Toxic Positivity and Epistemic Injustice

 

Toxic positivity (TP) is “the phenomenon of people being positive and optimistic to a degree that is unreasonable in a given situation, and as such makes others feel as if their own (less than positive) feelings are invalid or in some way wrong, thus having the potential to cause harm to the victim” (de Rijk 2025). For example, if one loses a loved one and tries to garner support from a friend who then tells you that you should not be sad because your loved one is in a better place, you may have fallen victim to TP. 

Features of  Toxic Positivity

TP has four features: 

1) appropriate emotion in the victim as a starting point

2) unreasonable optimism on the part of the perpetrator

3) dismissal of the victim 

4) potential harm to the victim 

Toxic Positivity and Epistemic Injustice

I have argued (de Rijk 2025) that TP is an epistemic injustice because it has the potential to undermine knowledge to which the victim ought to have a claim so wronging the victim as a knower (Fricker 2007). Further, this is a particularly sneaky kind of epistemic injustice because it often masquerades as something good, because optimism is seldom considered problematic. Knowledge might be undermined through TP in at least three ways, all of which have their root in the doubt-instigation that is caused through dismissal. 

First, TP can make a victim doubt their belief and genuinely doubting a belief means that it can no longer count as knowledge. Second, TP could make a victim lose their belief because they might think the best course of action in response to genuinely doubting their belief. Thirdly, a victim may lose self-trust, which is a precondition for acquiring and maintaining knowledge (e.g., Zagzebski 2012; Dormandy 2024), although this would only happen in the most serious cases. 

Toxic Positivity and Getting Proper Medical Help

I now argue that TP that undermines knowledge formed through negative emotional experiences related to health can prevent one from timeously seeking proper healthcare. Imagine you are suffering a serious bout of depression but remain highly functional. You confide in a friend that you think you are depressed and need help. But your friend responds by pointing out that you do not seem depressed, you are going about your life as normal and even cracking jokes with your friends and colleagues, he suggests that maybe you are just feeling stressed about an upcoming deadline and when it has passed you will feel better. 

This makes some sense to you, and you begin to seriously doubt that you really are depressed even though you continue to feel all the symptoms of depression. Nonetheless, the doubt sown by TP acts as a defeater to your belief that you are depressed. 

So, you do not seek proper treatment for your depression (because why should you seek treatment if you are not really depressed?) and eventually suffer a complete nervous breakdown. In this case, TP has prevented you from seeking timeous medical help and as a result you ended up in a far worse position than you might otherwise have been.

This is just one way that TP undermining knowledge in connection with our health can prevent one seeking healthcare. But it is sufficient to show that undermining knowledge formed through negative emotions related to health can be detrimental to taking the right steps to ensure that one receives proper medical help before one’s condition worsens. 

Shené de Rijk is a PhD candidate at the University of Johannesburg in South Africa. She is affiliated with the African Centre for Epistemology and Philosophy of Science (ACEPS). Her dissertation is centred on investigating the phenomenon of toxic positivity in the field of social epistemology. Other than toxic positivity and social epistemology (and epistemic injustice in particular), her research interests include applied ethics, especially bioethics on which she has also written.

The Case for Epistemic Justice in Mental Health Nurse Education

When I first encountered the concept of epistemic injustice, I experienced a powerful moment of epiphany.  As a mental health nurse, lecturer and patient, I recognised it instantly. Not just as a philosophical concept, but as something I had witnessed and sensed in clinical practice as both a nurse and a patient.  

Mental health patients are frequently disbelieved, discredited and silenced, often when they are in most need of being heard.  This began my passion to embed the concept of epistemic justice into mental health nurse education.

Nurses talking to each other

Listening Is Not Enough

Listening is a central tenet of mental health nurse education, enshrined in regulatory guidelines and nursing rhetoric.  However, patients and psychiatric survivors have long since complained of dismissal and silencing at the hands of healthcare professionals inflicting long lasting iatrogenic harm. 

Instructing mental health nurses and other professionals to ‘listen more’ is a woefully inadequate response to entrenched epistemic injustice that exists within healthcare structures. This oversimplification ignores the complexities of social and medical power entwined with knowledge creation and exchange.  

