Even More Epistemic and Hermeneutical Injustice......

My latest foray into the philosophical was reading a paper by Bennet Knox (1) called “Exclusion of the Psychopathologized and Hermeneutical Ignorance Threaten Objectivity”. In it he argues for inclusion of persons affected by mental illnesses or at least as they are defined in the DSM into the scientific process of revising the DSM. He prefers the term psychopatholigized that he shortens to pathologized to other terms used in the philosophical literature. He makes the argument against a severely truncated form of psychiatry that he can conveniently describe as hermeneutically ignorant while characterizing a brief comment by Spitzer as hostile. His argument hinges on a concept of social objectivity that necessarily means all viewpoints of the psychiatrically involved including those who want to burn the profession down are valid and must be considered.

As I have stated before on this blog (and given examples) – this is a standard philosophical approach to criticizing psychiatry while ignoring what actually goes on in the field and how psychiatrists are trained. So, I will start there.

Let me start with the concept of “social objectivity” since the early claim by the author is:

“Further, insofar as the objectivity which psychiatry should aspire to is a kind of “social objectivity” which requires incorporation of various normative perspectives, this particular form of epistemic injustice threatens to undermine its scientific objectivity.”

I am not completely sure of how philosophers use the term normative here so I am assuming that it means – what other people approve of or endorse.  The other people here would be the pathologized.  He uses examples of the pathologized in this paper as members of the Hearing Voices Movement and the Autistic Self-Advocacy Network (ASAN).  He states that social objectivity is defined in two books by Helen Longino but does not include an operational definition.  Instead, he comments throughout the paper on how various circumstances do not meet these criteria.  He openly acknowledges that his argument is deficient:

“Although I can provide only a limited argument for embracing the social objectivity model in psychiatry here, my main goal is to show fellow proponents of social objectivity that the particular kind of hermeneutical ignorance I describe presents a significant obstacle to achieving it in psychiatry.”

I agree that the argument presented is very limited.  If that is the case, why should it be achieved in psychiatry?  Will it be theoretically useful in some way? 

His introduction to the need for social objectivity and objectivity in general in psychiatry is based on the philosophy of psychiatry.  More to the point non-empiricist philosophy. If that is considered, an empirically adequate model is all that is required.  Instead, he introduces three models that all suggest that values play a role in psychiatric diagnosis. He acknowledges that dysfunction is a value free criterion for diagnosis but then goes on to separate out a category of mental disorder that also contains judgements about dangerousness.  He lands on the DSM definition of dysfunction but explains it away as “there is reason to believe that it is impossible (and undesirable) to uncover dysfunctions in mental processes without reference to values.”  He goes on to explain how “a scientific process is more objective insofar as it engages a diverse array of points of view with different normative background assumptions in a process of “transformative criticism.”

There are multiple points of disagreement with this viewpoint starting with a basic misunderstanding of what psychiatry is and how psychiatrists work. The key element in the DSM that is ignored here are all of the qualifications for subpopulations ranging from cultural differences to gender differences that include a moving threshold for the diagnosis of disorders and recognizing that in some cultures or subcultures varying degrees of psychopathology are tolerated (or not) and that also includes a tendency to stigmatize individuals with that psychopathology. Breaking that down – psychiatry parses scientific objectivity and normative perspectives when it comes to diagnosis and treatment planning. That not only occurs in psychiatry but in all of medicine and it may actively include the outside input from philosophers on ethics committees.  Here are a couple of clear examples.

Example 1:

Bob is a 65-year-old married man admitted for hepatic encephalopathy from alcoholic cirrhosis. The Internal Medicine team requests psychiatric consultation for further diagnosis and referral.  The psychiatrist assesses the patient as improved (less delirious) and competent.  No other psychopathology is noted. He discussed treatment options for the alcohol use disorder and the patient is willing to listen.  He has never attended an AA meeting or been in treatment in the past. The family (wife and adult children) enter the room and are all adamant about taking the patient home with no treatment. They are angry and state several times “If he wants to drink himself to death it is none of your business doctor. Let him drink himself to death.”  The family and the patient are approached by social workers and the Internal medicine team over the next two days but he is discharged home with no treatment.

