Epistemic Injustice in Indian Mental Healthcare Across Generations

Indian mental health care is marked by an astonishing diversity, ranging from state-sanctioned therapy sessions to mobile phone applications and traditional modalities like temple rituals, spiritual healers, and family customs. As urban Gen Z populations increasingly engage with psychotherapy, spiritual models based on assumptions of karma, nazar ("evil eye"), or spirit possession remain influential on models of distress. These plural systems are in competition with one another, especially within clinical environments where biomedical models hold sway, creating epistemic injustice.

Fricker (2007) imagines epistemic injustice as unfair treatment of individuals as knowers. In medicine, it manifests in testimonial injustice (when the patient's testimony is questioned due to prejudice) and hermeneutical injustice (when people do not have the authorized language or map to express their suffering). In India, patients quite often present symptoms in religious or idiomatic terms, which are quite often pathologized or ignored by doctors. Halliburton's (2005) ethnography of South India shows how patients shift between psychiatrists and religious healers with ease, not due to ignorance but in a reflective pursuit of care that is sensitive to their lived lives. Clinical practices are seldom responsive to such mixed-up modes of explanation.

While it is common for patients in India to make sense of their symptoms in religious terms, and seek help from religious healers and clinicians alike, clinical practice can be unresponsive to the blending of these explanations.

This trend is carried over to the virtual realm. Sehgal et al. (2025) discovered Indian teenagers who used mental health chatbots preferred products that were culturally appropriate, anonymous, and personally tailored. Authors note computerized treatments, although promising, risk maintaining clinical hierarchies unless they keep in mind sociocultural backgrounds.

Gen Z is in an interesting position—most are receptive to therapy but still ensconced in families that adhere to traditional systems of faith. Between therapists and temples, they generally experience anxiety when mental health providers dismiss their models as unreasonable or unscientific, which undermines confidence and continues epistemic hierarchies.

While this discussion is being situated in India, the same dynamics occur everywhere. Minority and migrant communities in the UK and elsewhere have also reported exclusion when their belief systems are not compatible with Western clinical definitions. The Indian context thus provides a window with which to interrogate bigger questions: Whose knowledge is considered legitimate in mental health treatment? Who gets to say what's real or treatable suffering? 

Both Gen Z Indians and members of migrant communities might similarly feel adrift in a Western medical system that isn't compatible with their beliefs.

To resist epistemic injustice requires more than cultural sensitivity; it requires epistemic humility. Clinicians are required to work with, not supplant, patients' own explanatory models—religious, family, local. True healing is only available by acknowledging, not erasing, these multiple forms of knowing. 

Gen Z, standing at the crossroads of tradition and worldwide conversation about mental health, can possibly spearhead this transformation—given that their diverse experience is taken seriously. Listening to them is crucial towards the creation of an expansive and equitable system of mental healthcare.

Parinika Arora is based in New Delhi, India, and is a postgraduate student pursuing an MSc in Mental Health at the University of Birmingham, UK. With an undergraduate degree in Psychology from India, she has contributed to 7–8 academic book chapters exploring the intersections of psychology, AI, and mental health. She loves writing and sharing insights on mental health and psychology to reach a wider audience. Parinika also runs an Instagram page called PsyPrism focused on mental health awareness. Alongside her academic work, she serves as a director at Minus One Experiences Private Limited, an event management company based in India.

Menopause Apps, Empowerment and Epistemic Injustice

In women’s healthcare the problem of epistemic injustice may be compounded by women’s structural marginalisation. Fricker argues that healthcare professionals (HCPs) rarely adopt these negative positions on purpose, nevertheless they present a substantial barrier to women seeking to access support and treatment for a range of health issues including menopause. 

Mobile health applications (mHealth apps) provide a resource across a range of health topics including women’s health and menopause but there is debate in the literature as to whether these apps are empowering for women or whether, at least in terms of their promotional narratives, they reinforce sexist stereotypes and diminish women’s credibility as people who can ‘trust their own experiences and gather reliable knowledge about their own bodies’ (Hendl & Jansky, 2022). 