Diagnoses that Drown Out Meaning

Discourses on epistemic injustice within mental health services often overlook the role of psychiatric diagnosis itself in perpetuating injustices around meaning making and testimony.   

I have taught students to assess people’s needs, plan care and manage risk. But I’ve also witnessed personally and professionally how quickly clinical language can strip meaning from a person’s story. And when we don’t teach students to notice this, challenge it, and reflect on their own assumptions, we risk reinforcing the very systems that silence the people we aim to support. We must deploy humility and acknowledge that mainstream psychiatric hegemony does not have the answers and has a questionable evidence base at the best of times.

Health education

Why It Matters in Nurse Education

As a mental health nurse lecturer, I believe that if we want to change clinical culture, we must start in the classroom. It is here that future nurses learn how to interpret, categorise, and respond to distress. It is here that they learn what counts as knowledge, and who counts as a credible knower. Are we preparing students to truly hear the voices of those they care for? Or are we, unintentionally, teaching them to privilege professional knowledge at the expense of lived experience?  

We need to create space in healthcare education to explore discomfort, ambiguity, and the limits of our own understanding. We must invite patients and survivors into the centre of our learning not as case studies, but as co-creators of knowledge.

What Would an Epistemically Just Education Look Like?

To me, bringing epistemic justice into mental health nurse education means:

• Teaching students to be critically reflective about whose voices are heard and whose are dismissed.
• Valuing lived experience as legitimate knowledge, not just as supplementary to clinical expertise.
• Interrogating the power of diagnostic culture, rather than accepting it as neutral or absolute.
• Creating space for discomfort and complexity, where not everything has to be neatly categorised.

It is not about teaching students to reject biomedical knowledge, but about holding it alongside other truths, especially the truths of those who have too often been silenced by the very systems designed to help them.

Why It Matters

I wrote this paper because I believe we have a responsibility, not just to care, but to care justly.  Bringing epistemic justice into healthcare means more than simply listening better. It means rethinking how we define expertise, how we structure conversations, and how we respond to stories that don’t fit neat diagnostic boxes.  It means recognising that silence is not always chosen, and that some voices have been trained into quietness by years of not being heard.

My hope is that by naming these injustices, we can begin to confront them. That we can move towards a model of care where knowledge is shared, where voices are valued, and where being heard is not a privilege, but a right.

The classroom is the place to begin.

Jane Fisher is a mental health nurse lecturer at the University of Central Lancashire.  She is simultaneously someone who has used mental health services, and lives with an imposed label of ‘mental illness.’  This gives Jane a unique vantage point.  

She has worked in frontline mental health services, accessed mental health services, and educates pre-registration mental health nursing students.  Jane is an internationally published author, offering a critical perspective on psychiatry and mental health, often using her lived experience to challenge the status quo.  

Published papers include topics such as epistemic injustice, identity, nurse education, and the problem with resilience.  Jane’s personal mental health struggles have fuelled her passion to challenge stigma and power asymmetries within mental health care, whilst shining a light on inequalities, iatrogenic harm and the true value of mental health nurses.

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.

Choosing Health Concepts: A Matter of Epistemic Justice

In healthcare, definitions matter. The way we define "health" is not just a technical issue — it shapes research priorities, clinical decisions, healthcare policies, and even citizens' rights. In my recent article, Health Concepts in Medicine and the Role of Philosophy, I argue that philosophers of medicine have an important role to play in this process. Choosing between competing concepts of health means not just offering better definitions, but also asking critical questions about the goals behind them and whose interests they serve.

Health and wellbeing

Although the article does not explicitly discuss epistemic injustice, the connection is clear. Epistemic injustice occurs when individuals or groups are wronged specifically in their capacity as knowers — when their experiences, knowledge, or perspectives are dismissed or undervalued. Conceptual choices in healthcare can either help correct these injustices or reinforce them. 

A narrow definition of health as simply the absence of disease, for example, can be useful if we want to defend healthcare as a universal right, but can marginalize people living with chronic conditions who still consider themselves healthy. On the other hand, concepts that emphasize adaptation and self-management may place unfair burdens on individuals in disadvantaged circumstances, turning social inequalities into personal "failures" of health.

