INTRODUCTION

Epistemic injustice is a philosophical theory concerning the ethics of knowledge and interpretation. The term was first coined by philosopher Miranda Fricker (2007), then widely discussed, and expanded upon in social epistemology and related fields. As a mental health nurse lecturer living with severe mental illness, I have fallen victim to epistemic injustice. This commentary highlights the relevance of epistemic injustice and aims to disseminate the theory among mental health professionals. It offers a contemporary psychiatric interpretation of epistemic injustice. By proposing how mental health professionals can offer epistemic justice, this paper aims to reduce incidents of injustice. Further exploration and application to the field of psychiatry are needed.

EPISTEMIC INJUSTICE

Epistemic injustice occurs when someone is doubted in their capacity as a knower, or giver of knowledge. This is a consequence of negative stereotypes or stigma based on the person's social identity or background (Fricker, 2007). Testimonial injustice arises when speakers receive a deflated degree of credibility resulting from prejudice or bias from the hearer. The speaker is subsequently disbelieved or doubted as an epistemic agent. The types of prejudice at play are negative stereotypes, generalizations, and stigma. These are resistant to counter-evidence, and dismissive of the individual's unique experience or knowledge. Hermeneutical injustice occurs when an individual or social group are unable to make sense of or interpret an experience owing to a gap in their knowledge base. Fricker (2007) terms this a hermeneutical lacuna.

The theory of epistemic injustice is both beneficial and significant to psychiatry. It provides a framework to understand why mental health service users are not consistently believed by clinicians to be accurate curators of the truth.

EPISTEMIC INJUSTICE AND PSYCHIATRY

People with physical health problems are vulnerable to epistemic injustice. According to Crichton et al. (2017) those living with serious mental illness (like myself) are especially susceptible to epistemic injustice. Pervasive negative stereotypes that exist surrounding mental illness are significant factors propelling epistemic injustice. Service users receive a deflated degree of credibility, based on prejudices around mental illness. Their testimonies are disregarded and doubted, thus undermining them in their capacity as a knower, or giver of knowledge. Consequently, harm is done to the speaker (or service user). Not only does this impact on care, treatment, and the therapeutic relationship with mental health services, it calls into question their value as an epistemic agent.

Most mental health professionals working in frontline services can recall a situation where a service user's account of their past, present, or interpretation of events has been treated with suspicion, or outrightly dismissed. There is an important distinction to be made between someone lacking credibility for ‘good reason.’ It is beyond the scope of this commentary to debate in detail what would entail ‘good reason’. However, one such example is a delusional belief that has been established as false with reliable counter-evidences. Epistemic injustice occurs when the lack of credibility is due to a negative stereotype or prejudice linked to someone's status as a psychiatric patient. Crichton et al. (2017) define epistemic injustice arising when the credibility deficit is unjustified.

Negative stereotypes and stigma exist at a societal and institutional level, both fueling the epistemic injustices that service users are victims to. This commentary will focus on the clandestine systemic stigmas within mental health services. These are used against the very people that mental health services are designed and intended to empower and protect. What follows are practical examples of epistemic injustice in the field of psychiatry that illuminate the prevalence and impact of the phenomena.

THE PATIENT WITH A DELUSION

In these occasions, service user accounts are disbelieved due to a preconceived idea, or stereotype, that individuals with chronic or acute psychosis are not accurate givers of knowledge. For example, it is common for a delusional patient to proclaim wealth or connection to royalty or a celebrity. Occasionally, this is later confirmed as fact. Mental health professionals involved have a ‘lightbulb’ moment reminding them not everything a ‘delusional’ service user asserts can be dismissed as fantasy. This is a more benign example of epistemic injustice, nonetheless frustrating for the service user involved.

More damaging is when individuals with psychosis are perpetually dismissed as irrational and nonsensical. Jeppsson (2021) states that when encountering people with serious mental illness, it is easy to slip into an assumption that one will fail to understand them. Even deeper and more damaging is an erroneous assumption that there is nothing there to understand. In these occasions, epistemic injustice can have serious implications for service users, where what they say is dismissed as illness noises. Their narrative is judged as irrelevant and inarticulate due to the presence of mental illness. Deemed as illogical, unsubstantiated epistemic agents, service users are ignored. This prejudiced dismissal prevents the hearer, or mental health professional, from trying to understand the service users' unique experience.

THE PATIENT WITH A PERSONALITY DISORDER

The diagnosis of an emotionally unstable personality disorder (EUPD) is deeply stigmatized within mental health services. This entrenched bias can result in service user accounts being viewed with suspicion, or disbelief. For example, service users diagnosed with EUPD, presenting to emergency mental health services seeking help for suicidal thoughts, can be quickly dismissed (Langley & Price, 2022). The credibility of the service user is much deflated and reduced, based on their diagnosis, or assumed diagnosis. Their testimony is dismissed as at best inaccurate, and at worst attention seeking.

This commentary proposes that this is a form of epistemic injustice originating from long standing institutional stigma and negative beliefs about personality disorder and suicidality. This subtle and nuanced form of epistemic injustice is complex and deserving of further exploration outside of this paper. The harm done to service users is catastrophic. It erodes self-esteem and self-worth, whilst damaging the therapeutic relationship and trust with mental health services. In some tragic cases, it can result in the death of a service user.

