I became aware of a paper on epistemic injustice (1) this
morning and just finished reading the paper.
I wrote a blog on this topic with reference to one of the paper the
authors discussed about 2 ½ years ago and I was interested in learning if the
authors agreed or disagreed with my position. As suggested by the title – my
position was that the concept of epistemic injustice was misapplied to
psychiatry and further that it was misapplied in much the same way that other
philosophical concepts have been. That misapplication typically begins with a
false premise and the application of the concept is built upon that.
I took the original authors definitions of epistemic
injustice in my original post. The
current paper defines epistemic injustice as occurring in two forms and once
again I will quote the authors directly:
“Testimonial injustice arises when an individual’s
factual report about some issue is ignored or taken to be unreliable because of
individual characteristics that are not related to her epistemic
(knowledge-having) ability.” (p. 1)
“Hermeneutic injustice… an
individual’s knowledgeable reports fail to receive adequate attention because
she, her listeners, or society as a whole lack the conceptual resources to
interpret them.”
They give numerous examples both within and outside the
field of psychiatry analyzing the arguments about why the epistemic injustice
does or does not exist. I took the same steps in the previous blog post and my
arguments were very similar to the authors of the current paper. We basically agree that psychiatrists need to
be focused on the subjective state of the patient. That means we cannot arbitrarily discount
what anybody says. We are also trained to not discount histories based on the
demographic, social or interpersonal features of the patient. In fact, we are the only physicians trained
to recognize those tendencies and correct them. The authors also agreed that all of the
patient’s narrative need not be arbitrarily accepted and as an example they
describe a patient who is at high risk for suicide and who is denying any risk
in the emergency setting despite obvious evidence to the contrary. They
suggest just accepting the narrative for the sake of social justice may result
in patients being placed at risk. I agree with that opinion.
I addressed this issue in my original post by describing
what I consider to be the clinical method of psychiatry. That involves listening carefully to the
patient but at the same time deciding about the continuity and plausibility of
the narrative. This is a general process
independent of any specific patient characteristic that recognizes all human
informants make errors and that there are multiple reasons for these errors. In other words, this general process needs to
be applied to every patient professional encounter with a psychiatrist. One of my mentors in residency also suggested
that at some point it extends to everyone a psychiatrist talks with including
informal contacts. That means that
psychiatrists may be analyzing many people that they encounter – but not in the
psychoanalytic or mind reading sense.
The clinical process
is important because it can refine the assessment and assist the patient in
communicating the problems that brought them in to treatment. The goal of the
interview is to establish a diagnosis and formulation and discuss them with the
patient. Agreement with the initial
assessment forms the basis for treatment planning and the therapeutic alliance
between the patient and the psychiatrist. There are also therapeutic aspects to this
communication. Interventions like
confrontation, clarification, and interpretation not only to improve the
factual report but to assist the patient in recognizing active defenses that
are limiting their insight into maladaptive behaviors and thought patterns.
The best way to counter any possibility of epistemic injustice
is to keep teaching psychiatric methods exactly the way they are being taught
right now. Psychiatric trainees need to
learn early on that analyzing the subjective communication is a rich source of
information that cannot be denied, but may need to be clarified. There are
never any clear reasons for rejecting this information – but like all
psychiatric communication it all has to be seen through a critical lens and in
some cases multiple hypotheses apply.
The authors have an interesting take as a footnote at the
end of their paper on why some authors may be interested in applying a
philosophical concept where it might not apply – especially if the critic is a
psychiatrist. There is after all an established pattern of some psychiatrists doing this. From the paper:
“To the objection that psychiatrists are the ones writing some of these articles, we would suggest that being a psychiatrist does not protect one from misunderstandings – or more likely, misrepresentations – of one’s own field when in the grip of an idea. This should be no more surprising than the possibility of an anti-psychiatric psychiatrist, a familiar figure in the philosophy of psychiatry.”
The
authors condense various motivations for misrepresentation as an intellectual
idea. That may be a possibility as a one
off paper but what about a pattern over years and decades? What about the associated self-promotion over
those years? What about the inability to recognize the good work of hundreds of
colleagues over that period or personal mistakes? There are always many unasked and unanswered
questions when it comes to an idea that criticizes an entire field of work.
It
is indisputable that no medical field has been mischaracterized more than
psychiatry. Philosophy has been one of the vehicles used to do it. I hope that
more papers are written to illustrate exactly how it happens. In the
misapplication of epistemic injustice, it starts with a false premise and
builds from there. Psychiatrists everywhere know that one of our best
attributes is being able to talk to anyone and more specifically people that
other physicians either do not want to talk with or are unable to. Most
importantly – we are interested in talking with these people and
can communicate with them in a productive manner. We do not get to that point
by rejecting what people have to say or not paying attention to them.
The
qualifier in my original post still applies:
“There is no
doubt that people can be misdiagnosed. There is no doubt that things don’t
always go well. There is a clear reason for that and that is everyone coming to
see a psychiatrist has a unique conscious state. There is no catalog of every
unique conscious state. The psychiatrist's job is to understand that unique
conscious state and it happens through direct communication with that
person. That direct communication can happen only if the psychiatrist is
an unbiased listener.”
There are plenty of external
constraints that directly impact the time needed by a trained psychiatrist to
interview and understand a person. That is probably a better focus for criticism
than the continued misapplication of philosophical ideas.
George Dawson, MD, DFAPA
References:
1: Kious BM, Lewis
BR, Kim SY. Epistemic injustice and the psychiatrist. Psychological Medicine.
2023 Jan 5:1-5.
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