Author:Neil Armstrong (Oxford University)
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.
Hermeneutical injustice, clinical imagination and patient discontent in mental healthcare