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.

Alice Monypenny joins Project EPIC

We are thrilled to announce that Dr Alice Monypenny will be joining project EPIC from May 2025. As an introduction, we asked her some questions about her research.

What are your research interests?

I’m interested in the idea of epistemic agency – what it means to be a part of the processes and activities through which we produce and share knowledge. A lot of recent research related to epistemic injustice focuses on the ways in which people may have their epistemic agency limited, for example by being excluded from conversations, lacking adequate hermeneutical resources or being regarded as unreliable informants. However, I am interested in exploring the strategies people from oppressed and marginalised communities develop to cope with epistemic injustice.

In my recent work, I have argued that sometimes epistemic vices, such as closed-mindedness or intellectual arrogance, can be developed as coping strategies in hostile environments. My most recent paper (coming out in the Journal of Philosophical Research soon) defends a position in virtue/vice epistemology, called ‘normative contextualism’, which states that sometimes, depending on context, these traits may not be intellectual vices because of the role they play in allowing their bearer to cope with the challenges of their epistemic environment. 

I’m also interested more generally in how positive environments enable people to have a voice, my PhD research focused on understanding the role of safe spaces in education. 

Alice Monypenny

Why is studying epistemic injustice in healthcare important?

Understanding what it is like to live in our own bodies is such a fundamental part of being able to understand and interpret our experiences and how we interact with the world around us. That is why I think that understanding epistemic injustice within healthcare is so important – if someone lead to doubt their ability to understand their own experience of embodiment and make sense of the symptoms or conditions they experience, then this can have a significant impact on how they view themselves as a knower. It’s important to think about the ways in which healthcare systems and institutions can undermine people’s sense of understanding their own experiences – whether that’s through negative interactions with healthcare professionals or alienating language and labels. 

What are you working on at the moment?

I’m currently interested in the strategies adopted by patients and those seeking diagnosis and treatment when they interact with healthcare professionals, particularly when they hold back information about their symptoms or medical history. I’m using Kristie Dotson’s concept of ‘testimonial smothering’ to understanding this practice and exploring the way in which it can be an exercise of epistemic agency by enabling those who use it to carefully navigate tricky relationships with healthcare professionals who are gatekeeper to treatment and diagnosis. At the moment I’m exploring two case studies: patients with chronic pain; and trans and non-binary individuals seeking to access gender-affirming care. I’m also interested in the ways that patient communities and networks share information and resources such as tips for engaging with doctors or what to say in order to be taken seriously and get access to the right diagnoses and treatments.

When patients hold back: Tactical choices and epistemic agency

Relationships between healthcare professionals and patients often involve an imbalance of power. Medical professionals are very often the gatekeepers of diagnosis, treatments and other support services. Patients on the other hand, typically lack the institutional markers of authority that come with medical qualifications and position. We’ve seen how epistemic injustices can occur in these settings as a result of the biases and prejudices of medical professionals who fail to appropriately recognise the reliability of their patients as sources of information or structural defects of healthcare systems. 

I’m interested in exploring the ways in which patients might respond. How do those seeking diagnosis or treatment navigate tricky relationships with medical professionals?  What epistemic strategies do patients develop? What forms can epistemic resistance take? One approach that is taken by some patients is a tactical one – being careful about what information they share and how they share it. U.S. based researcher Ann Neville-Jan describes her own relationships with doctors and other medical professionals in her long and often demoralising search for an explanation for her chronic pain and effective pain relief. 

Like many who experience chronic pain, Neville-Jan found herself fighting against the view that her pain was ‘just in her head’ – a perspective not uncommon amongst healthcare professionals who view patients with chronic pain as being unreliable in their understanding of the extent and cause of their own pain. As a researcher herself, Neville-Jan was able to play an active role in investigating her condition, leading to a breakthrough: she came across reports of the effectiveness of the use of the drug Paxil for pain relief. The treatment was effective and also provided an insight into the cause of her pain: a ‘hardwiring’ of pain signals in the brain, similar to phantom limb pain.   

Whilst she was successful in finding effective pain relief, Neville-Jan still had to navigate encounters with healthcare professionals. Given the prevailing “just in your head” attitude, Neville-Jan reasoned that if she shared the information regarding her treatment, healthcare professionals would be likely to appeal to psychosomatic interpretations that better fits their narrative, especially because Paxil could also be used to treat depression. The information that her pain does have a physical cause and is effectively manageable with Paxil may be deemed implausible or even unintelligible to some healthcare professionals. So as a result, she chose to limit what she tells them, holding back the information which she thinks they will be less open to. 