In this sense, choosing a concept of health is not epistemically neutral. Different definitions elevate different voices — whether those of patients, clinicians, policymakers, or researchers. Some concepts recognize and validate the experiences of marginalized groups, while others risk silencing them. A focus on self-management, for instance, might overlook the structural barriers that make adaptation difficult for many.

Cover of Lalumera's new book

Importantly, the same concerns apply to other concepts in healthcare, such as well-being and quality of life. These are not purely descriptive terms; they are value-laden, and how we define them has real consequences for research, clinical care, and policy. I explore these broader issues in my forthcoming book, Health, Well-Being, and Quality of Life: A Philosophical Analysis, where I extend the framework of conceptual choice to these crucial notions. 

Ultimately, conceptual choice in healthcare is not just a theoretical exercise. It is a site where epistemic justice is at stake. Being attentive to whose experiences are recognized — and whose are left out — is essential if we want health concepts to serve everyone, not just a privileged few.

Elisabetta Lalumera is Associate Professor in the Department for Life Quality Studies at the University of Bologna and she is also one of the partners of project EPIC. Her research applies philosophical analysis to conceptual and methodological issues in medicine.

Digital Age: Mental Health, Cognitive Robotics, and AI

On the 9th of April 2025, Seiara Imanova organised an event, along with Andrew Hicklin, called "The Digital Age: Mental Health, Cognitive Robotics & AI", held at the Edgbaston campus, University of Birmingham as well as online. This post is a report of the event.

Speakers of The Digital Age event

The goal of the event was to highlight just how important the digital world has become, and the ways it’s shaping so many areas of our lives. As technology continues to shape how we communicate, understand who we are, and engage with systems of care, it’s crucial that we pause and critically examine what this means for fields like mental health, psychiatry, and beyond.

Seiara Imanova introduced Lucienne Spencer

The event began with an insightful presentation by Lucienne Spencer (University of Oxford), titled “Social Media & Shifts of Ontic Power in Mental Health”, which explored how digital spaces, such as social media platforms, can act as catalysts for shifts in psychiatric authority. In other words, online platforms like TikTok, Instagram as well as AI powered chatbots, are changing who gets to define, talk about, and influence mental health and psychiatry. Dr. Spencer highlights that although this shift could be considered a kind of ontic empowerment for people with mental ill health, re-shaping diagnostic categories in digital spaces carries the risk of distorting and diluting their original meaning.

Spencer’s presentation was followed by another incredible talk by Alan Winfield (University of Bristol), titled: “The Ethical Roboticist - From robot ethics to ethical robots”. Winfield looked at questions such as what do robot ethicists actually do, what kinds of harm can robots and AI cause, as well as ways for setting an ethical standard and regulations. Perhaps most striking was his demonstration of The AI Incidents Database, which highlighted why ethics was important in robotics, and how AI is already causing harm in the real world.

Alan Winfield's presentation

Last but most definitely not least, the third presentation was given by Paris Lalousis (King’s College London) titled: “Artificial Intelligence in Mental Health: Challenges, Pitfalls, and Opportunities” which is based on the excellent work he does at his AIM Lab at King’s. In contrast, Lalousis discussed the growing need for AI in healthcare, particularly in psychiatry, by highlighting the limitations of current neuroscientific approaches, such as the constraints of neuroimaging, the challenges posed by diagnostic ambiguity and high comorbidity rates between psychiatric conditions. 

Presentation by Paris Lalousis

Lalousis argued that intelligent systems hold significant potential to address these gaps. He presented his study on how the use of machine learning can better predict remission for patients with mental disorders such as schizophrenia or bipolar, and a glimpse into precision medicine.

The event hoped to achieve its goal which was to foster meaningful reflection on both the possibilities and ethical tensions that arise as human experience becomes more entangled with algorithmic and artificially intelligent systems. You can watch the live recording of the event below.

