‘Epistemic Injustice’ in Therapy?

Most of the time I spend scrolling through Twitter is probably time I won’t ever get back, but the other day I ‘overheard’ an interesting conversation between two academics on what one said was psychological therapy’s primary aim: constructing a sense of dignity, and the other academic voicing the opinion that in fact, therapy often risks having the opposite effect. It also introduced me to the work of philosopher José Medina on ‘epistemic injustice’ – which I will write about in another blogpost.

I will quote Nev Jones’s Twitter thread before adding my thoughts:
“I fear I’m still not great at this in Tweet form but let me try. Again very important to my argument is that these are risks, not inevitabilities. (1) when, to quote José Medina, “the epistemic agency of an informant qua informant is…subordinated to that of the inquirer’s” Or, as he continues “at the service of the inquirer’s questions, assessments and interpretations” — in which case there can be no full & equal “epistemic cooperation”. [Here one might discuss at length how this does/doesn’t play out in eg in CBTp-style ‘reality testing’]. Then there is the issue of communicative “reversibility” and “reciprocity” which JM frames as central to equal epistemic exchanges. Reciprocity seems more fundamentally absent from the traditional therapeutic relationship but again a point one could debate at length…JM then underscores the interactional relationship between hermeneutic & testimonial injustices, viz “interpretive gaps are formed & maintained [when] those who are struggling to make sense are persistently not heard & their inchoate attempts at generating new meaning… unanswered”. To continue “because of difficulties in hearing and interpreting certain things — because of hermeneutical I sensitivities — people’s credibility gets undermined. Testimonial and hermeneutical insensitivities [thus] converge and feed each other.” “[Once] hermeneutical gaps are formed…they handicap our communicative lives and are hard to eradicate.” I will stop there and say that said gaps of course emerge at multiple levels of discourse—dyadic exchanges and also the more macro levels of clinical knowledge generation.” (bold font added by me)

I’ve recently started my own therapy, and this was something I felt almost immediately – the quite unsettling one-sidedness of the therapeutic relationship. Nev Jones and José Medina raise the possibility that this inequality might be more damaging than beneficial, if it perpetuates the sense that the patient is ‘at the service of the inquirer’s questions, assessments and interpretations.’

I can think of two things that might reduce the risk of this happening:
1) The therapist should undergo their own in-depth therapy so that they truly understand how it feels to be on the other side of the power structure. Only then can they properly empathise with how their patient might be feeling during this organised, and often expensive, form of self-disclosure.
2) We can think of Jessica Benjamin’s psychoanalytic Recognition Theory (also see her book ‘Beyond Doer and Done To‘) which describes how analyst and analysand can meet and speak as equals joined by the ‘Third’. Benjamin’s work centres around achieving that ‘reciprocity’ that may or may not be present in the therapeutic encounter.

To expand on Benjamin’s theory – she argues that the therapeutic encounter should be understood as dynamic, and with a two-way directionality, both analyst affecting the analysand, and vice versa. One way the analyst could highlight this ‘two-wayness’ would be by telling the analysand how what they are hearing is making them feel. Only when the analysand starts to see themselves as a being who makes an impact on other people’s subjective experiences can they regain the sense of agency that will help them recover. The risk this runs is that the analyst must make sure that they don’t then steer the conversation too much onto their own thoughts and feelings – it should always be based in the intersubjective encounter.

This is related to what I think might be the fundamental hurdle and balancing act implicated in the therapeutic encounter – the therapist must somehow help the patient regain a sense of agency, while at the same time not ‘blame’ them for the problem they came in with in the first place. The therapist needs to communicate: that what happened to you wasn’t your fault, but now you must find the strength and agency towards repairing that ‘damage’. It aligns with an interesting and complex picture of free will and responsibility, that I am yet to understand fully…

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