All of the people in this case were white 4^th or 5^th generation Americans. There are no assumed cultural differences, but they are implicit. Patients and families affected by substance use disorders have known patterns of adapting and some of them are not functional adaptations. Was an attempt at involuntary treatment needed in this case? The psychiatrist knew that hardly ever happens by local probate courts in substance use disorders unless there was an actual suicide attempt or the family supported civil commitment. Should adult protection social workers have been involved?  Referrals could have been made to county social workers who might invoke a societal level value judgment on this situation but instead dialogue was established with the family and they agreed to call if problems occurred and take referral numbers for additional assistance. They were also informed that the patient had a life threatening alcohol use disorder and severe complications (including death) could occur with any future episodes of drinking.

To the point of the article this example points out that DSM diagnosis (alcohol use disorder, delirium plus dysfunction) were the objective considerations. It also illustrates a point about social objectivity and that is that it needs to be elaborated for every individual patient, family, and culture/subculture specifically. Suggesting that physicians or psychiatrists don’t have the capacity for recognizing these exceptions and planning according is not accurate. Suggesting that the patient and family were ignored or that their opinions were not considered is also inaccurate.  The entire treatment and discharge plan was based on those opinions - even after the recommended treatment was rejected and the high level of risk was explained.

Example 2:

Tony is a 28-year-old man seen in hospital following a suicide attempt. He shot himself through the shoulder and is on the trauma surgery service. When interviewed by psychiatry he says” “I did not shoot myself. Sure, I had the gun pointed at myself but it just went off.  I am not suicidal and I want to leave.” He gives the additional explanation that he was using large quantities of alcohol even though he has been hospitalized for alcohol poisoning in the past. When the psychiatrist points out the dangers of alcohol poisoning including death he says “Look I already said I was not suicidal.  I was just trying to get high.  I get to the point where I don’t care if I live or die but I am not trying to kill myself.”  He has had multiple admissions for depression and suicide attempts in the past.  He is currently on a 72-hour hold pending a court hearing at that time. The psychiatrist requests a review from the Ethics Committee composed of a number of local philosophy professors. They decide that the patient should be released despite the recommendation to the court for extended treatment of the substance use disorder and depression.  During the hearing the psychiatrist testifies that he has seen this type of treatment work and that he considers the patient to be at very high risk.  The court releases the patient. A week later he is found dead from acute alcohol poisoning.

Again, there are no major cultural differences in this case but clear subcultural differences based on the patient’s family and social history.  The psychiatric diagnoses are clear and indisputable.  The clinical judgment of the psychiatrist based on risk factors was also clear. The value judgments introduced here are the probate court and Ethics Committee as a proxies for society’s charge to balance a persons need for autonomy against their need for protection.  Those decisions were spread over multiple people and agencies outside of the field of psychiatry.  

These basic case examples (I say basic because they are encountered in acute care psychiatry every day and multiple times a day) illustrate a few facets of social objectivity.  First, it is poorly defined.  Second, it is impossible to achieve primarily because is consists of an infinite number of subsets that cannot be averaged if the expected result is to achieve active input into the field of psychiatry. Third, for social objectivity to be useful it needs to be recorded as unique for every person that comes into treatment and handled as it was in the above vignettes.  That way the relevant considerations of every unique history and constellation of signs and symptoms can be evaluated in the proper context. It turns out that technique has been around in clinical psychiatry for as long as I have been a psychiatrist and it is called cross cultural psychiatry.

For 22 years, I practiced on an acute care unit where we had access to professional interpreters who were fluent in both the language and cultures of several countries as well as the hearing-impaired population who used American Sign Language to communicate.  There were 15 language interpreters who spoke a number of African and Asian languages in addition to Spanish. Professional interpreters do a lot more than translate languages - they also interpret cultural and subcultural variations as well as normative behaviors. We had access to telephone interpreters in any language if we encountered a patient outside of the hospital staff expertise. The interviews were lengthy and often incorporated family members, community members, and in some cases local shaman. Without this intensive intervention attempting to assess and treat these problems would be a set up for the epistemic and hermeneutical injustices the author refers to. In fact, treatment would have been impossible. In completing these assessments there was not only an elaboration of the stated problem, how the relevant community conceptualized that problem, a discussion of how it may be treated psychiatrically and the rationale for that treatment, as well as whether the family wanted the patient treated in general or more specifically in the hospital and whether their shaman or medicine man would be involved.

