The theme for Div. 24, indicating our central priority this year, is epistemic access. Our division’s president, Joshua Clegg, in this newsletter remarks, “One of the key forces shaping science is who has access to determine what counts as warrant, evidence, acceptable practice, and truth. Everything about science–including the culture of science, its disciplinary politics and economics, its sanctioned methods, assumptions, and conclusions–is shaped by the identities, histories, cultures, and social positions of those who make science.”
Epistemology escapes academia
This divisional priority is an apt example of the theme of this newsletter–how are philosophical and theoretical concerns, earlier relegated to margins in the psy-disciplines, helping us transform and reform it? Words like epistemology are traditionally heard in the hallowed corridors of academia, often floating out of classrooms where nervous graduate students are trying to prove they understand them. But recently questions of epistemic injustice have sauntered into the mainstream concerns of psy-disciplines. Epistemic injustice happens when the power differential between two parties ensures that the experience and knowledge of one is easily disregarded, and often mocked. For example, in a clinical encounter, the clinician’s word about patient well-being might be considered more worthy, accurate, and truthful than the patient’s own experience and assertions. The dangers of epistemic injustice are far-reaching and horrifying, as they allow psychological concepts to be weaponized against the powerless. Take the case of anosognosia (patient’s lack of insight into their own condition) and Kenneth Donaldson (Peterson, 1982). Donaldson received damages after he sued his psychiatrists because they had involuntarily institutionalized him for fifteen years. They justified the violation of his rights (and the United Nations Convention on the Rights of Persons with Disabilities considers involuntary confinement just that) by in part noting that during a certain assessment, he did not draw pupils on eyes of stick figures. According to the psychiatrists, Donaldson’s unwavering belief that he will find a job and write a book (about the hospital) post-institutionalization, only further proved his lack of insight into his own condition. The physicians were charged with acting maliciously or wantonly or oppressively and Donaldson’s was the first such case that made it to the Supreme Court (Peterson, 1982). Epistemic injustice can just as easily be found outside the clinical, for example in the colonial encounter.
Currently, these concerns are reflected as Participatory Health Research (PHR) becomes more mainstream in healthcare. This holds unique importance for the Psy-disciplines. In these research projects, service users collaborate with other experts in the field as it is understood that knowledge production should not simply be a top-down process if it has to be relevant, generalizable, and not deleterious to the health of those it purports to heal. After ignoring literature and patient experience on withdrawal for decades, such collaborative projects have helped create new tapering guidelines that are now being adopted worldwide (Groot & van Os, 2020). These shifts that emphasize epistemic access and shared decision making, and challenge traditional understandings of epistemology have helped reduced hospital visits, decrease dependence on medications, and improve patient outcomes (Pocobello et. al., 2019). Other real-world consequences of this growing understanding of epistemic access includes moving away from stigma reduction campaigns (after their spectacular failure) and their focus on the victim as a container of stigma towards ones that value and practice epistemic justice, which involves looking at those people and systems who practice discrimination; in other words, understanding mental health prejudice as an act of power (Harper & Vakili, 2020).
Philosophy makes a comeback after never leaving the scene
These examples and many more reflect the central theme of the newsletter–that concerns earlier relegated to those interested in philosophy and theory, are now returning to the mainstream and just might rescue the discipline from itself. I am now going to highlight the work of some such people and other growing movements that exemplify this inclusion, orientation, and rescue. This is not to say that researchers and clinicians were not doing similar work in the past, but instead meant to showcase the current attempts, and in some cases, their mainstream reach.
Hanna Pickard is a philosopher, bioethicist, and works in therapeutic communities (clinical settings) with people dealing with addiction issues. As a clinician, Pickard has incorporated her philosophical background by challenging our cultural and philosophical obsession of automatically linking responsibility and blame (receiving pushback from some philosophers). Her clinical work, built on the subversion of this seemingly natural relationship, focuses on helping clients assume responsibility in a collectively supportive environment while ensuring that others’ response is that of care and compassion, instead of blame; responsibility is treated as a forward-looking concept (Pickard, 2017). Set against the backdrop of therapeutic communities, this requires a profound reorientation of the way we understand responsibility, addiction, and identity. It rescues people from the fatalism of the brain disease model while ensuring that structural factors such as housing, poverty, employment, etc., are at the dead center of the dialogue; responsibility is not just attributed to the patient but to the community and us as society which made such systems of oppression possible. A deep philosophical exploration of ethics is the ground from which this work emerges.
While Pickard’s work brings philosophical questions (the assumed relationship between responsibility and blame in ethics) to clinical work, Helen Spander’s centralizes the role of theories created by service users, considering them as valuable as more prominent ideologies. Trained in the Marxist tradition, Spandler insists that starting with conditions on the ground (with human suffering in front of you) is more essential than moving forward with ideologically driven interventions (Spandler, 2021). Thus, Marx in her work is not a beating stick to be used on the clients but instead a framework that allows her to ask how the material conditions of this person’s life are affecting their mental health.
The work on epigenetics of Evelyn Fox Keller which destroys the dichotomy between nature and nurture rendering these categories absurd, was made possible by her background as a theoretical physicist, molecular biologist, a feminist, and most importantly, because of her specialization in history and philosophy of biology (Keller, 2014). Such paradigm-shifting thinking is often only possible by people who engage in a dialogue with history and philosophy rather than rendering them as mere thought-experiments. Her writings on the reactive genome, an understanding of genetics that shifts our thinking away from a conception of ourselves as collection of static genes (ready to give us schizophrenia), to one that understands the genome as responsive and reactive to context is groundbreaking. It is also of unique consequences to the psy-disciplines which have been mired in the debate of culture and environment versus brain or genes.
