What is Contributory Injustice in Psychiatry?

An article on contributory injustice describes the clinical and ethical imperative that clinicians listen to service users experiences.


An article on contributory injustice, published in the Journal of Medical Ethics, describes the clinical and ethical imperative that clinicians listen in an open-minded way when service users describe their experiences of hearing voices.

Alex James Miller Tate, at the University of Birmingham, UK argues in a new paper that harm is being done to service users when clinicians dismiss their experiences using biomedical language. The term “contributory injustice” refers to this type of refusing to listen to marginalized people.

Photo Credit: Pixabay

Contributory injustice, in philosophical parlance, occurs when a marginalized group’s explanations for their marginalization are summarily dismissed or ignored by mainstream society. In effect, people are not allowed to contribute their ideas about the position they are in.

This occurs for most (perhaps all, at some point) marginalized groups. For instance, Tate gives the example of the rape survivor whose dissociative speech is mistaken by the police as evidence of lying, rather than evidence of trauma. Tate suggests that others who have experienced similar events would readily understand the person’s explanation, but those who have not experienced it dismiss it—and the person’s experience along with it.

This injustice is pronounced in mental health service settings. According to Tate, service users who hear voices have developed a sophisticated cultural understanding of these phenomena, as evidenced by such groups as the Hearing Voices Network. A vital aspect of this groups approach is the idea that service users are partners in the search for understanding of their own experiences.

That is, the popular conception of mental health services is that a confused, “mentally ill” person is given a biomedical explanation for their problems, which enables them to heal. However, the reality (as evidenced by service users’ statements) is that mental health professionals ignore the explanations of the person and provide a rigid and unacceptable explanation, resulting in service users feeling unheard, invisible, and even worthless.

Tate argues that clinicians—and the mental health profession as a whole—are required to listen with an open mind for how the explanations of service users can be helpful in making sense of their experiences. This can be accomplished at the most basic level by accepting those service users who hear voices exist within a culture of people who do understand each other, even while the professionals and popular culture see their explanations as nonsense.

“I suggest that clinicians must become familiar with and take seriously concepts and frameworks for understanding mental distress developed in service user communities, such as Hearing Voices Network, and by individual service users.”

Tate also addresses the objections that are commonly raised by mental health professionals whenever they are asked to listen to the experiences of service users. For instance, one primary complaint is that mental health professionals cannot pretend to believe something they know is false (for example, agreeing with someone’s explanation that their voices are messages from angels).

Tate suggests that this is a misunderstanding of his point. He argues that one can both disagree with respect, as well as imagine how an explanation that seems false could be helpful in making sense of unusual experiences. That is, one does not also have to believe that voices are angelic messages to see how that belief can be comforting to the service user.

Tate essentially suggests that these objections come from the professional’s tendency to view mental health as a dichotomous condition—either people are sick and require a biomedical cure, or there is no problem at all. Since there are struggles, then the biomedical explanation must be correct.

However, the black-or-white thinking of professionals is a fallacy—one can struggle with unusual experiences and still have a holistic explanation that provides comfort, understanding, and the ability to work with others towards better coexistence in the world. And, according to Tate’s review of the research, the best way of treating someone’s delusions is not to argue against them and make the person feel misunderstood or unheard. Instead, listening and accepting that this is a person’s explanation—while still being free to disagree—is a vital part of the healing process.



Miller Tate, A. J. (2018). Contributory injustice in psychiatry. J Med Ethics. Epub ahead of print. doi:10.1136/ medethics-2018-104761 (Link)


  1. Who’s promoting the notion that professionals should get into arguments about delusions? Forty plus years ago, when I was a crisis volunteer, I was told to never get into arguments about delusions. Then my mentor (who once provided the only correct knowledge of a hospitalized client’s severe illness in a room full of doctors, which my associate wasn’t- paraquat poisoning) pointed out how delusions could provide clues to what was affecting an individual, such as altered senses of taste being caused by zinc deficiency.

    Report comment

  2. Once, there was one love expert. In Police Academy.
    There’s no spiritual experts or professionals, because spirit is not a science.
    And when they are, we have a similar situation as in the movie – The master.
    Spiritual professionals, psychological professionals === destroyers.

    So why we think that we can make a science from psychological reality? Authoritarian mind is the problem, and psychological man is even more human that mentally health people. Because mental health is a convenient illusion of apollonian ego, and we must remember that ego on apollonian level is separated from the death and psychological reality. So they do not feel connection with psyche, they feel better, more important, because they are materialists, and ego is their god. And when apollonian ego is the god, the psyche is the enemy, and psyche does not exists. And this is psychiatry – ego fundamentalism of psychologically blind people.