These are just a few examples of how social objectivity is approached in clinical psychiatry.  The result is that values are incorporated that are important to the patient and their family even if they affect diagnostic thresholds and treatment planning.  That is also clearly stated in the DSM.  It is a much more practical and personalized approach than trying to incorporate all of those opinions into the DSM diagnosis and it gives a voice to many more people than would be involved in that process. It also considers a multitude of local factors (budgets and attitudes of social service agencies, budgets and attitudes of local courts, community resources, etc.) that all factor prominently in values-based decision making.

The other important aspect of an all-inclusive process for social objectivity is that the normative thinking of some - may result in exclusion rather than inclusion. Normative thinking based on beliefs can be political thinking and in the past two years we have seen that lead to fewer rights for women, the banning of books, a widening scope of gun permissiveness in a society rocked by gun violence, gross misinformation about the pandemic, and an attempt to overthrow the elected government of the United States. These are all good examples of how including normative thinking outside the scope of medical practice could lead to disruption of the entire field. The author suggests that the opinions expressed do not need agreement - they only need to be aired. That strikes me as the basis for a very bad meeting. Unless there is basic agreement on the values and rationale for a diagnostic system – I think Spitzer has a point that opinions for the sake of stating an opinion is a futile exercise especially if it is not in basic agreement with medical and psychiatric values and ethics.

The author defines hermeneutical ignorance in psychiatry somewhat clearer. He suggests that marginalized groups (like the pathologized) develop their own conceptual resources that are not shared with other groups.  The example suggests that willful hermeneutical ignorance results when the marginalized group does not share the conceptual resources and the dominant group (inferring psychiatry) are unaware of the resources or dismiss them.  There are numerous examples of how this is not the case with psychiatrists.  Obvious examples include Alcoholics Anonymous and other 12 step groups as well as community psychiatry programs that actively use advocates and develop resources with the active input from people with severe mental illness who are affiliated with specific programs. Psychiatrists see a general knowledge about non-psychiatric resources as necessary to provide people with additional assistance.  In many cases that can include discussions of how to better utilize the resource and what to expect.  

There are several additional points of disagreement with the author on many points where he seems unaware of how psychiatrists actually practice or he is unwilling to give credit where credit is due. The best example is his description of Spitzer’s brief commentary (2) on a paper written in Psychiatric Services. He was responding to a lead paper (3) on including patients and their families in the DSM process. The author characterizes Spitzer’s general attitude toward the idea as hostile and characteristic of injustices that he writes about but important context is not given.  Spitzer was the major architect of DSM criteria and studied the process for decades. He wrote a comprehensive defense of psychiatric diagnosis in response the Rosenhan study that has been discredited. He was also responsible for removing homosexuality from the DSM and he did that by directly engaging with activists who presented him with clear information about why it was not a diagnosis. Critics like to use the homosexuality issue as a defect with psychiatry while never pointing out it was self-corrected and that correction happened decades before progress was made at societal levels.  Even now there is a question about whether societal progress is threatened by the normative thinking and agenda of conservative groups. Spitzer was responding to the political aspects of the process with political rhetoric. 

The best argument against inclusion in the original paper was:  “The DSM process is already compromised by excessive politics.” by several groups who are not psychiatrists.  That argument has been expanded in the past 18 years to the point where it is a frequent criticism in the popular media. Even in the original paper the authors suggest that these political processes may have stifled innovation and scientific progress.