Similarly, Helena Hansen’s work looks at how diagnosis and prescription-behavior are defined by how practitioners conceptualize their patients in moral terms. A philosophical exploration into how clinicians create moral subjects out of their clients has allowed for understanding systemic racism and classism in the Psy-disciplines (Hansen, 2019). Unlike most lip-service which is offered to issues of race and class, often made possible by the now-under-scrutiny implicit bias tests, work such as Hansen’s is based on deep theory which tethers itself to work on structural determinants of mental health–not as a diversity initiative but as a subversive practice. She provides an example of two patients at the NYU hospital, Jonathan (white, upper-class, prospective law student) and Ibrahim (African-American and poor), presenting with the same symptoms and getting diagnosed with either substance-induced psychosis (Jonathan) or schizophrenia (Ibrahim) based on their moral subjectivities.
Going back to epistemology, Elisa Lacerda-Vandenborn has challenged how child protective services, often nudged by the psychological knowledge which is considered universally true, allows us to rip children from indigenous communities. For example, a social worker might consider a child alone in the house as grounds for abuse and separation but in many indigenous communities (including in India where I am from), neighbors, aunties, and cousins regularly drop in every few minutes to check in on children if the parent is away for a few hours (Lacerda-Vandenborn, 2021). These challenges to Western theoretical assumptions that underlie developmental psychology and then influence public policy (often harming its others), are hugely a result of the decolonial movement which has gained traction in the last few years. Decolonization of thought, policy, and knowledge is becoming hugely popular as many realize the hollow promises of the diversity narrative, which yet again responds to systemic problems with individual training solutions.
Thus, methods of research and intervention in response to our epistemic violence (often causing other forms of violence) have grown globally (e.g., Mahi a Atua in New Zealand and Dang-ki healing in Singapore). They are not simply alternative therapies; for that matter many indigenous scholars such as Diana Kopua steer clear of calling Mahi a Atua “therapy.” As opposed to being considered side-practices of the natives which might enhance traditional psychotherapy and thus should be tolerated with bemusement, they now hold their own. As in the case of Amazonian medicine, these practices are also challenging the methodological criteria on which they are evaluated by the Global North, especially as the Global Mental Health Movement makes a U-turn as interventions of the Global South make their way into the territories which have until now been held strong by the psy-disciplines. They are effectively challenging the “right to science” framework (Bouso, J.S. & Sánchez-Avilés, 2020).
An engagement with theoretical assumptions and return to philosophical roots in research and practice might help us make our way back from the embarrassments of the replication crisis, humiliation of industry corruption, and shame of ineffective (and harmful) treatments. Whether it’s the United Nations Convention on the Rights of Persons with Disabilities which highlights epistemic injustice, or the Cape Town Declaration by Pan African Network of People with Psychosocial Disabilities which insists on going back to the lived experience of service users, or the 2018 Lancet Commission on Global Mental Health and Sustainable Development report which encourages a public health approach based on structural determinants (but promptly reverts to the Western “neuromania’” to conceptualize mental disorder), Husserl, Foucault, Lacan, Spivak, and Levinas among many others are resonant in these global movements. For how long and with what consequences remains to be seen.
References
Bouso, J.S. & Sánchez-Avilés, C. (2020). Traditional healing practices involving psychoactive plants and the Global Mental Health agenda: Opportunities, pitfalls, and challenges to the ‘Right to science’ framework. Health and Human Rights Journal, 22 (1), 145-150.Dhar, A. (2021, February 24). Uncomfortable truths in survivor narratives: An interview with Helen Spandler. Mad in America. https://www.madinamerica.com/2021/02/uncomfortable-truths-survivor-narratives-interview-helen-spandler/opens in new window
Dhar, A. (2021, November 17). How western psychology can rip indigenous families apart: An interview with Elisa Lacerda-Vandenborn. Mad in America. https://www.madinamerica.com/2021/11/an-interview-with-elisa-lacerda-vandenborn/opens in new window
Groot, P. C., & van Os, J. (2020). How user knowledge of psychotropic drug withdrawal resulted in the development of person-specific tapering medication. Therapeutic Advances in Psychopharmacology. 10: 1–13.
Hansen, H. (2019). Substance-induced psychosis: Clinical-racial subjectivities and capital in diagnostic apartheid. Ethos. Published Online First: 28 March 2019.
Harper, D., Vakili, K. Mental Health Prejudice, Discrimination, and epistemic justice: Moving Beyond Stigma and Biomedical Dominance. In M. Augoustinos, K. Durrheim & C. Tileaga (eds), Routledge international handbook of discrimination, prejudice, and stereotyping. London: Routledge.
Keller, E.F. (2014) From gene action to reactive genomes. J Physiol, 592(11):2423-2429. doi:10.1113/jphysiol.2014.270991
Pickard, H. (2017). Responsibility without Blame for Addiction. Neuroethics 10, 169–180.
Pocobello, R., Sehity, T., Negrogno, L., Minervini, C., Guida, M., & Venerito, C. (2019). Comparison of a co‐produced mental health service to traditional services: A co‐produced mixed‐methods cross‐sectional study. International Journal of Mental Health Nursing. DOI: 10.1111/inm.12681
Ayurdhi Dhar is an assistant professor at Mount Mary University. She has taught psychology in the United States and in India, where she also worked as a therapist. She is the author of "Madness and Subjectivity: A Cross-Cultural Examination of Psychosis" in the West and India. Her interests include discursive practices sustaining the concept of mental illness, decolonial theory, schizophrenic subjectivity, and trauma and immigration. She is also a science news writer for Mad in America and loves dogs.