    They see a power in this separation, and they see weakness in depression, psychosis, in death. Theology sees death as weakness, this is not psychology, this is childish negation. There is no logic in seeing psyche as the weakness. This is ignorance and also arrogance.

    Apollonian ego is using theology, not psychology to stressed it’s own separation from death, from psychological reality.
    Apollonians are convinced that every contact with psyche is a biological illness. This is apollonian ego problem.

    Why we feel the way we feel? And what to do to feel better?
    Empiricism is the problem, psyche is not a science.

    And theological negation cannot be the answer, the spiritual fascism is also a negation of psychological reality.

    They are the problem – the empiricists. Go back to school, far away from psyche.

    James Hillman Re – Visioning psychology.

    Report comment

  3. Most therapists and social workers would never “argue” with their clients who experience hallucinations or delusions. We are taught to be empathetic and work to understand our client’s experiences from their unique point of view. I do think psychiatry more often than not assumes there is a biological basis for these “symptoms” that the medical model “should” address; however, it’s important to separate out the other fields who were not indoctrinated in the medical model. I can’t recall once in the last decade that I told a client that their delusions are flatly wrong and need meds to correct them. That would be contrary to my values and training as a therapist. If I don’t respect my client’s perspectives and value them as equal human beings, I have no business being in my field.

    Report comment

    • There are plenty of psychiatrists and also some therapists who are told and believe that one should not talk to a client about the content of the voices they hear. They are told that engaging in such discussions strengthens the voices. Some are told that they are actually supposed to tell people that the voices are imaginary and that they have no meaning, being simply random outputs of a diseased brain.

      You may not have been trained that way, but I’d be willing to bet that lots of commenters here have heard similar messages. I’d be interested in seeing how others have been treated in this regard.

      Report comment

      • I and most of my colleagues (people trained after 2000) have been taught to focus on the emotion behind the voices. Of course, there are some clinicians who will poorly handle this area. Former clients who post on MIA have had horrid experiences with doctors and therapists, which is why there are here to begin with. For all the thousands of people who are generally content with their “treatment”, they have no need to go to MIA.

        I’ll also add that groups like HVN are a wonderful resource for people to go talk about their voices without influence from the medical model. I wish there were more chapters in the US.

        Report comment

        • Steve and Shaun F,

          when my wife and I first started our journey into her world of d.i.d. I was told exactly that: if I engaged the ‘voices’ I would strengthen them. And to a degree that is true. By engaging each girl/voice/alter, I validated her. Unlike most d.i.d. cases, I encouraged my wife’s to become ‘florid’ by our complete acceptance of the girls/voices/alters in our marriage and family.

          But in doing so, this gave me a much deeper access into the various ‘compartments’ of my wife’s personality and her memories. It allowed me to directly access the various memories and the lies associated with the abuse and begin to disentangle them and undo them. Once I helped each girl/voice/alter heal the trauma and securely attach to me, that seemed to propel her ability to begin the integration process with the others in the group..and so we came full circle. By validating the voices, we did enter a period of deeper division, but once the healing was mostly done, it seemed to allow them a MUCH deeper re-integration than much of what one would read is possible in the professional literature.

          But, Shaun F, let me assure you that there is MUCH more than just emotions behind the voices. The designations of ANP and EP are grossly simplistic. Each girl in my wife’s system seemed to control various personality traits and mental abilities that I had never or rarely seen in my wife. And as the healing and integration continued, these were unleashed and my wife’s overall personality began to radically, and beautifully, change.


          Report comment

          • I guess as I re-read what I wrote, maybe I should clarify to the survivors on this site because of comments directed toward me recently, that I never manipulated or coerced my wife. She was the one who asked me to engage the others, and then they ALL begged me NOT to read the literature that was available on d.i.d. because they were afraid I would stop loving them and engaging them, and so I obliged them until much later when I had seen such good results for us and knew I wouldn’t be influenced to change the methodology we were using….and it was only then that I realized how radically different we were doing things than most people.

            Report comment

          • Thanks Sam. I have read these comments from you before and appreciate you are not speaking OVER your wife. Most SO’s who do are not on this site.

            Every now and then a controlling (possibly abusive) relative does show up. Like that one woman who censored her adult daughter’s reading material–wouldn’t let her online without watching over her shoulder it seems–and said she didn’t care if the “meds” killed her daughter in her forties or fifties. Ick!