Psychiatry has not “escaped” from considering values – as noted in the above examples they are incorporated into clinic practice when the specific social and cultural aspects that apply to a certain patient are explored and considered.  Contrary to philosophical opinion – the pathologized are not a marginalized group to psychiatrists. It is who we are interested in seeing and treating.  Our interest in treatment goes beyond what is typically considered evidence-based medicine. We are interested in any modality that might be useful and that includes using resources developed or available to the people who need them. It is clear that the DSM has been overly politicized and it is routinely mischaracterized in the media. Adding  additional elements - some that have strictly political agendas that include the destruction of the field - adds nothing to improving that process. There are existing avenues for that input and they are readily available outside of the DSM process in day-to-day psychiatric practice.

 

George Dawson, MD, DFAPA

 

References:

 

1:  Knox B. Exclusion of the psychopathologized and hermeneutical ignorance threaten objectivity. Philosophy, Psychiatry, & Psychology. 2022;29(4):253-66.

2:  Spitzer RL. Good idea or politically correct nonsense? Psychiatr Serv. 2004 Feb;55(2):113. doi: 10.1176/appi.ps.55.2.113. PMID: 14762229.

3:  Sadler JZ, Fulford B. Should patients and their families contribute to the DSM-V process? Psychiatr Serv. 2004 Feb;55(2):133-8. doi: 10.1176/appi.ps.55.2.133. PMID: 14762236.

4:  Dawson G. More on epistemic injustice.   https://real-psychiatry.blogspot.com/2023/01/more-on-epistemic-injustice.html

5:  Dawson G.  Epistemic injustice is misapplies to psychiatry.   https://real-psychiatry.blogspot.com/2019/07/some-of-greatest-minds-in-psychiatry.html

More on Epistemic Injustice

 

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.

 

Epistemic Injustice Is Misapplied to Psychiatry

Some of the greatest minds in psychiatry have emphasized the importance of philosophy in the field and done some excellent work in that area. Unfortunately philosophy can also be used to attack the field and when it is, some of that work is not very well done. Since I’ve been writing this blog there have been a couple of examples. The first was the argument that the DSM-5 was a “blueprint for living”. My counterargument is available at this link and you can read the subsequent dialogue. It should be evident from my argument that the DSM-5 is the farthest thing from the blueprint for living that a psychiatrist could imagine. The political context for that article in the New York Times was the supposed controversy about the DSM-5. It was being portrayed in the media as almost apocalyptic and this opinion piece fit right in.  I always viewed the DSM-5 as the non-event that it proved to be.

The second couple of articles focused on critical psychiatry. One was an opinion piece about critical psychiatry and the second was a summary of critical psychiatry written by a couple of critical psychiatrists. In the philosophy literature as it applies to psychiatry there is always a lot of hedging around the issue of whether philosophical critics are anti-psychiatrists or something else. Some authors for example refer to them as skeptics. I have no problem with the school that sees them as anti-psychiatrists and made the argument that if critical psychiatrists based their criticism on antipsychiatry philosophers they are in fact anti-psychiatrists.

The latest philosophical criticism of psychiatry is an opinion piece (1) called “Epistemic injustice in psychiatry.” It is written by an author who has a doctorate in philosophy and is a psychiatrist and two academic philosophers. Their main thesis is that epistemic injustice occurs to a number of people based on biases against them and this prejudice undermines their credibility in that context.  In the case of medical treatment, that means the patient is not taken seriously and their treatment plan would be more unilateral on the part of the provider rather than collaborative and seriously considering their input. But I don’t want to minimize the authors definition and so I am including it at this point below:

“Epistemic injustice is harm done to a person in her capacity as an epistemic subject (a knower, a reasoner, a questioner) by undermining her capacity to engage in epistemic practices such as giving knowledge to others (testifying) or making sense of one’s experience (interpreting). It typically arises when a hearer does not take the statements of the speaker as seriously as they deserve to be taken.”

They cite racism and sexism as good examples where prejudical stereotypes lead to the subjects information being discounted. They build on this idea and suggest that people with mental illness are subjected to similar biases. From there they extrapolate and say that physicians and psychiatrists in particular make these same biased assessments and discount what patients say to them. They acknowledge that there are some circumstances where the credibility the patient may be questioned. They also suggest that this epistemic injustice is more likely to happen with psychiatric patients than other patients with physical illnesses. They suggest this has a detrimental effect on psychiatric patients, funding psychiatric services, and public perception.

