Epistemic Injustice in Psychiatry

These posts explore the themes developed in my monograph, Narcisso-Fascism, which is itself a real-world test of the central concepts of the Biocognitive Model of Mind for psychiatry.

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An article by psychologist Richard Sears in last week’s Mad in America is headed: “Minorities Face Higher Rates of Restraint, Chemical Sedation, and Psychiatric Detention.” He summarises three papers on how people from racial minorities face significant discrimination in public health services. The first, from the US, shows that people with limited proficiency in English are more likely to be restrained and/or sedated than native speakers. They investigated over 132,000 discharges over 54 months from a major medical centre in Boston, not a psychiatric unit. About 10% of patients had limited English but they were 30% more likely to be physically restrained and 12% more likely to be given antipsychotic drugs. The average age of all patients was 65 so drug abuse and alcohol withdrawal, which attract restraint and sedation, were less of a problem than in an emergency centre.

The second paper was a meta-analysis of papers from Europe covering nearly 39,000 admissions to psychiatric units. People from ethnic minorities were about 50% more likely to receive “rapid tranquillisation” (“chemically restrained”) than native-born admissions. This covered a number of countries in Western Europe so public health services were generally of a high standard. The third described a study in England from an area with about 12% of the population identified as “Black,” which they say is three times the national average. They interviewed staff regarding attitudes toward managing Black men in emergency setting. The intention was to explore the effect of epistemic injustice as it influenced the men’s experiences of mental health services. This is a sociological term, rarely used outside their field, which concerns wrongs inflicted on people because they are assumed not to know their own minds. They are wronged in their “capacity as knowers,” and it’s rife. It can be because they’re old, or young, or foreign-born, or struggling with English, or uncooperative, as in not wanting to be there, or just plain wierd. Instead of pressing on with a difficult interview, staff just give up, scribble a few notes and order drugs and seclusion.

An example from my training many years ago comes to mind. My supervising psychiatrist was a bit hard of hearing and the patient, a Calabrian lady in her 50s, hardly spoke English. I was struggling along with my schoolboy Italian, which she understood perfectly of course as it was Tuscan, whereas she spoke the southern dialect which I could hardly understand. The lady was born in the 1920s and life in Italy during the depression, the war and its aftermath was terrible. It was a laborious interview and the psychiatrist was obviously in need of a cup of tea. From time to time, he would interrupt with “What’s she saying?” Finally, he harumphed and headed for the door: “That’s the trouble with these mental patients,” he snorted over his shoulder, “if only they would stop mumbling.” That’s it. Mumbling is the cause of mental disorder. Elocution lessons for all. In fact, he liked patients, it was other psychiatrists he didn’t like. But the point is that the assumption is always: “If I don’t understand you, it’s your fault, not mine.” This is the dominance hierarchy in operation.

In 1987, I left Perth to move north to Western Australia’s remote Kimberley Region. It’s one of the most isolated parts of the Anglophone world, routinely cut off by cyclones or floods during the wet season and a long way from anywhere the rest of the time. The climate is harsh, monsoonal subtropical on the coast ranging down to the edge of the desert in the south. Temperatures are extreme – the first time I went to Wyndham, it was 48C (118F) and 90% humidity. Cyclones are common, bringing massive floods but droughts are even more common. The region is about 420,000sqkm and had a population of about 24,000, one person for every 18sqkm. For comparison, Victoria has 7.2million jammed in 220,000sqkm, and New York state has about 20million over 140,000sqkm, or one third the size of the Kimberley. The Kimberley population was then a little over half white, a lot of whom were transients: school teachers, police, miners and, of course, hospital staff. There were very few white people aged over sixty as they moved back to the southern states to retire. Mostly, the Aboriginal people lived within their traditional areas, even those who had travelled for education.

Housing was provided but was generally overcrowded and often damaged in drunken brawls. Each of the twenty or so main communities had a nursing post and a school but in the main, people lived traditional life styles. They spoke their own languages at home and their traditional belief systems were largely intact under a veneer of Christianity. This extended to health, of course, in paticular, the idea of preventive health. They were very fatalistic and just accepted as normal standards of health that white people would never accept. Coughs and colds, chronic bronchitis, ear and nose infections, bowel parasites and so on were seen as the normal course of events. All too often, they would simply put up with a chest infection until they were seriously ill with pneumonia and had to be flown to hospital. Respiratory disease was common as during the cold season, they would all sleep in the same room with the windows closed to keep warm but also because of smoke from the camp fires. They saw smoke as cleansing and therapeutic because it kept mosquitoes away. Alcohol was a major problem and other drugs were just starting to arrive but the fundamental issue was the lack of work. Apart from a bit of mining and the slowly dying cattle industry, both of which were highly mechanised, there were no industries sufficient to support that population. However, they couldn’t move away. They were tied to their land in the totemic structure, they struggled with English, their education was elementary, theirs was an oral culture so reading was simply not part of their lives, they hated cold weather but disliked working indoors, so where could they go? I don’t think things have changed very much since then.

