Paper short abstract:

This paper uses the notion of hermeneutical injustice to understand the relationship between clinical knowledge and patient narratives.

Paper long abstract:

In mental healthcare there is a striking mismatch between how clinicians and patients understand distress. Clinicians produce and use knowledge built of simple categories such as 'mental disorder' and 'symptoms' that may increase and decrease. The resulting narratives are easy to communicate and foreground medical interventions. Patients typically use qualitatively much thicker and more complex notions such as despair, shame, anguish and ennui and tell richer narratives that are both more complex and more ambiguous. It might seem strange that a prestigious form of knowledge is simpler than common sense. But the purpose of each is divergent. Clinicians are held accountable for their work. They need to record their decisions in an economical way and demonstrate conformity with related clinical activity. On the other hand, patients seek to express, communicate and understand intense, unusual sometimes sublime experiences, events and orientations.

This paper seeks to investigate these issues empirically. I will show how, over the course of treatment, clinicians often explicitly encourage patients to express themselves in clinical terms to tell clinically appropriate narratives. I will suggest that this makes accountable clinical work easier, but, as clinical terms and narratives supersede personal and non-technical understandings, patients are left with ever more restricted expressive resources. I try to understand this process using the notion of hermeneutical injustice. I think about what is left unexpressed and what the consequences might be. For example, efforts to promote self-understanding, self-efficacy or self-management are likely to be hampered by clinical knowledge that lacks expressive depth.

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Paper short abstract:

This paper explores therapeutic relationships in an intentional mental health activist community influenced by anti-capitalism. Examining how 'Service Evaders' incorporate practices of care into their daily lives, this paper reveals how mental illness can be a site of social re-generation.

Paper long abstract:

The UK's mental health system is in crisis, with demand rising and services being retrenched. In this environment, mental health activists argue that health services cannot respond adequately to the complexity and variety of human distress and can no longer offer the reciprocal, continual relationships that they seek. This paper examines the dynamics of therapeutic relationships and supportive encounters in an intentional mental health activist community influenced by the global Occupy anti-capitalist movement. 'Service Evaders' maintain that wellbeing is secured through collective, non-clinical methods and mutual support such as living together and 'being alongside' each other in a crisis. Rejecting (dyadic) therapeutic relationships as unequal and individualising, they aim to incorporate care, support and reciprocity into the structures of every-day life. By examining their epistemologies, experiences and strategies, this paper highlights the value Service Evaders place on the relational and affective aspects of care and the capacity to sustain relationships in times of personal, social and economic crisis. In doing so, it reveals mental illness and vulnerability as potential conditions for personal transformation and social re-generation, rather than of social disruption.

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Paper short abstract:

The paper argues that the experiences of health services both of children and of the mentally ill challenge some formulations of the notion of epistemic injustice, and proposes an alternative formulation.

Paper long abstract:

A form of epistemic injustice - testimonial injustice - has wide application in contexts where race and gender stereotypes operate in limiting, or alternatively inflating, a person's credibility. There is evidence that (not) being listened to affects service users' satisfaction with mental health services, and the services' therapeutic efficacy. However, some formulations of testimonial injustice suggest that only fully rational adults meet the standard for being knowers, and therefore for suffering epistemic injustice. Intuitively, however, that is just what children and the mentally ill do suffer - though not always in the same way - when they complain of not being listened to. We suggest ways of refashioning the notion of testimonial injustice so as to capture these cases.

Paper short abstract:

I argue that hermeneutical marginalisation of non-medicalised perspectives on mental health arises from unjustified reification of medical models of mental illness that are only intended to serve certain limited purposes and are not exclusive of alternative perspectives on the same phenomena.

Paper long abstract:

"On Prozac, Sisyphus might well push the boulder back up the mountain with more enthusiasm and creativity. I do not want to deny the benefits of psychoactive medication [… But to] see him as a patient with a mental health problem is to ignore certain larger aspects of his predicament connected to boulders, mountains, and eternity." So writes Carl Elliott in Better than Well. But why should it be the case that considering Sisyphus to have a mental health problem results in neglect of boulders or eternity? While such concepts do not easily find a home in the biomedical ontology, to assume they are thereby rendered impotent is to imagine that medicine says everything there is to say about the experience in question. If medical descriptions are taken to 'carve nature at the joints', and describe an underlying reality without remainder, such assumption might be valid; but if they are instead - as ubiquitous throughout the sciences - models of phenomena that are able to serve specific explanatory, predictive or interventional purposes, then this does not exclude interpreting those phenomena in different ways to serve different purposes.

I will argue that biomedical models in mental health are intended in the latter sense - as models - but that by treating them in the former sense, misappropriating their application to realms beyond the medical, we produce hermeneutical marginalisation of other, complementary, approaches that may produce epistemic injustice. Responding to this injustice requires interrogation of the social processes driving such misappropriation.

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Paper short abstract:

I respond to the mismatch between clinical language and patient experience drawing on my work as an inpatient consultant psychiatrist, and ethnographic research in psychosis. I present the findings of the ReCreate psychiatry project that seeks to address these imbalances through dialogue.

Paper long abstract:

My paper discusses the gap between mental health services and patients as an inpatient consultant psychiatrist, my ethnographic research, and the 'Re:Create Psychiatry' experiment.

In my clinical work there is daily conflict with patients - most are detained in hospital and treated against their will. There is a disjuncture between clinical language and the experience of mental illness. One of the commonest problems presenting to hospital is self cutting and suicidal overdoses, psychiatrists name this is emotionally unstable or borderline personality disorder. But only a small number of patients feel the diagnosis fits them. Many find it objectionable because it condemns, or has stigma attached.

In contrast, when I conducted ethnographic interviews with British Bangladeshis with psychosis I found a striking hope in psychiatric diagnosis and treatment. At the same time diverse beliefs were held about the cause of the illness from jinn possession to bereavement. I venture that in both borderline personality and psychosis, stories about the illness episode are co-created as a result of the interaction between health services, and the patient. Within this, both resistance and concordance is seen.

In recent years I developed the ReCreate Psychiatry project with the Mental Fight Club, a service user charity. This is to address conflict between service users and psychiatrists through open-hearted dialogue. It has revealed how damaging and counterproductive the encounter often is, but also how constructive progress can be made when discussion is taken out of institutionalised power settings.

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