Centering Social Justice in Mental Health Practice: Epistemic Justice and Social Work Practice

Discounting, ignoring, or minimizing client experience

Fricker (2010) identified discounting, ignoring, or minimizing a person’s account of their lived experience as the fundamental act of testimonial injustice. Operationalizing the principles of epistemic justice in dyadic conversations means centering empathic and active listening to ensure that discounting, ignoring, and minimizing do not occur. Relational thinking has been core in social work since the inception of the profession where centering “the inherent worth of the human being, the uniqueness of the individual, beginning where the client is, the centrality of the client-worker relationship in the helping process, and the importance of genuineness and mutuality” (Goldstein et al., 2009, p. xv) has been the gold standard. Psychotherapy scholars have long noted the importance of empathic listening, genuineness, and the use of self in building a collaborative and trusting relationship with clients (Berzoff et al., 2016; Herman, 2015; Norcross, 2011). Of equal importance is communicating respect and attentional listening back to the client through paraphrasing and summarizing (Johnstone, 2020).

Labeling and stereotyping

Fricker (2010) identified stereotypes as a basic mechanism in testimonial exchange and described how these cognitive frameworks of meaning or heuristics determine our credibility judgments. In the case of prejudicial stereotypes where there are disparaging associations between a social group and certain attributes, then this becomes systematic testimonial injustice and this form of pervasive and ongoing injustice is deeply harmful. When this identity prejudice is internalized, then a person listening to testimony will have a distorted credibility judgment and perception of the speaker. Fricker notes that a person who has persistent experiences of this kind of epistemic exclusion and testimonial injustice is harmed and that this “genuinely inhibits the development of an essential aspect of a person’s identity” (p. 54).

Then, there is a particular type of social power which Fricker calls identity power which is when stereotypic essentialized identities are ascribed to groups. Using Foucault’s idea that power is socially distributed in a net-like organization and is never held in the hands of a single person but rather fluid, changing and dispersed, she developed a model of the social power inherent in epistemic injustice where “this capacity may be exercised (passively or actively) by particular social agents, or alternatively, it may operate purely structurally” (Fricker, 2010, p. 13). In other words, these identities can be agential, that is, self-ascribed or part of the collective social imagination. In a testimonial exchange, these identities become critical factors:

if the stereotype embodies a prejudice that works against the speaker, then two things follow: there is an epistemic dysfunction in the exchange—the hearer makes an unduly deflated judgement of the speaker’s credibility, perhaps missing out on knowledge as a result: and the hearer does something ethically bad—the speaker is wrongfully undermined in her capacity as a knower. (Fricker, 2010, p. 17)

Sanism is a form of social identity power that oppresses Mad people which has been strengthened by the percolating of psychiatric diagnoses and conceptualizations of mental illness into the collective knowledge resources of everyday experience. This form of oppression includes negative stereotyping, discrimination, and arguments that Mad individuals are not worthy of membership in the professions or for many parts of life (Poole & Ward, 2013). Poole illustrates the social power of sanism by discussing the common human experience of grief. She completes a comprehensive literature review of traditional psychocentric approaches to grief generated through psychological and psychiatric scholarship which are all overlaid with a Western preference for a linear progressive sequence of resolution to the experience of loss. Benchmarks have been identified as indicators of what is considered “uncomplicated” “normal” and “good” responses to grief. Thus, this psychocentric version of bereavement creates normal and abnormal grieving responses complete with a time line so those grieving outside the prescribed time limits are not eligible for bereavement leave and are referred for psychiatric interventions. Furthermore, “other” stories about grief which do not conform to the established story of normal grief are excluded from the collective knowledge resources. Communicating testimonies or Mad knowledge has become the bedrock of the Mad movement to disrupt the assumptions in the collective knowledge resource and exert epistemic resistance to psychiatric epistemic violence. For social work praxis, understanding this social phenomenon and ongoing reflexive practice is essential.

Active ignorance: Leading people to underestimate their potential

Social injustice is always accompanied and underwritten by epistemic injustice, which supports and reinforces the dominant narrative. Feminist philosopher Jose Medina (2013) notes that

Racist and sexist ideologies make us all cognitively worse off: they instill distrust; they lead people to underestimate and overestimate their cognitive capacities; and they are the breeding ground for all kinds of biases and prejudices that distort perception, judgement, and reasoning. (p. 26)

