument to Strawson: Episodicity as Pathological 

In response, Mackenzie and Poltera (2010) argue that a truly episodic experience is always harmful, and precludes personal identity. They refer to the biography of Elyn Saks, The Centre Cannot Hold, in which she documents her struggles with a lack of identity and with alienation when suffering with schizophrenia. Her experience is one of randomness and disorder, rather than temporality and unity, and lacks a concept of ‘me’.

MacKenzie and Poltera claim that ‘this theme resonates with narrative approaches to identity’ and that Strawson’s own experience is not genuinely episodic. Rather, ‘the case of Saks shows what genuinely episodic self-experience is like and why it is identity-undermining’.

Episodicity and Epistemic Injustice

This dismissal of accounts of non-pathological episodicity can be understood as either testimonial or hermeneutical injustice. Testimonial injustice occurs when prejudice causes a hearer to give a deflated level of credibility to a speaker’s word, with prejudice in the economy of credibility (Fricker 2007). It is assumed that the episodic experience of self precludes personal identity, and must be pathological. Therefore the testimony of an episodic claiming personal identity and no mental distress is dismissed as being wrong about either their episodicity or their personal identity and mental wellbeing.

The irony is that narrative movement in healthcare aims to give the ill a voice. Yet here a testimony is dismissed as inauthentic because it has been predefined as impossible. The episodic faces a catch-22: if you are really an episodic, this is pathological and you do not have personal identity, but if you are mentally well and have personal identity you are not really an episodic. Either Mackenzie and Poltera are claiming that Strawson is fundamentally mistaken about his own experience, or they are redefining episodicity as identity-undermining, which begs the question.

This situation could also reveal hermeneutical injustice, which occurs at a prior stage, when a gap in collective resources puts someone at an unfair disadvantage when it comes to making sense of their social experiences. Narrativism is so dominant that we have failed to develop the resources for understanding non-narrative, episodic accounts of experience and identity as coherent and non-pathological. Many episodics are operating without Strawson’s hermeneutical toolbox for understanding episodic experience. In narratively dominant environments their experiences are not comprehended, leaving them misunderstood by others and even themselves.

Unless we recognise different experiences of the self (or lack thereof) as the starting point for approaching mental wellbeing, we risk seeing episodicity as illness instead of thinking about what episodic wellbeing and illness might look like, and this could have far-reaching and damaging implications.

Sally Latham is a Visiting Academic at the Open University and Research Assistant at the University of Birmingham. She recently defended her thesis in which she argues against the dominant narrative approach to mental illness, arguing that in many cases a non-narrative, Buddhist-inspired approach is preferable.

Stigma, Diagnosis, and Identity

This post is by Aneela Khan.

Unusual experiences

In a recent paper co-authored with Lisa Bortolotti, Andrew Fox, and Matthew Broome, forthcoming in Journal of Medicine and Philosophy, I explore how the stigma associated with a diagnosis of psychosis can result in epistemic injustice, wrongs done to someone specifically in their capacity as a knower. Drawing on findings from the Epistemic Injustice and Psychosis (EIP) study, I highlight how both testimonial and hermeneutical forms of epistemic injustice arise in clinical encounters and in people’s wider social worlds.

The study involved interviews with people diagnosed with schizophrenia spectrum disorders (clinical participants) and people who had unusual experiences without receiving a diagnosis (non-clinical participants). While both groups encountered stigma, it was only the clinical participants who experienced a significant loss of credibility and identity transformation as a result of being diagnosed. For many, the label of psychosis, often associated with stereotypes of dangerousness and incompetence, became a lens through which others interpreted their thoughts and behaviours, often overriding their own self-understandings.

Person having a religious experience

An example comes from two clinical participants, Anna and Zara. Both had experiences they initially interpreted through spiritual or religious frameworks. Anna felt guided by God, while Zara understood her voices as a punishment for her sins. In both cases, these meanings were overlooked or pathologised during their engagement with mental health services. Although both eventually found aspects of the medical model helpful, especially in accessing support, they also described feeling “funnelled” into a diagnostic identity that clashed with their personal beliefs and values.