Metaphor and Epistemic Injustice in Schizophrenia

Today we interview Francesca Ervas and Lina Lissia on their project entitled: “Metaphor and Epistemic Injustice in Mental Illness: The Case of Schizophrenia” funded by PRIN, an Italian funding scheme to support research project of national interest. The project investigates epistemic injustice in metaphorical communication in the case of mental illness. A series of seminars has been planned as part of the project and the final meeting will be a conference held in Cagliari on 22-24 October 2025.

Metaphorical communication

Lisa: What are the research interests that gave rise to this project? 

Francesca and Lina: The project was born due to a common interest in metaphor as a way to express the self/mental illness relationship. The link with epistemic injustice, defined as the injustice towards a person as a knower, came later, and was based on the idea that metaphor can precisely be seen as an epistemic device. We were interested in both forms of epistemic injustice, as Miranda Fricker defined them in 2007: 1) as a failure to attribute credibility to people with mental illness (testimonial injustice), and 2) as an attempt to marginalize their epistemic resources thus not recognizing their ability to interpret their own experience of illness (hermeneutical injustice). 

The project builds on understanding and empirically investigating both the cognitive and social mechanisms behind testimonial and hermeneutical injustice, where people with mental illness often face epistemic challenges in credibility and interpretation. We hypothesized that metaphor can have a role as a communicative tool to overcome the ineffable and inarticulate nature of the mental illness experience and, notwithstanding social stigmas and interpretive difficulties, to reach an affective attunement with the relevant others (families, friends, doctors, healthcare professionals, other people in their social lives, etc.). 

Lisa: What are the main objectives of your project?

Francesca and Lina: Focusing on schizophrenia, the project analyzes the cognitive and bodily mechanisms at the root of the failure to attribute credibility (testimonial injustice) and interpretive capacities (hermeneutical injustice) to people with mental illness, when they communicate their illness to other people via metaphors vs. their literal counterparts.

We hypothesized that affective attunement in communication is a cooperative enterprise that needs to overcome both patients’ difficulties in embodying metaphors in illness communication and interpreters’ negative social and moral stereotypes, which concur to create the case for epistemic injustice.

The project involves three research units: the University of Cagliari (UniCa), the University of Messina (UniMe), and the University of Chieti (UniCh), respectively exploring:

1. the interpreter’s perspective (UniCa, Prof. Francesca Ervas, PI of the project)
2. the mental-ill speaker’s perspective (UniMe, Prof. Valentina Cuccio)
3. the mental-ill speaker/interpreter interaction (UniCh, Prof. Francesca Ferri)

Such factors help us understand the cognitive mechanisms responsible for the missing attunement between people with mental illness and interpreters. 

Metaphor is proposed as a valuable resource to foster a better attunement between the speakers with schizophrenia and the interpreters and to possibly prevent or overcome epistemic injustice in illness communication. Metaphor is indeed a necessary tool for people with schizophrenia to express their illness and themselves in relationship with the illness, but also for relevant others to access what the speaker feels as meaningful to articulate of their experience of illness.

Working together

Lisa: Does your project involve different disciplines and perspectives? 

Francesca and Lina: The three research units have different disciplinary backgrounds and methodologies: philosophy of language and experimental pragmatics (UniCa); philosophy of mind and psycholinguistics (UniMe); cognitive neuroscience and psychiatry (UniCh). UniCa and UniMe embrace a theoretical-philosophical approach to the problem of epistemic injustice in the case of metaphor. 

All the units adopt an experimental approach to empirically investigate the cognitive mechanisms at the basis of the problem, focusing on schizophrenia. However, each unit tackles the very same problem from different angles and via different empirical methodologies. Check the members and the disciplinary background of all our teams.

Lisa: What do you expect the impact of this project to be?

Francesca and Lina: Results will significantly advance the understanding of the theoretical, linguistic and cognitive aspects of metaphor use in mental illness communication, with interdisciplinary scientific and academic impact and social impact on public policies and health institutions. A social campaign, based on the experimental data on metaphors production/understanding and the active engagement of stakeholders, will also be designed and produced, with an impact on the general public. 

Finally, the outcomes have the potential to lead to the development of novel rehabilitative interventions and novel social behaviors to prevent epistemic injustice.

