A recent article by Jasna Russo, a long-term scholar-activist in the international user/survivor movement, delves into the complex relationship between psychiatry, epistemic justice, and the individual agency of people with lived experience in mental health discourse. The article, titled “Psychiatrization, Assertions of Epistemic Justice, and the Question of Agency,” was published in Frontiers in Sociology.
Russo explores the implications of the medicalization of mental health issues and its impact on the recognition of individual agency and the pursuit of epistemic justice, particularly from the perspective of those with personal experience of psychiatrization.
“Thus far, the application of Fricker’s work [on epistemic injustice] in psychiatric and mental health literature is characterized by descriptions of psychiatric patients’ vulnerability to epistemic injustice and by calls to ‘listen better’ and ’empathize more.’ These approaches typically leave the concepts of ‘mental illness’ or ‘psychiatric disorder’ unquestioned. The biomedical framing of human crises and the practice of psychiatric diagnosing are hardly ever considered as a foundation of othering, or as principal enablers of epistemic (and other) injustice,” Russo writes.
“The notion of epistemic injustice has been less elaborated by psychiatrized people ourselves than by clinical academics. Yet, to those who have adopted it, it has proved helpful as a simple and convincing way to frame the disqualification of our knowledge and our truths that we face individually but also collectively, as organizations and movements.”
Epistemic justice is the equitable treatment of individuals concerning knowledge production and distribution. Russo argues that the growing medicalization of mental health, known as psychiatrization, may inadvertently undermine epistemic justice by privileging medical perspectives and sidelining alternative viewpoints. This process can result in the marginalization of non-medical perspectives on mental health and well-being.
The article emphasizes that, thus far, the concept of epistemic injustice in psychiatry has been discussed more widely by clinical academics than by authors with personal experience of psychiatrization. Russo critiques the practice of attributing testimonial injustice solely to the “stigma against mental illness,” pointing out that psychiatric diagnosing itself is a principal enabler and re-producer of this form of injustice.
She also examines initiatives that seek to incorporate collective first-person knowledge into the dominant epistemic systems of mental health service provision and research. In doing so, she highlights the challenges in achieving epistemic justice for psychiatrized individuals and advancing collective knowledge, given the incompatibility of psychiatric knowledge claims with first-person ways of knowing.
The research calls for a reevaluation of current approaches to mental health and a movement toward epistemic justice that respects the value of the diverse experiences of those affected by mental health issues. This would involve changing laws, abolishing practices that enable and sustain testimonial injustice, and fostering political will to create more inclusive and equitable mental health discourse and practice.
Russo develops her argument by exploring how, in the context of psychiatry and mental health, epistemic injustice has emerged as a significant concern, particularly for those who have been deemed “mad.” Two intertwined issues contribute to the problem: the presumption of the inability of people deemed mad to articulate their experiences and knowledge and the question of who is qualified to work toward justice. These issues result in a wide range of practices that range from overt control to subtle forms of silencing.
Russo argues that hermeneutical injustice is a critical concept in understanding the relationship between psychiatry and the collective knowledge of those deemed mad.
Several critical works have documented and analyzed the failure of bio-medicalized participatory practices in psychiatry to uphold the distinctiveness of marginalized perspectives. These practices often sustain dominant structures and reproduce inequalities, despite the intention to integrate first-person knowledge. Efforts to incorporate “lived experience” as a historically missing perspective have been limited, as the distinctiveness of this epistemic source is often not recognized.
Russo turns to Kristie Dotson’s concept of “irreducible epistemic oppression” to demonstrate the incompatibility of psychiatric knowledge claims with collective first-person ways of knowing. Addressing this oppression requires recognizing the limits of one’s overall epistemological frameworks, which is rarely a viable option in a field dominated by the biomedical model of mental illness.
For Russo, the collective first-person knowledge of people deemed mad transcends both the research questions and the methodologies of psychiatric and mental health research, and, therefore, a different epistemological framework is needed to explore and deepen this body of work. Unfortunately, such a framework is unlikely to emerge within disciplines founded on the denial of “mad” people’s rationality and remain reluctant to make room for their perspectives.