Sanism is the pervasive belief system or discourse that drives the oppression of Mad people. As social work scholar Jennifer Poole notes “you don’t have to have a diagnosis to experience sanism…you just have to look, or sound, or feel, or smell a little bit different than the everyday” (Dumbrill & Ward, 2019; Poole, 2014). Sanism was described in the 1960s and was later popularized by a disability rights lawyer called Michael Perlin who established that structural stigma, prejudice, and discrimination were used against persons who were considered disabled, and he then used this phenomenon in his legal arguments of defense (LeBlanc & Kinsella, 2016). He described sanism as “an irrational prejudice of the same quality and character of other irrational prejudices that cause prevailing social attitudes of racism, sexism, homophobia, and ethnic bigotry” (p. 536). Sanism claims that sane people are different from insane people and validates the idea that human problems or deficits are lodged in pathological individuals rather than being the result of social and structural inequities. It is the medically based psychiatric profession that has built on this idea and established the socially acceptable and “scientifically” established norms and authority to rule on who is sane and who is insane (LeBlanc & Kinsella, 2016). The ideas which embolden sanist discourses are pervasive and often reside outside of awareness.

Reid and Poole (2013) interviewed Mad identified social work students about their experience in the classroom. While this survey interviewed only eight students, the results are thought-provoking as they suggest that anti-oppressive practice is taught but not modeled in the social work university setting. Students reported that if they came out as Mad, their peers were supportive however many of the professors and the university counselors were not and interviewees reported being told that they should consider another profession and there was a reluctance to provide accommodations and to organize accessibility for them. They experienced being viewed as “needy, difficult, and unworthy of what was perceived as special treatment” (p. 217). They reported that courses in mental health social work which were offered were based on the medical model. In addition, the language used in classrooms by both student peers and professors was not respectful with indiscriminate use of expressions such as “crazy” and “insane” and Mad people spoken of pejoratively. The author of the paper discussed her own coming out as a Mad Professor and how to her astonishment this triggered the arrival of numerous students to her office to disclose their own accounts of Madness and experiences of marginalization in the academic community. Not only must critical reflection to identify and deconstruct pervasive oppressive discourses be integral to social work education, but anti-oppressive principles need to be embedded and modeled in our pedagogy.

Silencing or narrative erasure

Exclusion from participation in a communicative exchange is another form of epistemic injustice, when the opinions from marginalized groups are not sought. An example of this is medical model psy knowledges that are held to be the official version of the truth and so alternative views are given no quarter. Social work scholar Clive Baldwin (2013) calls this narrative erasure which reflects the power that influences how stories are told and who listens to them. Psychiatric diagnosis and labeling, which represent a prescriptive medical narrative, are examples of this, as these narratives of identity override any existing narratives of identity. Baldwin observes that narrative foreclosure

means that some stories are celebrated and welcomed, while others are deliberately discouraged from being told, with negative consequences for those whose stories are shut down. On a pragmatic level the effects of this could range from larger narratives that disenfranchise considerable groups of people to smaller, individual stories that cast a person as possessing moral or personal defects. (p. 105)

Disallowing personal agency and reducing clients to cases to be managed

There is an agreement in the literature that case management services are the most effective way to deliver community mental health care (Greene et al., 2006; Ziguras & Stuart, 2000). In Canada, the federal government establishes national health standards and the individual provinces are responsible for providing the service delivery. However, critical scholars observe that the standards set by the Ministry of Health reflect the managerial approaches characteristic of a neoliberal welfare state (Goering et al., 2000; Gourlay, 1998). The focus is on housing, employment, income assistance, individual responsibility, and budgeting as well as staying out of hospital (a much more costly option than community care). Greene et al. (2006) argue that case managers are directed to assist consumers to “accept the limitations their illness created, encouraging them to manage their illness and to lower their expectations for future achievement and growth” (p. 340). Thus, case managers approach their work with a task orientation where they must “invoke authoritative voices while managing client resistance” (Lee et al., 2018, p. 11). This disallowing of personal agency is what Fricker describes as epistemic objectification which changes the participation role from one of active epistemic agent to passive object to be studied, observed, or managed.

Another example of epistemic objectification is what Baldwin (2013) describes as a form of narrative foreclosure where the stories a person tells are internalized from dominant meta-narratives. Another name for this is internalized oppression where we carry a blueprint in our individualized psyche of our culture’s oppressive patterns or narratives/discourses. This process results in experiences of helplessness, despair, and feelings of inferiority (Bishop, 2015; Mullaly, 2010). By failing to assist clients to challenge and deconstruct these internalized narratives we are contributing to a lack of personal agency.

Hermeneutical injustice: Experiencing which has yet to be conceptualized and is absent from the collective knowledge resource

Fricker (2010) describes hermeneutic injustice as developing out of social power which accumulates a collective knowledge resource of shared understandings so

the powerful tend to have appropriate understandings of their experiences ready to draw on as they make sense of their social experiences, whereas the powerless are more likely to find themselves having some social experiences through a glass darkly, with at best ill-fitting meanings to draw on in the effort to render them intelligent. (p. 148)