Thus, combatting epistemic injustice is not a matter of assuming epistemic peerhood (as it is for gender and race). Rather, preventing epistemic injustice for mental illness will involve a balancing act between ensuring that we do not make a priori or undue attributions of epistemic deficiency (either in terms of an individual’s rational capacities, understanding or testimony) on the basis of stereotype, whilst also acknowledging that some people with mental illnesses have genuine limitations in these capacities. Any strategy for combatting epistemic injustice must be able to support (whilst not needlessly interfering with) those individuals who have mental health issues but few epistemic limitations, yet also those whose limitations are more severe. It must also be able to cope with diverse kinds of limitations.
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I suggest that advocacy is likely to be an appropriate strategy for this task. The charity Mind (2015, no pagination) describes advocacy as “getting support from another person to help you express your views and wishes, and to help make sure your voice is heard”.An advocate can assist mental health service users in a variety of tasks. For instance, advocates can help service users to work out what they want to achieve in a meeting (for instance, with the psychiatrist, a GP, a social worker, or in a benefits hearing) and assist them in finding a way in which they can successfully achieve that. Service users can express concerns that they are not being listened to or that they are being dismissed. Advocates are then able to support the service user, and can either speak for them, query things on their behalf in meetings or interject where they feel that the service user is not being granted due respect or adequate time in which to express themselves. Depending upon the confidence and competency of the service user, advocates can be more or less involved in the degree of support they offer. For this reason, I suggest it may be a useful strategy by which epistemic injustice may be fought whilst attending to the epistemic limitations and differences of some service users.
How can advocacy help to combat epistemic injustice? Having an advocate present in the room can give service users the confidence to express themselves, and an advocate can back the service user up where they feel they are not being listened to. Having someone on their side empowers service users, and either they or the advocate can speak out where they feel that epistemic injustice is being committed. Indeed, service users may feel that they can speak out in the presence of an advocate where they did not feel able, or confident enough, to do this alone. Given that advocates can play a vital role in the identification and protest of epistemic injustice, it would perhaps be prudent to integrate a brief education programme about epistemic injustice and its various forms and manifestations into advocacy training. For instance, advocates could be provided with examples of real-life cases of epistemic injustice which they
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may come across in their practice. This should be possible, given that advocacy training is often quite lengthy, and there is time in which this could be done.
Yet, advocacy is also capable of recognising epistemic deficiency and making sure that it does not disadvantage the service user. It acknowledges that some service users do struggle to understand what is being said to them, and equally struggle to communicate their own experiences in a clear, ordered and concise way. As such, in many cases the role of advocacy is to facilitate understanding. Advocates help service users to access information, support them to query things that they do not understand, and can explain information or procedures to them. Often, pre-meetings are held in which service users can discuss with their advocate what they want to get out of the next meeting, what they want to say, what they are concerned about, and how they want the next meeting to proceed.
By working through concerns and getting their thoughts together with an advocate, service users have an opportunity to decide on the aims of the cooperative exchange and can work through any distress, cognitive interference or anxiety with their advocate before attending a GP appointment, for example. This gives them a chance to better structure their contribution to the exchange with the GP by thinking about potential problems beforehand, and can often make service users calmer when they attend the appointment. There is a great deal of anecdotal evidence from service users that this improves their experience of the GP meeting. Advocacy (particularly when pre-meetings are held) helps to make it easier for service users to understand the purpose of the cooperative exchange and what is conveyed in the exchange. It also allows service users to plan their contributions so that they are relevant, carefully thought out and well-structured. Thus, where deficits of understanding obtain, well-conducted advocacy can
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ensure that the service user is not disadvantaged and does not have a poor experience, whilst still combatting epistemic injustice. Hence, whilst advocacy services are available, I might tentatively suggest that more funding should be allocated to this area. More people should be made aware of the possibility for advocacy, and advocates themselves should be given robust training.
VIII. Conclusion
In this chapter I have explored a phenomenon which I believe is a large part of the stigma of mental illness: epistemic injustice. The mentally ill are often experience status loss. They are disempowered in social relationships, and one way in which this commonly occurs is in their capacity as epistemic agents. Some of the material in this chapter has links to chapter 2, in which I noted that the disempowerment of mentally ill people may be problematic as it removes them from the decision-making process (either regarding their own lives or about those of others). This is concerning because it exacerbates the risk of implicit stigma occurring. Further to this, a culture of testimonial injustice makes it impossible for mentally ill people to practice meaningful criticism of practices they do not endorse: for instance, where mistreatment or abuse occur. In this way, epistemic status loss may play a profound role in implicit stigma.
To explore this further, in this chapter I outlined Fricker’s (2007) account of testimonial injustice. I argued that the mentally ill constitute a group which suffer identity-prejudicial credibility deficits, and provided examples of this. I then outlined Goguen’s account of stereotype threat, before discussing how the mentally ill not only likely experience stereotype threat, but that it may be particularly profound given the common stereotypes of rational
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deficiency. I also noted that the mentally ill were liable to experience severe epistemic spillover due to the myriad cases in which epistemic doubt (both justified and not) could be engendered within them. I suggested that stereotype threat may explicate a range of phenomena and behaviour encountered in mentally ill people and their interaction with others and services.
Finally, I noted that our strategies for combatting epistemic injustice in mental illness are likely to differ from those used in gender and race. For one, the stereotypes of rational deficiency can occasionally be accurate, and so cannot be dispensed with altogether. There are genuine epistemic limitations associated with at least some mental illnesses, and so combatting epistemic injustice is not simply a matter of establishing epistemic peerhood. Rather, a more nuanced strategy must be adopted. I have suggested a few strategies we might use to combat epistemic injustice in mental illness, including refraining from making assessments of epistemic credibility where possible, where necessary making these on a case-by-case basis, and being responsible with our application of stereotype. I concluded by suggesting that advocacy may be a suitable means of both avoiding overgeneralisation and fighting epistemic injustice, whilst at the same time appreciating and factoring in many of the epistemic limitations associated with suffering from at least some severe mental illnesses.
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