Russo points out that the way hermeneutical injustice has been defined involves no culprit and is a purely structural notion. However, she argues that in the context of official knowledge production on madness and distress, it is essential to consider the practical implications of this framing. If no culprit is involved, how can hermeneutical injustice be addressed, particularly in projects seeking to involve first-person knowledge-holders within psychiatric and mental-health disciplinary frameworks and on their terms?
In conclusion, although exploring epistemic injustice in psychiatry and mental health is neither systematic nor complete, some general trends can be observed. Testimonial injustice is mainly seen as intrinsic to “mental illness,” and there is little willingness to question the role of what is known as the psy-complex (psychiatry, diagnostic procedures, psychological assessment practices in education and the workplace, and so on) in the making of “psychiatric patients.” Meanwhile, there is a growing eagerness to include “lived experience expertise” in mental health. However, this eagerness is fraught with contradictions and raises essential questions about identity, representation, and the future of Mad Studies.
Ultimately, Russo argues that advancing collective first-person ways of knowing requires a focus on ethics, methodologies, and independence from the psy-complex. She concludes:
“I wish for Mad Studies to keep fostering hermeneutical justice—not as a desirable nor once-and-forever achievable state, but as an ongoing process which never shies away from taking an honest look at itself; which resists the seductiveness of having the last word; and which always stays open to those who have not yet spoken.”
Russo, J. (2023). Psychiatrization, assertions of epistemic justice, and the question of agency. Frontiers in Sociology, 8. (Link)
Psychiatry is a classic case of the pot calling the kettle black.
So its claims of addressing “epistemic injustice” is, using my own “hermeneutical” language, A BOATLOAD OF BULLSHIT.
Sounds about right.
Glad you think so.
This is something I’ve noticed in our culture that could be beneficial in an objective scientific environment where experimenters aim to minimize their impact on the objects they study. However, when this approach is applied outside of a laboratory and individuals adopt the same detached mindset with their clients, it can lead to what is commonly referred to as gaslighting. What this type of environment creates is people who are extremely knowledgeable almost as good as the doctor themselves but unable to switch to their own observation or validation and depend on the doctor’s validation as the empirical result of the experiment.
One thing I noticed lately though that this is coming to a very interesting end now. A lot of the young people are doing self-diagnose, which I am not condoning nor encouraging but it shows the end of epistemological ownership by the authority.
Thank you so much for sharing this information. It is something that is concretely problematic because mental health is social and relational aspect (short of biological binding for some) but ultimately each person needs permission to validate and know their situation as good as the person one is relating to.
People aren’t objects and shouldn’t be used as lab rats to further someone else’s idiotic idea of a “career”.
are we not all ‘Psychiatrized Individuals’’ the DSM mindset is so thoroughly embedded we mostly all view ourselves using its language.
Where are these mythic human beings without ‘lived experience’? they must be floating above clouds – surely everyone with a beating heart and family and friends suffers? yes because of resources many escape the toxic nonsense of the modern mental ill health system but suffering is universal.
I’m a bit worried about giving priority to those indoctrinated by the system unless they have found a way to break from its cult like ways and can see a bigger picture.
Very interesting. You can actually see this happening in the growing autism and adhd self ID movement, I think. The pushback experienced by some as they seek diagnosis from a Dr, as well as from others invested in old models and diagnostic criteria. Collective knowledge production on tiktok and youtube, and other spaces, endless testimonials of lived experience in the comments. I guess the final frontier will be justice and a voice for those deemed “mad” and “irrational” as you say. But you can find that on social media too. There’s also a strong lobby for infantilising autistics and minimising the difficulties experienced by those classed as “high functioning”.
A late autism diagnosis in middle age set me free and gave me a positive frame to view my social experiences, as the article says. I might have edited out all the hermeneutics and epistemology language and put it more plainly though because it could be made more accessible