Abolitionist perspectives on epistemic injustice in psychiatry

This post by Cath Roper and Nina Joffee-John explores abolitionist perspectives on how to address epistemic injustices in mental healthcare, drawing on interviews with mental health service users/survivors.

Unlike physical health, which protects the principle of informed consent to treatment, specific legislation enables public mental health services to authorise detention, administer treatment to persons without consent, and use restrictive practices. In most jurisdictions, such legislation operates across inpatient and community settings, invoking human rights issues.

People who have been labelled as ‘mentally ill’ belong to a group whose testimony can be doubted on grounds that it is faulty, unreliable, untrustworthy. We are often seen to lack ‘competence’ and ‘insight’ and our knowledge is not given credence. We can even be placed under the aegis of mental health legislation on these grounds.

Most of the researchers in our study had a lived experience of public mental health services.  Because of this, our perspectives could be regarded as inherently untrustworthy and we could experience  ‘testimonial injustice’.  The epistemic power of law and medicine, with their positivist, scientific worldviews, have the potential to combine and disqualify other worldviews, in particular the worldviews of people labelled ‘mentally ill’.

As researchers, we ourselves could be subject to testimonial injustice.  Our research could be dismissed on grounds of being ‘biased’ because we sought our key informants for their critique of mental health laws, a voice seldom heard in the formal literature. We aimed to gather the opinions of advocates and survivor activists on this topic in order to amplify these perspectives, contributing to epistemic justice.

Ongoing debate about coercion authorised under mental health laws is generally discussed by legal and clinical academics and typically centres on when it can be justified and how it can be reduced. Using a snowball sampling technique, we conducted interviews with 15 key informants across 5 different countries, who were known to hold a critique of mental health laws.

Informants thought these laws were discriminatory, caused harm and could not be justified. Mental health laws were criticized for breaching human rights, denying legal capacity, and displacing consent while forced psychiatric interventions were equated with torture and violations of freedom of opinion and expression. Psychiatric abolition was linked to broader movements like prison abolition and anti-colonial activism. Activism was positioned as essential to dismantle coercive systems and create new possibilities for non-violent, community-led care.

Abolition was proposed as a necessary response to the injustices of mental health laws,  involving daily steps toward creating a more just and equitable society.  Our findings showed imperatives to dismantle mental health laws on human rights grounds and to de-carcerate care. An urgent need to consider First Nations or Indigenous peoples’ activism and self-determination as abolition leadership was prominent in our findings. Informants suggested investing in social determinants, community-based care, and peer-led support systems as alternatives to coercive mental health practices.

Examples from countries without mental health laws, such as Thailand and Nepal were highlighted.  Peru was presented as a country that has come closest to putting a supported decision-making regime in place that operates on an equal basis for all citizens. Community-based models like Trieste, Italy, were highlighted which were founded on social inclusion and human rights. Human rights frameworks, such as the UN Convention on the Rights of Persons with Disabilities (CRPD), were seen as powerful tools for advocacy and reform.

Abolition theory and practice provide ‘hermeneutic resources’ so people can understand their social experience, informing social justice and community-led responses to care. Taken together, our findings provide a step-by-step model for abolition in psychiatry.

To read the full open access article and share through your networks: https://www.sciencedirect.com/science/article/pii/S0160252725000937 

Author bios

Cath and Nina are lived experience academics working at the University of Melbourne, Australia. Each has lived experience of involuntary mental health treatment and detention, including seclusion and restraint, which profoundly shaped their understandings of and commitment to social justice, equity, and freedom. They use these perspectives to consistently critique the ethics and operations of mental health laws. Nina is pursuing a career in law.