The Metaphor and Epistemic Injustice in Schizophrenia project team:

Francesca Ervas, Martina Montalti, Valentina Cuccio, Alice Guerrieri, Francesca Ferri, Lucienne Huby, Lina Lissia.

Rethinking silence and epistemic agency in mental illness

In the scholarship on epistemic injustice and mental illness, silence figures almost exclusively as an epistemic harm. More specifically, we usually understand silence as a deficit in epistemic agency resulting from social prejudice or an unfair lack of adequate conceptual resources. Often that is indeed the case, and breaking such imposed and harmful silences is crucial for achieving epistemic justice.

However, this picture of silence is incomplete and potentially harmful. It ignores the possibility that silence can play an epistemically constructive role in the lives of people with mental illness, and that discouraging or breaking silence in such cases could be destructive. This is a possibility I explore in a recent article. Focusing on experiences of silence among people experiencing mania, I argue that silence can be a powerful act of epistemic agency – the capacity to acquire, maintain, and share knowledge competently and freely.

Epistemically agential silence

I articulate three kinds of epistemically agential silence: communicative silence, listening silence, and withholding silence. Each refers to a literal silence – an absence of speech or noise – through which a person is attempting to perform an epistemic action:

1. Communicative silence is a silence through which a person intends to share knowledge with others. An example would be when you use your silence to express disapproval of something inappropriate someone has said.
2. Listening silence is a silence through which a person intends to acquire knowledge from a speaker. An example would be when you fall silent in a conversation so your interlocutor can speak and you can hear what they have to say.
3. Withholding silence is a silence through which a person intends to withhold knowledge from others. The function of such a silence might be to maintain knowledge, as when you decide not to share something with a person who might manipulate you into thinking you are mistaken. Its function can also be to avoid sharing knowledge, as you might do when you know an audience isn’t equipped to understand what you have to say.

These silences are plausibly important for everyone, but they seem particularly important for those who experience mania.

Losing silence in mania

Two common symptoms of mania are increased talkativeness and an uncontrollable urge to speak. First-person accounts suggest that people with these symptoms often find that their capacity to perform epistemically agential silence has been impaired.

Some describe losing the ability to perform listening silence. For example, in her memoir of living with bipolar disorder, Terri Cheney describes how, when she was severely manic, she’d become unable to ‘shut up and listen’. Another writer with bipolar, Bassey Ikpi, says that in mania she sometimes 'couldn’t remember how to quiet her brain enough to listen’.

Others report becoming unable to perform withholding silence. For instance, one contributor to a bipolar forum says that when she is manic, she does not ‘know how to stop talking’ and ends up telling everyone that she has bipolar, even if they have no need to know or are prejudiced or ignorant about mental illness.

This can have a profoundly negative impact on individuals with mania. Losing the capacity for silence can deprive them of vital information and undermine their support networks. Meanwhile, losing the capacity for withholding silence may lead individuals to reveal information about themselves and their illness in circumstances where disclosure might expose them to misunderstanding or discrimination.

People who experience mania are often well aware of these risks. Therefore, when they feel their capacity for silence is deteriorating, they may look for new ways to stay silent when they need to—for example, by clenching their jaw, jiggling their leg, or digging their nails into their palms. For them, silence is not an epistemic harm but a hard-won epistemic achievement.

The costs of misunderstanding silence

So silence can clearly have significant epistemic value for people with mania. This is why the assumption that silence is a sign of epistemic injustice may inadvertently perpetuate or even exacerbate harm. For example, it may prompt a well-intentioned individual to misunderstand a manic person’s epistemically agential silence as evidence of epistemic oppression and, therefore, seek to break their silence, perhaps by urging them to speak. That may end up undermining the epistemic agency of the manic person and expose them to epistemic and hazards they were trying avoid through silence.

To avoid contributing to this, those of us researching epistemic injustice must begin to explicitly acknowledge in our work that silence is a diverse phenomenon. Sometimes it does represent epistemic oppression. But it can also be empowering, constituting a vital epistemic tactic that ill persons and other vulnerable individuals use to navigate complex interpersonal, institutional, and social landscapes. If analyses of epistemic injustice in healthcare and beyond are to be relevant and helpful, this is not something we can ignore.