This is an example of a practice which feminist philosopher Kristie Dotson calls ‘testimonial smothering’ in which a speaker ‘truncates’ their testimony – withholds certain information, avoids presenting it in a particular way, or doesn’t share it at all – because they believe that their audience will not find it plausible or intelligible. This practice is often the result of bad experiences: attempts to share information where audiences were found to be incredulous or tended to misinterpret or resist the information being shared. Of course, the practice carries with it numerous negative consequences. It restricts what the speaker is able to share and means that they are unable to challenge the misconceptions of their audience. In Neville-Jan’s case it had specific drawbacks – she had important information regarding the cause and treatment of her pain which can help those involved in her care. She had done a significant amount of research and had knowledge about her condition which she was unable to share. In some sense, this limited her agency. Despite all her work in researching treatments, she was not able to fully engage in discussions about her health.

The problem is that holding back on sharing this information can be a sensible tactical choice for someone in Neville-Jan’s position. By presenting only what is viewed as plausible and intelligible, they ensure that they remain seen as a reliable and intelligible source of information in the eyes of medical professionals.

What does this kind of tactical choice tell us about what it means to have agency in the generation of knowledge? Neville-Jan can be seen as being coerced into holding back information because of the power that healthcare professionals have over her access to treatment. But the intentional negotiation of these relationships through her careful choice of words, suggests a resistant form of agency. She is neither a powerless victim of silencing nor wholly free, but she finds a way of having some control over her situation despite the difficult relationships she must navigate with healthcare professionals. She ‘bargains’ with an unjust system by sacrificing one good (being able to share all information about her treatment) for another (being seen as a reliable source of information). Even though it involves testimonial smothering, a practice of silencing, this is an expression of a resistant form of epistemic agency. 

Alice Moneypenny completed her PhD at Nottingham on safe spaces and epistemic practices, before becoming a Teaching Fellow. Her research focuses on epistemic virtues and vices in a non-ideal world, philosophy of education and epistemic agency. 

Is there a right to silence?

Silence is often perceived as politically harmful and something that has to be broken. But what if silence can also be politically beneficial in democracies and we have good reasons to protect our right to stay silent?

Specifically, is speech always better than staying silent in situations of compelled speech and possibly compelled lies due to social pressure? Is speech better than silence when the audience might misinterpret or deconstruct what we way?

In our article (open access in Philosophical Quarterly, 2024), Dan Degerman and I address the political importance of being able to hold to one’s silence and we argue that a democratic right to silence can be motivated by politically relevant epistemic reasons.

Generally, the right to stay silent is seen within the legal context as the right one has to protect oneself against self-incrimination. However, we can broaden this and argue in favour of the right to silence as the entitlement one has to stay silent, either by not speaking or by not speaking about something in particular.

The right to silence so formulated can have many benefits, but specifically we can focus on some epistemic benefits silence can bring. The first is that silence can prevent the risk of jeopardising the individual’s credibility and spreading falsehood while undermining the notion of truth. This is the case when someone might be compelled to lie in public. These situations can be present due to political, legal, and social pressure. Cases of this kind are show trials, but we can also imagine contexts related to free speech on the internet or in public spaces. A robust right to silence can allow individuals to adhere to it while avoiding the epistemic harms that can be generated by publicly admitting what is known to be false

The second benefit is the one of preventing the misconstruction of what someone might say when they are faced with an audience that pressures them to speak. This case can be seen in cases of compulsory representation when someone is asked to speak in quality of representing a given minority and whatever is said risks being misinterpreted. The epistemic damage in these cases is not limited to the epistemic agency of the speaker but also that of the group they are taken to represent. Again, in the context of internet and speed news, it is not difficult to imagine a case in which someone’s option might be misconstructed or re-interpreted for given purposes. As we argue, in both these cases silence is a better option.

How can we implement the right to silence? The answer is not simple and many steps have to be taken politically and legally. However, we believe that a first step can be seen in making people comfortable with their right to be silent in situations of pressure or in which their status as epistemic agents might be compromised. And our paper aims to guide them to do so.

Francesca Bellazzi is Teaching Fellow in Philosophy in the Department of Philosophy, Theology and Religion at the University of Birmingham and Honorary Visiting Fellow in Philosophy at the University of Bristol.

Francesca works in the metaphysics and philosophy of science and in applied philosophy and ethics.