They describe three examples of “epistemic injustice in psychiatry”. In all three cases the patients were put on acute psychiatric holds. In the first case a man claimed to be related to a Soviet leader and that was seen as delusional when it was true. In the second case a woman had cultural beliefs and practices that were misinterpreted as delusions. In the third case the patient had chronic suicidal thinking and visited the same cliff numerous times. He was admitted on hold when he was at the cliff for an hour and the decision was eventually made to treat him as a chronic high-risk patient on a voluntary basis. In all three cases the patients were released from the hospital by the civil commitment authority.

There are several problems with these vignettes and the inferences. The first is that the patients are being held on legal basis and not because of a psychiatric diagnosis. At least that is what happens in the United States. In other words, people cannot be held on the basis of a diagnosis they also have to present an imminent danger to themselves or others. It is a contested legal process and that in itself blurs the diagnosis and inhibits communication. The vignettes also seem to say that people are never adequately assessed based on their history and released even before the legal hold is released. As an acute care psychiatrist I have had to assess and release thousands of people when we determined that the history they gave us was accurate. In other words we believed them and released them. Of all the people I assessed and treated I am not aware of anyone who was released by a court because I made in an inaccurate assessment by not listening to the patient.

The authors move on to talk about contributory factors for epistemic injustice.  They discuss a number of archaic stereotypes (for a psychiatrist) of people with mental illness such as believing substance use users have a “lack of willpower” and that they are responsible for their own particular problems. I have never really met a psychiatrist with these beliefs and doubt that people with those beliefs go into psychiatry. I have certainly met other medical specialists with these beliefs and in fact argue with them regularly about that. The authors do have a rare point when they point out that negative stereotypes and stigma lead voters and politicians to underfund treatment for mental illness but that has nothing to do with the way psychiatrists communicate with their patients.

They discuss the topic of hard versus soft evidence. They use this to develop the argument that health professionals have epistemic power because “only they have access to this evidence and have the training to interpret it”. They really stretch to come up with the statement that some psychiatrists think of their patients as "objects of epistemic inquiry" rather than collaborators. I wonder if the authors are familiar with the psychiatric concept of therapeutic alliance. In the therapeutic alliance the psychiatrist and the patient are active collaborators and both the psychiatrist and the patient focus on solving problems that the patient identifies. That is an active process that as far as I know is taught to all psychiatrists. It wouldn’t work if a psychiatrist was looking at the patient as an object of inquiry.

The third contributor to epistemic injustice is negative stereotypes. The common stereotype mentioned by the authors is that “people with a mental illness are responsible for their condition”. I don’t think any psychiatrists think this way but at the end of this section the authors go back to making an argument about how psychiatric services are inadequately funded because the public and politicians maintain these negative stereotypes. So in the end two of the three contributory factors have more to do with the public’s lack of knowledge about psychiatric disorders than how psychiatrists function.

They discuss dementia and schizophrenia as conditions where the patient’s input may be minimized because of cognitive factors or their psychiatric status. The main stereotypes mentioned are the dangerousness stereotype with schizophrenia and the hopeless case stereotype with dementia. It is very difficult to understand how either of these descriptions support their main argument. Psychiatrists are trained to weigh what the patient is telling them and whether or not it might be plausible. Compared to practically all people - psychiatrists should have the best framework for what might or might not be plausible in the area of human behavior.  I can recall being interrupted during team meetings with news that one of my patients had communicated some behavior that the staff in the room were discounting as implausible and I suppose that is congruent with the authors’ argument. Those behaviors range from self reports of severe self endangering behavior to behaviors with a high likelihood of aggression. In most cases I considered the patient report to be accurate.  I had no doubt that a very low frequency behavior had occurred based on that patient’s history and in those cases it was generally corroborated.

The authors do not elaborate on the case where the patient's statements are uncritically accepted by the treating physician.  That is a likely cause of overprescribing and unnecessary testing.   