            Most of us know you aren’t anything like “Kate.” Glad for your wife and you as well. Most “Kates” are very unhappy people. No wonder their SO’s are so crazy to start with.

            My own parents played a more ambiguous role in my psychiatrization. Most do. Other SO’s know the loved ones are being hurt, losing all ability to function but can’t stop it.

            I know you’re not a “Kate.” Many others do too. But I hope you’ll be charitable and patient to those whose suffering makes them uncharitable and impatient with kindly SO’s like you who only want to love and heal.

            Report comment

          • Rachel,
            thanks again. I try to remember the dynamics going on here, but it is hard when I’m hurting as well. I remember when my wife and I first started down this path and her ‘defender’ joined us, filled with vitriol toward me. Admittedly, I had done some things over the course of our first 20 years that had contributed to her vitriol, but I also realized that I was a convenient figure for her to vent her anger from the original abuse. But at least she and I had a relationship, and as I allowed her to vent all that anger on me, in time, it dissipated and now that ‘alter’ and I just got engaged in December (10 years later).

            But I know there is little hope of me overcoming the anger of many who were wronged on this website because we simply have no relationship other than the words we see on our screens…

            As for your parents and other SO’s, my heart goes out to them. Many of them aren’t trying to be ‘evil’ but the system is set up against them as much as it was you, and my wife and others in mental distress. I believe there are many out there who wouldn’t shove their loved ones into the ‘system’ if they knew there was a viable alternative, but helping them learn there is an alternative is the problem and Open Dialogue and Soteria just aren’t widely available. And it’s not easy the path my little family took, especially when the system waves magic pills in front of them and says these will take care of all their problems…

            Report comment

    • Shaun:

      You are the exception not the norm. Are you in private practice? My husband was informed by a social worker at a hospital that my daughter’s ‘mental illness’ was like diabetes and that she would have to take medication for the rest of her life. Social workers, counselor workers, psychologists, and peer specialists at hospitals and secure facilities nearly always espouse the medical model. If they didn’t, they would get fired. Most choose to keep their jobs and espouse nonsense. People in private practice may be more at liberty to take a different tack but most people considered to have ‘severe persistent mental illness’ are receiving public services populated by professionals who espouse the medical model exclusively.

      Report comment

      • Madmom, I sure hope you are wrong but clearly the medical model still dominates “treatment” in hospitals and clinics. Any system where psychiatry is at the top of the chain the DSM labeling will be used because of billing. The truth is that many professionals would rather not use the labeling but the system requires it. I do agree that if we don’t fall in line we will get fired. Big pharma and the APA have gone to great lengths to develop a system which is focused on diagnosing and prescribing. Private practice therapists do have more liberty and rarely espouse the SPMI perspective or agenda. I do work in community mental health but plan to make my way out in the next year. I am tired of the overdrugging and pathologizing we do. Many of my colleagues feel similarly. I think we too often follow the status quo because it’s easier than making our own path. Maybe some of my ideas about clinicians being progressive like myself is wishful thinking? I sure hope not but you are probably right. I think all doctors and other “helpers” should be required to read the articles on MIA to better understand the perspective of people who have been harmed by this dysfunctional system. Thanks for sharing your thoughts.

        Report comment

          • Thanks Rachel. I’m nervous but it’s time. I want to get as far away from the system as possible. I want to continue to work with people without feeling entrenched in the biological view of human suffering.

            Report comment

        • I do think there are a lot of clinicians who think the way you do. But it takes a lot of course, and willingness to accept harsh consequences, for people in the system to take a stand. Maybe you can create a subgroup of those who think differently and start supporting each other in speaking up?

          Report comment

          • I think that’s a good idea, Steve. I would be curious how many would actually support standing up against the status quo in some kind of meaningful way? There are always consequences for going against the grain but it can be worthwhile.

            Report comment

          • Steve,
            True. Certainly something to consider. I think many of my colleagues are scared to push back because it feels like David v. Goliath. The entire system is structured around the idea that SPMI is a valid concept and “should be treated.” We clearly need a revolution, but the powers that be won’t go away easily. I feel daunted fighting against Big Pharma, APA, and psychiatry in general. The power differential is huge.

            Report comment

          • It is, indeed, daunting. However, one strategy followed by those in power is to create the impression that nothing can be done about it. If we all accept that, it makes their position into the truth.

            Fight back where you can! Even if you only accomplish making other clinicians aware that you feel the same way and that their perceptions are correct, that’s still something important.