I use the concept of epistemic injustice to make sense of these experiences. Testimonial injustice occurs when someone’s credibility is unfairly deflated, something that happens frequently to people with a diagnosis of psychosis. Hermeneutical injustice arises when individuals lack the social resources to make sense of what is happening to them, or when their interpretations are dismissed. This was particularly evident in how spiritual or cultural frameworks were marginalised in clinical settings.

Communication

Importantly, I found that non-clinical participants, those with unusual experiences but no diagnosis, were often able to make sense of what they were going through using personal, cultural or religious resources, and did not report the same harms to their credibility or sense of self. This comparison suggests that epistemic injustice is not caused by the experiences themselves, but by how they are framed and responded to by others.

I make several recommendations for clinical practice, including: 

• creating open epistemic spaces where patients can express alternative interpretations of their experiences, 
• supporting meaning-making; and 
• improving communication around diagnosis. 

By exploring the interplay between stigma, identity, relationships, and knowledge, we can contribute to  structural changes to reduce stigma and promote epistemic justice, not only in clinical settings, but also within families, communities, and wider society. 

The Importance of Kindness – and some great tunes

Today's post comes from EPIC's Jude Williams and it shares the experiences of members of the Choir with No Name on finding a community where they could be heard and understood.

The Choir With No Name Birmingham, Summer Spectacular 2025
St Martin’s in the Bullring, Birmingham, 19th June 2025

I’ve had the privilege of being part of the Choir with No Name Birmingham as a volunteer since 2017. And despite a couple of long absences due to health problems, I’m always welcomed back with open arms. And that’s the thing about this choir. It’s a weekly welcoming hug, for people affected by homelessness and marginalisation. Everyone is held and supported by the love and efficiency of Choir Manager Sally, the musical genius of Choir Director Pete, and a group of volunteers who cook a hot dinner for 50 and provide a friendly face and a listening ear for those who need it. 

Our members are all ages and from all walks of life, and together we raise the roof of St Martin’s Church in the Bullring, in joyous 4-part harmony. Our gigs range from homeless shelters to tv award ceremonies to recording with pop stars. If HS2 ever does get built, we’ll be the sound of the new Birmingham Curson St station clock. And although it’s the singing that we all adore, the camaraderie and the feeling of belonging, it’s the effect that choir has on individuals, in a safe place where their voices are heard, which is the most profoundly moving aspect. This choir changes lives, with a good dose of belted-out bangers along the way.

Our members have arrived at choir after years of trauma - homelessness, addiction, domestic abuse, to name but a few. Many have had countless experiences of epistemic injustice - they are resigned to not being listened to. And yet at choir, a safe non-judgmental space, members come back week after week, gaining in confidence and voice.

Gabriel, Bass brings the house down with his ‘Earth Song’ solo All Together Now

Jenny, our youngest member, joined choir nearly 2 years ago, at age 18. Living with autism and anxiety, Jenny had to leave home quickly, 2 days after her 18th birthday, moving into a flat which she sat in, alone, for 6 months. 

“When I came the first time I was really anxious but I got to like it and then love it. You can always speak to people so I got really close with Sally and it’s nice that I can sit with her and have a sing. She checks in midweek which I find quite helpful, especially when I’m having a tough week, I know she’s thinking of me. I don’t think people understand how much autism and anxiety can affect someone, especially when something in the past has happened. People might think it stays in the past, but it doesn’t, it’s like a luggage tag that you keep with you, so I find it hard some weeks cos it can just pop up out of the blue.”

It wasn’t long before Jenny was holding a mike on stage and singing solos. She’s in charge of the ‘clicker’ too, moving the screen on in rehearsal as we learn the songs off by heart. “Singing is very important in my daily routine. There’s always music on through my headphones..to try to control the background, to help with my anxiety.”

Jenny struggles with seeing healthcare professionals as she doesn’t believe they always take her needs into account. 

“I used to go to the doctors a lot when I was living with my Dad, because of my mental health, but I feel like, they didn’t really do much. They’d say ‘it’s just the situation that you’re in’, but there was more to it. I used to be referred to family services and stuff and I feel like they didn’t really understand it either, I feel like they were oblivious to it all, they misunderstood the whole situation. They let me down. Even things like a simple blood test, which could be quite easy for you. The minute I walk in that room I’m nervous and I feel like the nurses don’t take into consideration that I’m autistic. I don’t even think they read the notes, they just call you in and expect you to get on with it, and it’s not that simple.”