Picking up on this debate we wanted to understand more from the perspective of women using menopause apps and to find out what if any role they played in their experiences of empowerment and epistemic injustice. In our study we spoke to peri and post-menopausal women about their experiences of using menopause apps. Women told us they used the apps to find out more about menopause, to read other people’s experiences and in many cases, they tracked their menopausal symptoms, symptom triggers and menstrual information. 

This tracking data was often used to 'evidence' women’s symptoms and their changing menstrual cycle as part of their discussions with HCPs. Women felt more confident in talking about their menopause with their HCP if they had a visualisation or record of their symptoms whilst others simply used the tracking data to bolster their confidence in explaining their concerns and their treatment preferences. For these women, many of whom had previously had an unsatisfactory encounter with a HCP in which they felt they hadn't been believed or listened to about their menopause, using the apps was empowering. 

Whilst the idea of turning personal experience into knowledge and evidence seems to fit with a healthcare context that often priorities objective scientific decision-making, the app played a role in a number of ways. It certainly didn’t seem to ‘reveal’ knowledge of the body but allowed women to capture and document what they were already aware of in a format that made it easier for them to collate and present to HCPs. 

Many didn’t feel the need to share the data with HCPs; consulting the app before the appointment provided a confidence boost to their discussions. The data had other meanings for women beyond sharing and evidencing. These related to ongoing self-reflection, self-care and positive decision-making around their health and wellbeing and for many it complimented or was a natural progression from paper-based journaling.

Importantly, experiences with HCPs varied with some women discussing positive conversations with empathetic and understanding HCPs and using the apps led to positive acceptance of menopause and increased discussion with friends, family and work colleagues. Technology like this does not solve the problem of epistemic injustice and the marketing narratives around ‘taking control’ are often misleading. But for our women, the apps supplemented rather than undermined their belief and understanding of their own experiences of menopause. They felt confident to express their personal testimonies with a backup plan in their pocket if needed. Menopause apps might be a resource that supports productive and supportive encounters with HCPs and one that some women will find helpful even if only for a short period of time.

Elizabeth Sillence is an Associate Professor in the PaCT Lab at Northumbria University. Her work focuses on the role of digital technology in health and wellbeing with a particular focus on trust and decision-making. 

Alison Osborne is a senior researcher engaged in research focusing on health, well-being, technology, inclusion, and social justice. Her work has involved working closely with a variety of populations including women, veterans, bereaved families, LGBT+ communities and military children as well as stakeholders including local authorities, the NHS, charities, local and national government. Alison’s research aims not only to understand experiences and needs but to support meaningful change.

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.

Epistemic Justice in Mental Healthcare

This week we announce the publication of an edited collection which is entirely open access: Epistemic Justice in Mental Healthcare: Recognising agency and promoting virtues across the lifespan (Palgrave 2024), edited by myself, Lisa Bortolotti. The book is an output of project EPIC, featuring eight new chapters exploring epistemic justice in mental health. 

Epistemic Justice in Mental Healthcare

In the Preface (downloadable here), Matthew Broome and I frame the discussion as a way to affirm the role of the mental health patient as a person, an agent, and a collaborator. When we are mental health patients, we are persons because we are more than our health or our diagnosis, we have needs and interests that matter and that affect the way in which our health impacts our lives. 

We are also agents, because despite the vulnerabilities of our status as patients, we have a perspective that matters and the capacity to contribute to positive change. Crucially to the success of clinical encounters, we are partners in the project of addressing our health issues. We can collaborate with healthcare professionals by sharing our experiences and participating in decision making.

