Psychotherapy, self-understanding, and epistemic injustice

This post by Anna Drożdżowicz and J.P. Grodniewicz explores the epistemic injustices that can arise in the context of psychotherapy.

Despite the recent surge of interest in the topic of epistemic injustice in various health care settings, relatively little attention has been paid to the risks of perpetrating epistemic injustice in the context of psychotherapy. In our recent article (Epistemic injustice and psychotherapy) published in Philosophical Psychology, we focus specifically on this topic. We propose, first, that many forms of epistemic injustice can arise in psychotherapy, and, second, that we should pay close attention to them, as they threaten an important goal of therapeutic work, namely, helping and empowering clients/patients to understand themselves better.

The goal of psychotherapy 

But let’s start from the beginning. What is psychotherapy? In general, we can think of psychotherapy as a psychological service that relies on collaboration between a psychotherapist and a client/patient. Usually, psychotherapy consists of a series of meetings and conversations that often span years (although some therapies are considerably shorter). The therapist and the client/patient talk about different aspects of the client/patient’s life, focusing especially on various forms of mental suffering that the client/patient experiences, and looking for ways to alleviate them. During that process, they also develop a relationship that most psychotherapeutic traditions consider to be an important healing factor.

Typically, the main goal of psychotherapy is to improve the client/patient’s mental health and well-being. Interestingly, an important aspect of therapeutic work consists in creating the context in which clients/patients can learn more about themselves, know themselves better, or—as we like to think about it—deepen their self-understanding.

Understanding and self-understanding

What is understanding? Whenever we try to understand a complex phenomenon, be it the political history of 19th-century Poland, jet propulsion, or genetic drift, we need to do two things. First, we need to acquire a lot of information about this subject domain, a significant portion of which has to be true. Second, we need to figure out the ways in which the information relates to each other. How did partitions and uprisings shape the fate of 19th-century Poland? How do the forces of combustion and aerodynamics interact to make jet propulsion work? How do random mutations and population size together influence genetic drift? And so on.

It is no different in the case of self-understanding. In order to understand ourselves, we have to possess a lot of information about how we feel and what we think in various situations, what motivates us, how we behave and react, and so on. Moreover, we have to figure out what the relations between these things are. What causes what? Which elements tend to co-occur, and how do they influence each other?

Good psychotherapy can be an excellent opportunity to acquire such self-understanding, thereby helping us make various choices and decisions on the way to the life we envision for ourselves and hope for.

Epistemic injustice in psychotherapy

Unfortunately, epistemic injustice in psychotherapy can preclude clients/patients from improving their self-understanding.

First, if the therapist treats the client/patient only as a source of information and not as an active partner in their joint work, the client/patient loses the chance to contribute their perspective. In the paper, we interpret cases like that as cases of participatory injustice in psychotherapy. In such cases, the resulting self-understanding of the client/patient may be less accurate or limited.

Second, we can think of cases in which a therapist attaches little weight to, or outright does not believe, some of the things the client/patient says, because they have previously classified the client/patient as suffering from a particular psychiatric disorder (e.g., narcissistic personality disorder) and have acquired a certain prejudice against that group. We present this as an example of testimonial injustice in psychotherapy. In such cases, the therapist may prevent the client/patient from acquiring new information about themselves and from grasping the relations between different pieces of information.

Finally, if the therapist is excessively attached to using certain categories, such as medical categories employed in a classification of mental disorders, which are alien to the client/patient, they may deprive the client/patient of the opportunity to develop their own, and more helpful, forms of self-understanding. We interpret this as an instance of hermeneutical injustice in psychotherapy.

Epistemic injustice in psychotherapy may not be more common than in other areas of medicine and healthcare. Nevertheless, the epistemic harms it can produce are, in our view, particularly interesting, given that psychotherapy relies heavily on fostering one’s self-understanding.