 

Talvin, Tenor at choir rehearsal, Spring 2025

Talvin, a gentle but vivacious singer-songwriter in his 30s, spoke to me about his experiences. Having coped with homelessness and mental health issues, he found the choir through SIFA Fireside, a Birmingham organisation offering homeless support services. 

“It was everything that I was told it was – welcoming, loving, communal, entertaining, dynamic - right up my street music wise. It helped me to elevate back to a stronger place because there were other people I got to interact with that could understand my brokenness and understand my position. Everybody from the choir has come from the streets, from brokenness, from broken marriages and they just needed time away. When I first came to choir, I saw all the mixture of people and I felt at home. The warmth, the singing, the love and eating together and I look forward to every Thursday. No matter what is going on, I feel like I’m coming to see family.”

Talvin has had good experiences with healthcare professionals, feeling lucky that he’s been aware that there is help out there. 

“For me to navigate my mental health through my traumas, I needed help and therapy has helped me a lot. I’ve had to wait a few years, but I’ve had it. Others I know have had problems with reaching a level of understanding with people who are supposed to be helping them from the mental health sector. Either just been given tablets or just not getting them and listening to them. I must say, I feel I’ve been spoiled that way, I’m getting emotional about that, because I know that’s not everyone’s experience. I love people who want to give back and I wasn’t aware that groups, like the choir existed. Had I known these groups were about, I feel that I’d have had more stability because what I’m seeking, needing, to help soothe my overwhelming mental moments, is based in these places.”

The Sopranos and Altos singing their hearts out

Each week we get to sing and laugh together, and there is an implicit understanding that as individuals, we are exactly who we are, and that’s ok. As Talvin so eloquently puts it: 

“There is such a dynamic of people here, and when we communicate and how we engage, we all somehow take that into consideration. Without even saying it. There is that understanding. It’s so unwritten, no one says anything, everyone just acts accordingly. Every week, it shows you what the world is but it comes with such an acceptance. I’ve seen people who are not necessarily getting up to sing, but they just need to be here, just need to be around something, and this ‘something’ is here. Sally’s love and sternness and keeping things together, but with all love. And Pete’s discipline in keeping the structure of our music is like a very silent hug. All of you, everyone is just amazing.”

It's humbling and a real privilege to be part of the Choir With No Name. We are a family and we hold each other up, quite literally as we hug and clap each other on the back in the middle of performances. It’s a simple idea – to sing and eat together – but it’s those simple acts, with kindness and acceptance that make such a profound difference to people’s lives. As Jenny says: 

“You might not understand autism but the thing is, you’re all very friendly and I know I can approach you, I can talk to you. Kindness is important. It’s not about being able to read the person inside out, it’s about being very understanding and kind. You don’t expect everyone to understand but everyone can be kind, kindness is a choice.”

And Talvin’s mental health has hugely improved since attending choir. 

“That consistency of coming week after week has really helped me. I know I have a place on a Thursday and it’s guaranteed, I can come. I can join in with the meal at moments when I can’t do that with my own family or any close people, and I’m yearning for it. There’s so much that pulls me back here and gives me that consistency.”

Our 2024 Member’s Survey showed that 96% of members surveyed felt that being part of the choir helped to improve their mental health. 97% had reduced their stress and /or anxiety and 100% felt a greater sense of belonging, confidence, positivity and purpose. And that is shown in bucketloads at a Choir With No Name gig – it’s a joy to behold. Come and check us out. And if you can’t make it to Birmingham, there are 6 other Choirs With No Name across the UK delivering equally brilliant results.

Jude Williams is an Alto, cooks a mean dahl for 50 and is Project Administrator for Project EPIC at the Institute of Mental Health, University of Birmingham. 

Understanding Experiences of Mood Disturbances in Depression

Anthony Fernandez answers some questions on an exciting new project, Understanding Experiences of Mood Disturbances in Depression.

Could you give us the background to the project?

Understanding Experiences of Mood Disturbances in Depression is a new project combining qualitative and philosophical methods to establish a preliminary taxonomy of mood disturbances experienced by people diagnosed with depression. It will be carried out in the Department of Psychology, University of Southern Denmark.