Chapter 1, Being understood: epistemic injustice towards young people seeking support for their mental health, is authored by Michael Larkin with members of the Agency Projects team including lived experience researchers from McPin. It addresses some of the factors that make clinical interactions unsuccessful, offering some suggestions for improving clinical communication. The focus is on ensuring that young people are understood and supported at times of crisis, that they are not blamed for the difficulties they face, and that they are not reduced to a diagnostic label.

Chapter 2, Challenging stereotypes about young people who hear voices, is authored by myself, Lisa Bortolotti, Kathleen Murphy-Hollis, Fiona Malpass, and young people from the Voice Collective. It highlights three stereotypes associated with voice hearing that have harmful consequences for young people's relationships and opportunities to thrive, in the family, the school, and the clinic. These are incompetence, dangerousness, and diversity leading to exclusion. The chapter illustrates the impact of these stereotypes based on the young people's experiences, and encourages further empirical research in this area.

Chapter 3, Reacting to demoralization and investigating the experience of dignity in psychosis: reflections from an acute psychiatric ward, authored by a team led by Martino Belvederi Murri, addresses the unique challenges to epistemic justice that emerge in an acute ward, where coercion may be used. The use of coercion may engender situations that are detrimental for individual dignity and morale. One such effect is demoralization, which may increase the risk of suicide. The chapter provides an overview of the work on these topics and offers some suggestions for strategies that might improve the experience of psychiatric inpatient care.

Chapter 4, Not all diagnosis are created equal: Comparing depression and borderline personality disorder diagnoses through the lens of epistemic injustice, authored by Jay Watts, examines four aspects of epistemic injustice: objectification, moral agency, trivialization, and narrative agency. It compares personality disorder and depression, arguably the least and most popular diagnoses with patients in psychiatry. The analysis emphasises the importance of epistemic injustice as a tool in critically evaluating the usefulness of specific psychiatric diagnoses, encouraging a shift in clinical training to embrace reflective practices and restructure power dynamics in clinical encounters. 

Chapter 5, Resisting perceptions of patient untrustworthiness, authored by Eleanor Palafox-Harris, argues that a beneficial therapeutic relationship between patient and clinician requires mutual trust. In order to effectively treat someone, a clinician has to trust the patient’s reports of their symptoms but many psychiatric diagnoses are stereotypically associated with traits that indicate untrustworthiness (such as irrationality). In this chapter Palafox-Harris illustrates how psychiatric labels can signal stereotypes of untrustworthiness, reducing patients' perceived epistemic credibility.

Chapter 6, Preserving dignity and epistemic justice in palliative care for patients with serious mental health problems, with Luigi Grassi as lead author, considers the challenges faced by people with serious mental disorders who are at the end of life and promotes a person-centred approach, which can increase the sense of personal dignity and epistemic justice. Dignity Therapy can be applied in palliative care settings, offering people an opportunity to reflect upon crucial existential and relational issues and prepare their legacy.

Chapter 7, Promoting good living and social health in dementia, with Rabih Chattat as lead author, explores the notion of good living in the case of dementia and highlights the role of social health in preserving wellbeing. Discrimination impacts people with dementia in diagnosis disclosure, advance care planning, and decision making. The chapter critically examines the labelling of the behaviour of people with dementia as problematic and pathological even when it is a reaction to difficulties in communication.

Chapter 8, Ameliorating epistemic injustice with digital health technologies, authored by Elisabetta Lalumera, discusses the potential of digital phenotyping for ameliorating epistemic injustice in mental health. There is a concern that the evidence digital health technologies gather may overshadow individual experiences but, through a fictional case study, Lalumera portrays digital phenotyping as way to support shared decision-making. 

The book aims to help understand how the demands of epistemic justice relate to and complement recent research on agency in youth mental health, person-centred care, dignity therapy, stigmatising diagnoses, good living, social health, and access to digital technologies. As illustrated in the figure below, people seeking help should preserve crucial roles as agents and collaborators with valuable perspectives, multiple interests and needs, the capacity to contribute to positive change, and the capacity for shared decision making.

The mental health patient as an agent