THE COMPLAINING PATIENT

Equally nuanced and complex examples of epistemic injustice can be found in service user experiences of care. Patient experience is not always taken seriously within the National Health Service (NHS), the United Kingdom (UK) provider of healthcare. In a report by Sibley (2020), there are documented accounts of patient harm which were avoidable. Patients and their families had repeatedly spoken out about poor care and treatment of their physical health. However, their voices were unheard, or catastrophically, silenced due to institutional deafness to the voice of service users and their loved ones. This occurs at both an institutional and cultural level and has been evident in investigations into poor care.

Sir Robert Francis, Inquiry Chairman into the Mid Staffordshire UK NHS Trust, identified a failure of the Trust to take patient feedback and experience seriously. Tragically, this was a contributing factor to the failings in the trust. This is an extreme example of epistemic injustice in healthcare with a catastrophic impact. For example, patients were left in soiled clothing and not assisted for lengthy periods. Water was left out of reach from patients. There was a lack of basic care, privacy, and dignity (Francis, 2013).

Shifting the focus towards mental health care in the UK, there have been several recent undercover investigations into abuse in psychiatric hospitals. These devastating discoveries of systemic abuse and negligence in UK mental health services highlight the vulnerability of mental health patients to epistemic injustice. Many service users had complained about their experiences of care; however, this ‘evidence’ was seen as unreliable, or dismissed as ‘illness noises.’

Evidence in the form of patient experience and feedback has less value that evidence from clinicians, thus being a form of epistemic injustice. Here we can see the evidence of social and epistemic power. Mental health staff are seen as credible, trustworthy, and objective. In contrast, patient accounts are labelled as ‘stories’ or ‘complaints.’ This attributes patients to markedly less epistemic and hermeneutical power.

The power of language cannot be ignored in this form of epistemic injustice. If a clinician highlights an error, or omission in practice, it comes under the title, or one might say guise, of ‘incident report’. In contrast, when a service user raises concerns about their care or treatment, they are branded at best a ‘complainant,’ or at worst a ‘difficult patient.’ This can have profound effects on future care and experiences of services.

Further use of language amplifies the injustice and power imbalance. Patient comments and accounts are often labelled as ‘patient stories.’ In stark contrast, professional accounts are labelled as ‘record keeping’. The language alone confirms and perpetuates a power imbalance. Staff accounts would never be labelled as ‘telling stories.’ Yet there is compelling evidence that record keeping is open to abuse and manipulation. Patient stories may be unreliable at times, for numerous reasons (Sibley, 2020), however, the same can be said for professional accounts and testimonies. This indicates a double standard and highlights epistemic injustice.

THE SUBJECTIVE PATIENT

Crichton et al. (2017) distinguishes between hard and soft evidence. Mental health professionals are trained to hold ‘hard evidence’ as epistemically valuable and credible – for example staff accounts of someone's mental state, or objective tests such as blood results. This is often viewed as more credible that the patients' subjective, or anecdotal accounts. The professionals are given increased levels of credibility, thus further lowering the patient's credibility. This is due to them having the knowledge, skills, and training necessary to their profession within mental health services. This immediately gives them epistemic power.

Also at play here is hermeneutical injustice. Mental health service users may not have the language and knowledge to interpret their mental health challenges in a way that is clearly understood by others. This is a further form of injustice, as this gap, or lacuna in their knowledge fuels their credibility deficit. What they say is seen as less valuable or dependable than the clinician's clinical judgement or assessment. This highlights the epistemic privilege that mental health professionals hold around scientific and medical language.

THE IMPACT OF EPISTEMIC INJUSTICE

Both testimonial and hermeneutical injustice means that the hearer misses knowledge and information from the speaker. As well as the hearer missing knowledge, damage is done to the speaker. They are undermined as a credible giver of knowledge. This fuels the oppression and discrimination of mental health service users. Our voices are silenced, and experiences dismissed. We are rendered powerless in a hierarchy based on power and expert knowledge. As someone who has experienced this dismissal and associated trauma, I call for mental health professionals to consider their potential underlying bias and stigma towards service user accounts of their experiences.

THE ROLE OF THE MENTAL HEALTH PROFESSIONAL

According to Fricker (2007) epistemic injustice calls for a correction or amelioration on the part of the hearer. In this commentary, the hearer is the mental health professional. This should be in the form of epistemic justice. Professionals must have an open mind when listening to service user accounts of their past and current situations. They should put aside any bias or preconception and be open to accepting the knowledge and interpretations offered by the service user. This encompasses being both nonjudgmental and an advocate for service users.

Regarding hermeneutical injustice, mental health clinicians can be a powerful advocate for truth and justice. They can identify lacunas and be aware that gaps in interpretative knowledge and understanding can lead to the oppression and discrimination of mental health service users. Mental health professionals, and particularly nurses, due to the time spent with patients, are ideally placed to fill this lacuna and provide service users with interpretative knowledge and understanding. In doing so, they advocate for the rights of service users. Thus, making their silenced voices heard.

CONCLUSION

Epistemic injustice can offer an explanation, or account, as to why mental health service users are not always believed by clinicians. The service user maybe telling the truth; however, clinicians can deflate the level of credibility given to the service user based on prejudice. The clinician, therefore, does the service user an injustice, and they are undermined as a reliable giver of knowledge. This can have a catastrophic impact on experiences of care, treatment, and the therapeutic relationship with mental health providers. Frontline mental health staff, especially nurses, are ideally placed to correct these injustices and amplify the voice of the service user.

AUTHOR CONTRIBUTIONS

Author meets the authorship criteria according to the latest guidelines of the International Committee of Medical Journal Editors.

CONFLICT OF INTEREST STATEMENT

None.