Epistemic injustice in assessment of delusions

Abstract

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.

Identity and schizophrenia: Who do I want to be?

“…It is acknowledged that change decisions can, at times, be grounded in delusional thinking, leaving clinicians in a quandary as to how to respond. Sanati et al[82] argue, however, that not taking a person’s statements at face value constitutes an act of testimonial injustice[83], an unjustified devaluation of a person’s word. Individuals with a diagnosis of psychosis are often exposed to this form of injustice because the term, schizophrenia, is linked in many people’s minds with personal attributes such as irrationality and untrustworthiness.…”

Epistemic injustice and responsibility in borderline personality disorder

“…This fact, along with the known prejudice against patients with BPD provides us with good context for the presence of epistemic injustice in these patients. The case of BPD is interesting as unlike some other cases of epistemic injustice it is not a case of invalid attribution of invalidity but rather an invalid attribution of validity.…”

Ethical complexities in assessing patients’ insight

“…Repeated studies over the last 30 years have revealed that mental health professionals tend to have negative attitudes and therapeutic pessimism towards patients with a diagnosis of personality disorder,3 which likely affects even the possibility of a trusting therapeutic relationship. In case scenarios involving patients with delusional disorders, Abdi Sanati and Michalis Kyratsous found that ‘clinicians attributed less credibility to their reports and expressed behaviour, biased by the general view that it is almost impossible to have empathetic access to the emotions and cognitive processes of a deluded subject’ 4. Sanati and Kyratsous show that presumptive distrust can cloud clinicians’ perceptions of any and all reports from the patient; distrust is not necessarily isolated to particular testimony against which there is clear and convincing evidence.…”

“…Individuals with current and past psychiatric diagnoses are susceptible to this kind of injustice, as described by Deegan. Sanati and Kyratsous argue that these ‘patients are not given the same credibility as a non-patient on the basis of having an illness that is so often associated with attributions of irrationality, bizarreness, and incomprehensibility ’ 4. Caregivers should take steps to minimise this vulnerability in healthcare environments, which includes carefully scrutinising insight assessments.…”