            Report comment

          • Shaun F,
            I know you didn’t direct your last comment to me, but it made me think about all the changes I had to go thru to become a good healing partner for my wife. It seemed like the biggest hindrance was how I was raised to believe. When those beliefs just didn’t work out in the real world, the cognitive dissonance began to grow until it got so massive that I couldn’t ignore the warring thoughts in my head.

            I had to break a number of cardinal beliefs of mine to become a better partner for my wife, but in the end I had decided which was my ‘supreme belief’ and so those cardinal beliefs were expendable.

            I guess all that to say I wasn’t open to major change until I had a crisis: my wife’s d.i.d. overwhelming both of us, and much of what I believed was a hindrance to what we needed to make it thru the journey.

            I think most people are the same and they will NEVER examine the cognitive dissonance between what they were taught, e.g. the biochemical model, and real life until there is a major crisis. And sadly, I’ve seen most people in my little sphere bend reality to their beliefs rather than the other way around.

            Report comment

          • Well said, Sam. Crisis can be an opportunity to bring about growth and change. Belief systems we hold are very powerful and can get in our way of being more effective. Ego defense mechanism, such as cognitive dissonance, are natural ways for humans to cope with distress. Unfortunately, they can get in our way of moving forward!

            Report comment

    • Glad to hear that Shaun.

      It stinks not being believed. Oddly enough I took to telling crazy stories after a few years of “treatment.” I guess I decided no one believed me anyhow so I told a lot of over the top stories. More dramatic at least.

      The weird thing is I had always been scrupulously honest before. I couldn’t tell truth from falsehood at one point. 🙁

      Not being believed by anyone drove me crazy.

      Report comment

  4. Who have given the power over psyche, to psychiatry? The power to eliminate suffering,the power to eliminate death? Who gives them the power to treat psychological man as a impaired human being?
    The answer is -theology, god. And economy of course.
    And spiritual god has got no human traits, he has got only claims to human nature, to human psyche. And now we are hideous creatures,empty creations of biological impulses. Without psychological image, human being is not even a human anymore.

    Mythical gods represents our psychological traits, not the god of spiritual negation. And psychiatry represent the spiritual negation, not psyche. And we have what we have. Contemporary inquisition, negation.
    Psychiatry does not represent human psyche.

    Psychiatry represents ego or god, not the psyche.

    Report comment

  5. Clinicians don’t listen because they harbor odd and false delusions that all distress is “caused by a chemical imbalance in the brain.” And when they do listen, like when something good has happened in the client’s life, the doctor writes in his records, “not believed by Dr.” In the end, out of terror, because they never garnered any insight whatsoever into their client’s life, they declare the entirety of their client’s life to be “a credible fictional story.”

    Today’s “mental health professionals” believe 9/11/2001, and all the subsequent wars against the concept “terror,” rather then a real enemy, are wonderful. And all who stand against the never ending wars have a “chemical imbalance in their brain” and must be drugged forever. This is political abuse of psychiatry, in America today.

    Today’s “mental health professionals” believe child abuse is a wonderful thing, and all who stand against child abuse have a “chemical imbalance in their brain,” must be drugged forever, and have all their money stolen from them. Although, profiteering off of covering up child abuse is the number one actual function of our “mental health professionals,” both historically and today, according to their industries’ own medical literature.


    Today’s “mental health professionals” believe Chappaqua, NY is Chippawa, NY. Despite the fact there is no Chippawa, NY.

    Today’s “mental health professionals” believe Miami University is a “fictional” university.

    Today’s “mental health professionals” believe driving from the suburbs of Chicago, into the city to get a haircut from the hair stylist one has been going to for over a decade, is a “sign of mania.” I presume this means they believe all who commute from the suburbs of Chicago into Chicago for any reason are “manic” too? That’s millions of “manic” people in the Chicagoland area alone. Hurry, hurry, “mental health professionals.” Drug them all!

    Today’s “mental health professionals” believe that when a banker’s daughter donates $400 to a children’s charity, this is a “sign of mania.”

    Today’s “mental health professionals” believe that losing 30 lbs by regular moderate exercise, rather than dieting, and upon the recommendation of a doctor, is a sign of “depression caused by self.” Even when the person is pleased with the weight loss, says she’s not depressed, and is discussing interpersonal problems with some, what turned out to be, child rapists.

    Today’s “mental health professionals” believe all thoughts, dreams, and gut instincts are “voices.”