Dan Degerman is a Research Fellow on the EPIC project and a AHRC Research, Development, and Engagement Fellow on the 'Beyond Voice' project. His current research explores the relationship between silence and epistemic injustice in bipolar disorder.

Tackling Hermeneutical Injustices in Gender-Affirming Healthcare

As any trans person will tell you, it is a scary time to be living in the UK. One reason is that gender-affirming healthcare is becoming increasingly hard to access. In December 2024 the Health Secretary made a ban on prescribing puberty blockers to trans adolescents permanent, following the recommendation of the deeply flawed Cass Review. This ban has been criticised by several relevant professional bodies, diverges significantly from the consensus on best practice in peer countries, and flies in the face of decades-long histories of these drugs’ safe and effective use.

                                               
           

As a result, trans adolescents are being forced against their wills to undergo puberties distressingly at odds with their gender identities. Simultaneously, trans adults hoping to access gender-affirming healthcare from the NHS are being made to wait several years for their first appointment at a Gender Identity Clinic (GIC). These long wait times are taking a considerable toll on their mental and physical health. Moreover, convincing the relevant doctors at a GIC of their need for gender-affirming healthcare is no longer always sufficient since some GPs are unilaterally refusing or reversing GICs’ recommendations to prescribe hormones to their trans patients.

  

Trans identity and hermeneutical injustice

In addition, convincing the relevant doctors at a GIC of their need for gender-affirming healthcare is not always easy. Doing so is a matter of a patient rendering it intelligible to these (usually cis) doctors that they are indeed trans. This can prove difficult when the relevant doctors employ overly-narrow conceptions of transness. For instance, gay patients sometimes struggle to render their transness intelligible to doctors who assume that to be trans is necessarily to be straight. 

Similarly, non-binary patients sometimes struggle to render their transness intelligible to doctors who assume that to be trans is necessarily to identify as either a trans man or a trans woman. Moreover, that doctors sometimes work with such overly-narrow conceptions is a result at least in part of trans people having been deprived of opportunities to shape how people think about transness. In sum, trans adults sometimes suffer hermeneutical injustices when attempting to access gender-affirming healthcare from the NHS.

What can be done?

What should be done to prevent such hermeneutical injustices? In a recent paper, I distinguish between two sorts of strategy that might be pursued to this end. Interests-as-given strategies would take for granted trans patients’ interests in it being intelligible to the relevant doctors that they are indeed trans, and aim only to enable them to satisfy these interests. For instance, we might look to educate the relevant doctors or to engage in political activism aimed at propagating better-fitting conceptions of transness. 

All previously proposed strategies for preventing hermeneutical injustices are of this sort, yet it is sometimes possible to go about preventing hermeneutical injustices very differently. An interests-in-question strategy would instead look to do away with trans patients’ interests in it being intelligible to the relevant doctors that they are indeed trans, and thus with the possibility of these interests’ unfair nonsatisfaction. 

Consider that trans patients only have these interests in the first place because the prevailing gatekeeping model makes it a requirement on the provision of gender-affirming healthcare that trans patients first convince the relevant doctors at a GIC of their need for it. I argue on grounds of trust, privacy, and respect that the NHS ought to cease making this a requirement. One way to do so would be by switching to an informed consent model, under which pretty much all that a well-informed adult capable of consent would have to do to access gender-affirming healthcare would be to ask for it – an example of a more materialist strategy for preventing hermeneutical injustices. 

Unfortunately, in a time of intense anti-trans backlash it seems unlikely that the NHS will make such a progressive move anytime soon. We thus may need to think about what else can be done to prevent such hermeneutical injustices in the unjust meantime.

Nick Clanchy is a Postdoctoral Research Fellow with a joint appointment at the Canada Research Chair on Epistemic Injustice and Agency (UQAM) and Le Centre de Recherche en Éthique (UdeM) in Montréal, where they are also a member of the philosophy department at McGill.

Most of Nick's work is dedicated to thinking about hermeneutical injustices. They also have research interests in trans philosophy, the philosophy of love, and the work of a number of figures on the margins of philosophy - especially Roland Barthes. 

More about Nick and their work can be found here.