A one-year pilot is currently running, funded by EPICUR, The European University Alliance, and co-funded by the European Union. The pilot is carried out in collaboration with Julian Kiverstein at the Lemon Tree Center for Psychiatry, Psychotherapy and Philosophy, Department of Psychiatry, Amsterdam University Medical Center. The full four-year project is funded by Independent Research Fund Denmark. Parts of the project will be carried out in collaboration with Evan Kyzar and George Denfield at the Department of Psychiatry, Columbia University.

What do you want to investigate?

The project investigates how people diagnosed with depression experience mood disturbances during their depressive episodes. However, the aim isn’t to generate general descriptions of what it’s like to live with depression or how depression affects one’s day-to-day life. Rather, the project aims to critically interrogate common psychiatric concepts and develop more nuanced or refined concepts that better capture the variety of mood disturbances experienced by this population. 

The concept of “depressed mood”, for example, is poorly defined or not defined at all in psychiatric textbooks and diagnostic manuals. Instead, these texts tend to list a variety of affective states that are merely indicative of depressed mood, such as feeling sad, blue, despondent, empty, hopeless, or cheerless. It’s therefore unclear what a depressed mood even is, or what we mean when we say that someone has a depressed mood. By generating detailed descriptions using in-depth interviews and analyzing the transcripts with philosophical methods, we aim to revise and develop new mood-related concepts, producing a preliminary taxonomy of mood disturbance that can inform psychiatric research and clinical practice.

Why is this important?

Despite depression being one of the most common psychiatric disorders, treatments remain ineffective for many patients. One possible reason for the low response rates is that the diagnostic category of depression doesn’t capture a single disease entity. Rather, it likely captures a variety of heterogeneous conditions that, due to superficial similarities in experience and behavior, we’ve lumped under a common label. This heterogeneity is also reproduced at the level of symptoms, where a single symptom construct, such as depressed mood, may lump together states that should be disambiguated.

We aim to develop more precise concepts that capture specific mood disturbances experienced by people diagnosed with depression. These more specific concepts can then be used by researchers in other disciplines, such as clinical psychology, psychiatry, and neuroscience to determine, for instance, the prevalence of these mood disturbances, whether they correlate with treatment effects and course of illness, or even whether they correlate with biological markers. This is all work for after the project, though. Our immediate aim is to develop a preliminary taxonomy of mood disturbances.

Will the research programme be interdisciplinary?

The project is interdisciplinary through and through. My own background is in philosophy, although I’ve worked collaboratively with clinical psychologists and psychiatrists since my Ph.D. Julian Kiverstein, who’s collaborating on the pilot, has a similar background. The project also includes Martin Vestergaard Kristian, a postdoctoral researcher and clinical psychologist. He will conduct interviews using Phenomenologically Grounded Qualitative Research, an approach to qualitative study design and interviewing I co-developed with Allan Køster, also a philosopher and psychologist. Then we’ll hire on a PhD. student with a background in phenomenology and philosophy of psychiatry to help analyze the data and work on concept development. That’s the core team. But we also have two neuropsychiatrists, Evan Kyzar and George Denfield, who will help not only to develop our new mood disturbance concepts, but also make them accessible to an audience of psychiatrists and neuroscientists so we can disseminate our results in major journals in these fields.

What do you expect the impact to be?

I think the immediate impact will be more evidence that what we call major depressive disorder actually captures a diverse array of experiences and behaviors, which may be best to distinguish, both for research and clinical practice. In the longer term, I hope we’re able to identify and conceptualize mood disturbances that will eventually be shown to correlate with different course of illness or treatment outcomes, since that will have the most impact on clinical practice.

Anthony Vincent Fernandez is Associate Professor of Applied Philosophy and Theoretical Psychology at the Department of Psychology and the Department of Sports Science and Clinical Biomechanics, and a Senior Fellow of the Danish Institute for Advanced Study at University of Southern Denmark. His work focuses on the use of phenomenology in disciplines outside of philosophy, including psychiatry, nursing, anthropology, and sociology. He is co-editor of The Oxford Handbook of Phenomenological Psychopathology and co-editor-in-chief of Phenomenology and the Cognitive Sciences. He is currently writing new introduction to phenomenology, which details how researchers in the psychological, social, and health sciences, as well as in art and design, understand and use phenomenology.