Delusions are one of the most elusive concepts in psychiatry. There have been several theories on the nature and definition of delusions. Jaspers described them as entailing a total transformation of reality and considered primary delusions as un-understandable. When it comes to clinical practice, psychiatrists resort to criteria of falsity, incorrigibility, conviction and being out of keeping with the person's culture. All these criteria have been subject to various criticisms, some of which will be discussed in the paper. We will use the concept of epistemic injustice to explore the role of stereotypes and prejudice in the identification of delusions. We will discuss cases where patients are suffering from testimonial injustice by virtue of having a mental disorder that is so often associated with attributions of irrationality, bizarreness and incomprehensibility. Two vignettes will be presented to show that this is often the case in clinical practice. We will discuss relevant issues around the epistemology of the delusions. We think that in order to challenge the testimonial injustice, there needs to be an awareness of its possibility and thus recognition of the role of certain stereotypes in assessing these mental states. Challenging the stigma against mentally ill and adopting a holistic view of delusions can help tackle the prejudice that pre-empt the testimonial injustice.
Miranda Fricker's concept of epistemic injustice has been quite a novel idea in epistemology. It brings something new to the fields of epistemology and ethics. Fricker draws our attention to a distinctive species of injustice, the epistemic injustice, in which someone is specifically wronged in his capacity as a knower. There has been a significant amount of work done in epistemic injustice, both in race and gender studies. The application of the concept in the context of mental health is less explored. Here, we aim to apply the concept of epistemic injustice in attributing responsibility to patients with borderline personality disorder. Attributing responsibility involves holding someone accountable for his presumed wrongdoings, making judgments on whether the agent has control on his action, on whether is aware of its consequences. It is generally agreed that in order to be morally responsible for an action the person should be worthy of praise or blame for it. Following Aristotle, we focus on epistemic condition in attribution of responsibility. We will discuss the role of epistemic injustice in assessment of epistemic condition of responsibility. We will show that we can misinterpret the agent's intentions because of the presence of systematic prejudices. We will focus on patients suffering from borderline personality disorder. We provide a case vignette to show a tendency in the professionals in holding these patients responsible for their action when it can be argued otherwise. We argue that prejudice against the patient with borderline personality disorder where the person is seen as manipulative plays a significant role in the process of epistemic injustice. The suggested manipulative nature of patients with borderline personality disorder leads to professionals to ascribe agency and knowledge where it is not due.
Quality of prescribing is an important aspect of clinical practice. In a study of the effect of electronic prescriptions on prescription quality in the UK, Donyai et al (2008) found errors in 3.8% of their sample before the introduction of electronic prescription. In a psychiatric setting in Leeds in the UK, Nirodi & Mitchell (2002) found that 16.1% of prescriptions written for a cohort of elderly patients were illegible, and a third lacked information on dose, frequency or indication of use of medications. They found that only 18% were legible and free of all errors.
Therapeutic communities also specialise in being able to treat those who have a particularly severe presentation of personality disorder, such as in prisons. This severity can be measured by diagnostic criteria, comorbidity, risk, complexity or unmanageability. 12 The therapeutic environment, including techniques such as peer mentoring and deliberate informality, facilitates engagement of people who would otherwise be 'untreatable' . Also, by managing risk primarily through continuing, empathic and intense therapeutic relationships, therapeutic communities can manage levels of risk that would be unacceptable in other services. This study demonstrates that democratic therapeutic communities have now started to accumulate the evidence to earn a place in the therapeutic pantheon for moderate and severe personality disorder.
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