This article introduces the idea that injustices in knowing and understanding are an underlying cause of mental health problems.
Harvey Lidstone-Lane and Andrew Garman
What is mental health injustice? In a world where mental health is traditionally seen as a medical matter – a problem with the brain – the term ‘injustice’ might seem to be somewhat out-of-place. And yet many mental health professionals are now embracing the evidence that poor mental health is primarily caused by the social environment, not by a biological brain problem. If that is so, it is not difficult to see how social injustices which result in poverty, discrimination and other forms of disadvantage can lead to mental health problems: these disadvantages may for example feature compromised access to knowledge sources such as books, the internet and experts. Such a situation constitutes an injustice in that it results in an impairment in a person’s ability to access and know important things that are necessary for survival and flourishing in life.
The pioneering work of Miranda Fricker (2007) goes much further than such disadvantages; rather it has to do with how certain people may be wronged by the impairments in knowing and understanding which result from society’s culture and power structures. To describe this, Fricker coined the term ‘epistemic injustice’ (‘epistemic’ means relating to knowledge and understanding): it is this type of injustice that we explore in this paper.
Fricker conceives two types of epistemic injustice: testimonial and hermeneutical.
Testimonial injustice arises when someone’s testimony – what they have to say – is assigned low credibility by some listener, typically someone in a more powerful or privileged position. As a result, the content of what someone says may be dismissed by others based on negative stereotypes associated with that individual, leading to a credibility deficit. Both the speaker and the listener are harmed by this deficit. The speaker is harmed because they are unable to get across what they would want to say, which may lead to or perpetuate discrimination and the continuation of unmet needs. Less obviously perhaps, the listener is also harmed by not having an accurate understanding of the speaker’s world.
It is easy to conceive of examples of testimonial injustice within mental health: it is a commonly observed that people who exhibit mental health symptoms are not taken as seriously as others. An extreme example can be found in the 2005 Mental Health Capacity Act, which allows individuals with a mental illness to be deemed to lack the capacity to make certain decisions regarding their welfare. Perhaps more commonly, the downgrading of someone’s credibility is arguably often part of that person’s psychological decline – as their suffering and their needs in the world are not taken seriously by significant others – parents, partners and bosses for example.
Later thinkers have broadened this idea of testimonial injustice to include the concept of credibility excess (Medina, 2011). This idea captures the situation where an individual’s testimony attracts disproportionately more credibility due to positive stereotypes/assumptions relating to the groups that the individual belongs to. Medina (2011) has argued that testimonial injustice exists due to the existence of both credibility deficits and credibility excesses.
It could be argued (but not here) that there is a credibility excess associated with some mental health clinicians and the high status they enjoy in society. This would create a situation where those deemed to suffer with mental ill-health acquire a credibility deficit while those diagnosing this acquire a credibility excess. This would be fertile ground for the testimonial injustice to take root.
Fricker’s second type of epistemic injustice is hermeneutical injustice. This is something that results when society does not provide the concepts – or framework – with which a sufferer can accurately interpret their experience. They cannot make sense of the world around them; not because they lack rational thinking, but simply because their culture and social environment has not provided them with the means to do so.
Fricker provides a number of helpful examples of hermeneutical injustice. The most well known of these is the story of Carmita Wood and society’s creation of the concept of sexual harassment in 1975. As a result of persistent inappropriate attention by her boss, Carmita suffered severe anxiety, and related physical symptoms. She had no way of thinking about or talking about this challenge and was instead forced to conclude that there was something wrong or different about her. After resigning her post, she joined a group of other sufferers who came to coin (for the first time) the concept of sexual harassment. Once society grasp this concept, talk about it and appreciate its negative impacts, future sufferers were more accurately able to understand their plight and take the appropriate externally-focussed action (now with legal backing). In the jargon, they acquired the hermeneutical resources to be able to do this; as did society. Carmita’s was a mental health problem caused by the lack of a concept for understanding her experience.
This transition – from blaming self to adopting a more nuanced and accurate understanding of the social environment – is familiar to most counsellors as a turning point in therapy. The treasure trove of client stories deserves to be better articulated and understood by society at large. Together, these narratives suggest that we could usefully recast many mental health problems in hermeneutical terms. For it is evident that every living organism needs to accurately perceive, and effectively interact with, the world in order to survive. For humans, whose basic needs are so dependent on the social world, this is a complex cultural matter and one which is intimately entwined with how power is distributed and exercised in society. The link between not having access to an accurate interpretive concept and the development of psychological distress has been suggested by Munch-Jurisic (2021).
The medicalisation of mental health
To add to the above situations and examples, we suggest that there exists a more over-arching epistemic injustice in the way most of society frames and addresses the whole field of mental health. For when psychological distress is conceived by society in terms of something wrong with the individual, rather than something harmful that originates in the environment, then the sufferer is unjustly deprived of the hermeneutical resources that would lead to the cessation of unnecessary psychological suffering. We see here hermeneutical injustice and testimonial injustice feeding off each other. For the status and power imbalance between the clinician and the sufferer causes the medical paradigm to persist in society and, conversely, the medical paradigm cements the status of the clinician as expert.
We might question the role of the clinician as the expert in mental health matters. While broken limbs have a finite range of presentations and treatments that create a solid medical expertise base, mental health is different. Every sufferer of persistent psychological distress has a different story to tell, which needs to be heard and understood in holistic terms. In humanistic counselling, the most unmedical of the talking therapies, it is the client who is regarded as the expert – she needs to be heard in a testmonially-just way and not generically diagnosed and treated. Such counselling enables the client to find a more accurate hermeneutical framework, one that facilitates a shift away from self-blaming towards to a better understanding of the social environment and of the interaction between that environment and the individual.
Mental health injustice permeates all of society as a result of its power structures, beliefs and ways of interpreting the various feature of society. Whilst others address the more overt causes of psychological suffering – poverty, social media, abuse etc. – there is a role for philosophers to create and promote the frameworks and concepts to enable discussion of epistemic injustice in its many manifestations. The priority might be changing the concepts and language that society uses to talk about mental health, in particular replacing the medical framework with a holistic perspective which is more empowering and respectful. We shouldn’t expect those who suffer to do all the changing.
Fricker, M. (2007). Epistemic injustice: Power and ethics of knowing. Oxford: Oxford University Press.
Medina, J. (2011). The relevance of credibility excess in a proportional view of epistemic injustice: Differential epistemic authority and the social imaginary. Social Epistemology, 25(1), 15-35.
Munch-Jurisic, D. M. (2021). Lost for words: anxiety, well-being, and the costs of conceptual deprivation. Synthese, 199, 23583-13600.
Bentall, R.P. (2010). Doctoring the mind: why psychiatric treatments fail. London: Penguin.
Davies, J. (2022). Sedated: how modern capitalism created our mental health crisis. London: Atlantic.