    Today’s “mental health professionals” know less than zero about the adverse effects of the drugs they prescribe. They don’t know that opioids are mind altering, dangerous, and addictive drugs, they think opioids are “safe pain meds.” Congrats on your opium epidemic, doctors. And the doctors believe the antidepressants are “safe smoking cessation meds,” too.

    Today’s “mental health professionals” believe their drugs are “wonder drugs.” When in reality the ADHD drugs and antidepressants create the bipolar symptoms. And their antipsychotics create both the negative and positive symptoms of schizophrenia.


    Today’s “mental health professionals” believe that when one doesn’t have “voices” this is “disturbing” for the doctor. I guess that psychiatrist should have drugged himself up for his distress at that point?

    Today’s “mental health professionals” believe that when their drugs create “voices” in a person’s head, this is a good thing, so even more neurotoxins should be forced onto that client.

    Today’s “mental health professionals” threaten their clients, “If you don’t take all the drugs as prescribed, all the doctors will call you paranoid.” When in reality it was my paranoid of a non-existent, but deserved, malpractice suit doctors, and my child abuse covering up doctors, who were the paranoid people after all.

    Today’s “mental health professionals” believe that the best way to help an abused child, four years after the abuse, but once the medical evidence of the abuse was finally handed over, is to massively drug the child.

    Today’s “mental health professionals” are war mongering, child abuse covering up, insane, delusional, Holy Spirit blaspheming, thieving, criminal deadbeats.

    But thanks for pointing out that “the black-or-white thinking of professionals is a fallacy.” And that “The term ‘contributory injustice’ refers to this type of refusing to listen to,” the people that the “mental health professionals,” and only the “mental health professionals” and their child raping friends, try incessantly to marginalize.

    Marginalization the “mental health professionals” do, because they do not want the world to know that profiteering off of covering up abuse of children is the primary actual function of our “mental health professions.” And this marginalization of millions and millions of child abuse survivors has helped to aid, abet, and empower the pedophiles and human traffickers in the West, even according to world leaders today.


    Thank you so very much to our child rape covering up and profiteering “mental health professionals,” for collectively and systemically working so very hard to destroy Western civilization. Given the reality that most of your clients today are misdiagnosed child abuse survivors, and covering up rape of children is illegal, most of you likely belong in jail. But you wouldn’t know, since you don’t listen to your clients and believe their lives are a “fictional story.”

    And you are seemingly very proud of your “mental health system,” whose primary actual societal function today is whacking the hell out of child abuse survivors when they’re down. While you make believe, and are fraudulently claiming to the world, that you are “helping” people. Pardon my disgust that I dealt with a, by design, systemic child rape covering up “mental health system.”

    But the world should be educated to the reality that NO “mental health professional” may EVER bill ANY insurance company for EVER helping ANY child abuse survivor EVER, unless the “mental health professionals” first misdiagnose the child abuse survivors with any one of the plethora of “invalid” but billable DSM disorders.


    Western civilization’s multibillion dollar, iatrogenic illness creating, primarily child abuse covering up “mental health system” is satanic. I must agree with the “evil Russian,” Putin, and disagree with our satanic, Holy Spirit blaspheming, child rape covering up, DSM “bible” thumping, material world only believing, “all distress is caused by a chemical imbalance in the brain” believing “mental health professionals.”

    But I will say one of the abusers of my children was an “evil Russian.” So I’m quite certain, there are good and evil people within all nationalities. Although I’m not certain that is true of all professions, since I’ve never met a “mental health professional” who didn’t want to profiteer off of covering up rape and abuse of children personally.

    “The dirty little secret of the two original educated professions,” our multibillion dollar, medical/religious, primarily child abuse covering up “mental health” system, does die hard though. Just like me. Thank you, Jesus, for allowing me to survivor 14 distinctly different anticholinergic toxidrome poisoning attempts at my life, by satanic, child abuse covering up and profiteering “mental health professionals.”

    Report comment

  6. Contributory injustice, in philosophical parlance, occurs when a marginalized group’s explanations for their marginalization are summarily dismissed or ignored

    Wait a minute — that’s the PURPOSE of psychiatry, isn’t it? — especially when those explanations hold outside forces responsible for the problems at hand, rather than their being considered “personal” problems. Maybe “contributory injustice” could be employed as a synonym/euphemism for psychiatry itself?

    Report comment

  7. Psychiatrists cannot pretend to believe something they know is false.

    Hmm….Does that include telling the “consumer” that their distressed states are known to be caused by chemical imbalances in the brain? And that’s okay since psychiatry has a bunch of “safe and effective treatments” which are magic bullets “just like insulin for diabetes”?

    Report comment