Author bios

Anna Drożdżowicz (left) is a Professor of Philosophy at the University of Inland Norway (website: https://annadariadrozdzowicz.wordpress.com/)

J.P. Grodniewicz (right) is an Assistant Professor of Philosophy at the Copernicus Center for Interdisciplinary Studies at the Jagiellonian University (website: www.grodniewicz.pl)

Combatting Epistemic Injustice through Self-diagnosis

Endometriosis is a chronic disease characterised by the growth of endometrial tissue outside of the uterine cavity (Parasar, 2017). Symptoms include infertility, cyclical and non-cyclical chronic pelvic pain, dysmenorrhoea (painful lower abdominal cramping during menstruation that effects quality of life), dyspareunia (pain during sexual intercourse), dyschezia (pain on defecation) and dysuria (pain on urinating) (Horne, 2022).

Endometriosis

The path to diagnosis can be long with an average wait time of 8 years and 10 months in the UK. According to Endometriosis UK, throughout this journey, many people feel dismissed by doctors and struggle to feel heard. 

As a response to the struggle to receive diagnosis, many have identified this condition themselves through research, resulting in self-diagnosis (Hallstrom, 2024).

Epistemic injustice and self-esteem

The gold standard test for diagnosing endometriosis is laparoscopic surgery (Allaire, 2023). According to NICE, more accessible tests, such as examinations and ultrasound scans, cannot be used to exclude it.  Therefore, referral for surgery strongly relies on testimony. This testimony is vulnerable to epistemic injustice. 

Fricker describes epistemic injustice as the idea that people can be discriminated against in their capacity as a knower based on prejudices about them. Testimonial injustice is where prejudices impact the credibility given to a knower’s testimony. Hermeneutical injustice is structural discrimination due to gaps in resources attributed to underrepresentation of marginalised individuals (Byskov, 2021). 

By denying credibility to these testimonies, we devalue contributions of experience and are dismissive of patients’ attempts to understand themselves. This undermines epistemic self-esteem by creating situations where people question their judgement of their experiences (Hallstrom, 2024).

I argue that self-diagnosis can combat epistemic injustice by improving communication in consultations.  This may not result in confirmation of the self-diagnosis but can combat the undermining of epistemic self-esteem.  

Communication

Effective bidirectional communication is vital in healthcare. However, the use of different language and concepts to express their situation between the patient and the clinician can cause misunderstandings. This can constitute testimonial injustice as their pain may fulfil the referral criteria but be denied due to their language not reflecting or mimicking the official NICE guidance surrounding the pathological pain of endometriosis. This undermines epistemic self-esteem by devaluing the patient’s contribution.   

The processes involved in self-diagnosis can combat this through creating access to communication aids. These aids, such as The Endometriosis Toolkit, can bridge the gap in communication by targeting language, providing a guide for noting observations and exploring other symptoms (check out the Menstrual health project). This can combat testimonial injustice by promoting a shared language and promoting effective communication. Therefore, epistemic self-esteem is maintained by having contributions valued. 

However, barriers to finding communicative aids online include variations in digital literacy. By encouraging individuals to improve their knowledge, whilst not supporting those unable to access resources, we risk worsening epistemic disparities. However, these aids are now available to those on social media and through schools, as in 2021 the UK Department for Education has mandated menstrual education which includes advice on when to seek help.

As many patients are young when symptoms first appear, discussions with those in their social groups are vital (Hallstrom, 2024). They can compare their symptoms to their peers and medical framework. Understanding the framework in doctors’ appointments can help them communicate their issue in accordance with guidelines, allowing them to access resources. This knowledge can diminish testimonial injustice through promoting a shared language and promote epistemic self-esteem by valuing their testimony.

Endometriosis

Dismissal of self-diagnosis

Affirmation of one’s self-diagnosis is not the aim of the appointment, but rather is a starting point for discussion. It can help understand and communicate the patient’s perspective. This questioning of symptoms and self-diagnosis can feel undermining, but effective communication in consultations can validate experiences even if the conclusion is not the acceptance of one’s self-diagnosis. When experiences are validated, damage to epistemic self-esteem can be negated.

This post is by Emily Bywater, a recent graduate from the University of Birmingham who completed an elective project with Kathleen Murphy-Hollies on tackling epistemic injustice in healthcare, with a focus on endometriosis. She provides us with a summary of her essay, which explores the philosophical and ethics issues which relate to practicing as a doctor.