The reason for putting a psychiatrist in that distant region was to deal with mental problems on the spot rather than have them sent to the mental hospitals in Perth, 2,200km away (almost the distance from London to Moscow). They would not go voluntarily so they were always detained but once they went south, it was very difficult to get them home again. The average stay was about six months, four times as long as for southerners. There was no follow-up so they would often relapse and be sent back to Perth again. My job, as the first isolated psychiatrist in the country and, it turned out, the most isolated in the world, was to ferret out looming mental problems in the region and fix them. Great, not a problem, can you send my magic wand to this address? But isolated meant isolated. It meant no office, no staff, no facilities of any kind and, above all, no support. In the six years I was there, I was never once contacted by the health dept or by the college of psychiatrists, even to see if I was still alive. There was absolutely no interest so I got on to build what I thought a remote service should be like: no service, just a psychiatrist roaming around in a 4WD vehicle or coming in with the flying doctor. I drove about 60,000km a year and had about 15 flights to the remote communities, such as Balgo, on the edge of the Tanami Desert or Kalumburu on the Timor Sea. And it worked. In the first full year, the number of admissions to Perth dropped from 52 to 2. Because they had to go by plane, either commercial or flying doctor, that represented an enormous saving alone, plus the cost of admission because they were managed at home, not in hospital.

The idea of a mobile psychiatrist was alien to the psychiatric culture and I could not convince anybody of its value. Traditionally, the psychiatrist sits in an office in the inner city area or in a large and forbidding mental hospital, and patients have to travel to be seen, which means they often don’t get there. If you see them at home, you see exactly where they live, you meet all the relatives and the neighbours who will be delighted to tell you what they think is wrong (with no mumbling) and they all get to see that the shrink doesn’t have two heads. Next trip, it’s a lot easier and after a year, patients would push their brothers or cousins who were “silly in the head” through the door to see the doctor. This was the model I have used since.

Back in Brisbane in about 2014, I compared my costs as a private bulk-billing psychiatrist with the traditional mental health service 2km down the road. It was traditional in the sense that they would only see patients who were “case-managed,” meaning chronics who had been in hospital. Ordinary cases who didn’t need admission had to go to the city 16km away which, for women with young children, was traumatic in its own right. This was a working class area jammed between two industrial areas, with a lot of immigrants and Aboriginal people, high unemployment, a lot of broken families or single parents, drugs and alcohol, the usual. Bulk-billing means I was paid by Medicare to see public patients, but only 85% of the scheduled fees, out of which I had to pay rent, staff costs, vehicle, phones, insurance and so on. Most private psychiatrists head for the city where they can charge privately-insured patients 200-300% of the scheduled fees. Using figures from the Health Department, I showed that the cost for half an hour of a well-qualified psychiatrist’s time was $73.50. The cost for half an hour of non-medical staff time down the road was $274.50. When I sent these figures to the Health Dept, I was told it was impossible, I must have got it all wrong. That was built into the system, both the grossly inflated costs and the denial.

The problem is, the overwhelming majority of psychiatrists and other staff are scared of leaving their institutions. They like the feeling of being part of a powerful system, of having keys on their belts and the security men a minute away. They feel safe and reassured that they’re on the right side of the glass wall but again, it’s a domination thing. Psychiatrists like it because they can stroll around knowing they’re at the top of the foodchain and everybody has to smile and step aside; nursing staff because they have absolute job security and they know they all stick up for each other; psychologists start to talk about chemical imbalances; and social workers are the enforcers of last resort. In one hospital years ago, by reducing the admission rate and shortening the average stay, we were able to close a ward and shift staff into the community. Who objected loudest and most violently? Nursing staff, of course.

How did we get onto this? Oh yes, epistemic injustice, the injury that comes from power imbalances that lead to discounting what a person knows. This is built into modern biological psychiatry. The patient says:

I’m a mess. My early life experiences weren’t good and my recent life has been terrible. I need somebody to show me how to get out of this mess otherwise I may as well be dead.

Psychiatrist smiles knowingly:

Don’t you worry about all that stuff. You’ve got a chemical imbalance of the brain caused by your genes. Your DNA has caused you to have bad experiences, not the other around. Take these tablets and this ECT and you’ll be fine, all your bad luck will disappear [1].