The entire first section of the paper does not seem to reflect modern psychiatric practice. I just put up a post on about 50 different factors that can be discussed with the patient at the end of the interview and a few real life examples of what is discussed. All treatment planning is based on what the patient says in that interview. The authors examples are cases where psychiatry and psychiatric assessment is secondary to legal considerations and all the impaired communication that involves. So there appears to be no epistemic injustice at the level of psychiatrist talking to patients in an outpatient setting.  The only exception would be a psychiatrist with insufficient expertise or one under severe constraints.  Those constraints can include a lack of time with the patient and unrealistic productivity and paperwork demands by the bureaucracy. 

The authors move on to discuss ways to overcome epistemic injustice. They suggest changing training to emphasize the subjective perspective of patients. I don’t understand that argument because the psychiatric evaluation should be focused entirely on the subjective perspective of patients. If the psychiatrist has any technical expertise at all, empathy is used to communicate that the psychiatrist knows what the patient is going through. The best description of empathy comes from British psychiatry as follows:

“Empathy is achieved by precise, insightful, persistent and knowledgeable questioning until the doctor is able to give an account of the patient’s subjective experience that the patient recognizes as his own.” (2)

That hardly seems like an exercise in disbelieving or ignoring what the patient has to say. Further psychiatric assessment should be focused on the entire conscious state of the patient rather than just what they have to say. Psychiatrists should be adept at diagnosing and treating patients who are unconscious and comatose, delirious, cognitively impaired, and experiencing severe psychiatric symptoms. A psychiatric assessment is more than believing what is said. I have frequently been in the position of having to explain to the patient what was happening to them and helping them make sense of their current experience. That is a singular focus on the patient’s subjective state when they are confused and unable to describe it.

The authors suggest multidisciplinary teams with a focus on the emotional aspects of care. I don’t know if that happens in England but in the United States I had team meetings every day for 22 years. The emotional aspect of care including interpersonal dynamics with patients and among the staff was routinely discussed in those meetings.

The authors suggest that medical students should be “taught to believe what psychiatric patients tell them unless there is a good reason not to do so”. My hope would be that medical students are able to see how attending physicians approach evaluations and treat psychiatric patients much differently than other physicians. The main factors that lead to that different approach include therapeutic neutrality, a lack of bias toward people with severe psychiatric disorders and addictions, and an ability to talk to all people with those problems. There is a more technical point that might not be as evident and that is psychiatrists are the only physicians who are systematically trained to understand and analyze their reactions to the patient and what that might mean. That is what psychiatrists do and why they are consulted by other physicians and by everyone else when problems are significant.

A much better approach is to go after institutional countertransference or the collective emotional and interpersonal reactions that can be seen institution wide based on psychiatric and addiction diagnoses. This is the single most important factor in being able to provide quality care to people with these conditions. A negative institutional countertransference toward these patients is evident in most hospitals and clinics where I have worked.  Only one person - the director of an emergency medicine program was interested in addressing it and had me speak as a consultant at a Grand Rounds on the subject. These negative attitudes are driven to an extent by stereotypes but also by the neglectful way society and political systems treat these people. They have been cast as a burden on the medical system, always uncooperative, people who deserve minimal if any treatment, and their treatment resources are cut to the bone. Psychiatrists working in these settings and promoting a model of therapeutic neutrality facilitating appropriate care is one of the best solutions - but more cooperation outside of the psychiatric community is needed.

In summary, epistemic injustice appears to be another philosophical concept that is misapplied to psychiatry.   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.

George Dawson, MD, DFAPA

References:


1: Crichton P, Carel H, Kidd IJ. Epistemic injustice in psychiatry. BJPsych Bull.  2017 Apr;41(2):65-70. doi: 10.1192/pb.bp.115.050682. PubMed PMID: 28400962;

2: Sims A. Symptoms in the Mind. Elsevier Limited; London; 2003; p 3.


Graphic Credit:

The above photo was downloaded from Shutterstock per their standard user agreement.  The title is
Joshua Trees in Mojave Desert, California by Dean Stanisavljevic.