This is the ultimate epistemic injustice. It says that anything you believe about yourself and your life is of no consequence. The only thing that counts is what we believe about your mental state, and we always believe that you can’t get yourself better, you can only get better by doing as we say. And if you object, we have ways of dealing with that, too. Take an example of Billy, a 19yo single Aboriginal man from a remote community. He is full Aboriginal, reads at about Year 4 level, can drive but knows nothing about mechanics apart from changing a wheel, drinks erratically and smokes a bit of weed. His English is limited as he normally speaks his own language at home but his accent is very thick and he uses a lot of slang terms from his culture so it’s hard to understand him, especially when he gets upset. He has been diagnosed with a paranoid psychosis and is scheduled to get depot antipsychotics because everybody knows he won’t take tablets at home and it’s easier for the nursing staff to give an injection each month rather than chase him to take tablets. He doesn’t like the tablets because, he reluctantly reveals, they affect his sex life and he thinks they are trying to change him into a girl. The main problem is that he believes he has been “sung,” i.e. somebody who doesn’t like him has used a “kadaitcha man” or shaman to sing a curse on him. He thinks it may be some of the other boys at home who don’t like him because once or twice, they have called him a “poof,” or homosexual. He feels people talk about him and sometimes when he has been drinking, he is sure he can hear their voices coming from just outside his house. On the basis of auditory hallucinations and paranoid delusions, he was given the diagnosis of psychosis.

Over several days, it becomes clear that he has always been anxious and insecure. He has no idea who his father was. His mother was an alcoholic and left him to be raised by her elderly mother when she went to the city years before. When he was about nine, his grandmother died so he went from one relative to another, with one spell in care. His schooling was broken by frequent moves and he has never had regular work, only a couple of work placements but he didn’t do well as the other boys made fun of his poor reading. He had a lot of social fears and was also scared of water, dogs and snakes. Water wasn’t a problem where he came from but dogs and snakes were. Over time, he started to believe all this was being done to him deliberately, which made him feel worse.

Culturally, Aboriginal men don’t like talking about their mental state and definitely don’t like admitting fears or loneliness. Aboriginal culture itself is like classic Greek culture, i.e. anything bad that happens is the result of machinations, not chance. It is a paranoid culture, not unlike modern American culture. For example, a certain president wanted the reflection pool in Washington dolled up for his appearance at the 250^th Anniversary, so he gave the job to some unqualified friend who did what the president wanted, paint it blue. As predicted, it has turned into a major cockup, the water has turned green and the blue plastic liner has broken into bits. Now the president says it wasn’t his fault, it’s vandals and saboteurs what done it and they gotta be strung up. That is, “Nothing is my fault. If anything goes wrong, somebody did it to harm me.” That is part of the classic paranoid stance.

Anyway, back to Billy. He is seriously anxious as a result of his early life experiences; his teenage years have been miserable; he feels a lot better if he drinks but he is left with fierce hangovers and the sense of hearing people plotting against him. He thinks that if this is all he can expect from life, he may as well be dead, at least he’d be reunited with his grandmother again, she was the only person who had ever cared for him. He takes his frequent panic attacks as proof of the singing ritual directed against him but he can’t talk about it to Aboriginal people because that’s forbidden; he is allowed to talk to a white person, especially a doctor, because he knows it will not go back to the people who have done it.

Cross cultural psychiatry is very interesting, the first thing it teaches is that everything you’ve been taught is completely wrong. That’s always the first step in correcting epistemic injustice: come down from the hierarchy. Epistemic injustice derives from one person misusing power over another person but the urge to dominate is innate and immensely powerful. With its unsubstantiated doctrine of “biological psychiatry” and its rigid institutional structure, mainstream psychiatry licenses dismissing the other person as “sick in the head” and not somebody who actually knows what has happened but can’t express it or is too scared to reveal it. That is a direct product of biological psychiatry; it cannot be otherwise.

1. Crouse J et al (2024). Patterns of stressful life events and polygenic scores for five mental disorders and neuroticism among adults with depression. Molecular Psychiatry (2024) 29:2765–2773; https://doi.org/10.1038/s41380-024-02492-x

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My critical works are best approached in this order:

The case against mainstream psychiatry:

McLaren N (2024). Theories in Psychiatry: building a post-positivist psychiatry. Ann Arbor, MI: Future Psychiatry Press. Amazon (this also covers a range of modern philosophers, showing that their work cannot be extended to account for mental disorder).

Development and justification of the biocognitive model:

McLaren N (2021): Natural Dualism and Mental Disorder: The biocognitive model for psychiatry. London, Routledge. At Amazon.

Clinical application of the biocognitive model:

McLaren N (2018). Anxiety: The Inside Story. Ann Arbor, MI: Future Psychiatry Press. At Amazon.

Testing the biocognitive model in an unrelated field:

McLaren N (2023): Narcisso-Fascism: The psychopathology of right wing extremism. Ann Arbor, MI: Future Psychiatry Press. At Amazon.

The whole of this work is copyright but may be copied or retransmitted provided the author is acknowledged.