Tuesday, 9 March 2021

Self Harm and Epistemic Injustice

In this post, Lauren Dixon examines arguments by Sullivan, Pickard, and Pearce on epistemic injustice and nonsuicidal self-injury in healthcare. Lauren argues that the notion of epistemic injustice is useful for patient care and clinician education but that harm minimisation techniques are not the way forward. Lauren is a current MSc student at the Institute for Mental Health, University of Birmingham. Her research interests include childhood well-being, bullying risk/protective factors, special educational needs and mental health advocacy.





NSSI (non-suicidal self-injury) “refers to the direct and deliberate destruction of one's own body tissue in the absence of lethal intent.” Epistemic injustice (a notion developed by Fricker, 2007) can be encompassed as failing to recognise a person as a ‘knower’ based on preconceived, and often incorrect ideas, about their identity.

Fricker argues that there are two types of epistemic injustice: Testimonial Injustice (TI) and Hermeneutical Injustice (HI). The former stipulates that a person’s word is not believed to be credible based on the listeners’ beliefs about their identity. The latter is where the person is not given the tools to impart their knowledge onto a prospective listener. It is well known that those who engage in NSSI are subject to stigmatisation within the healthcare system; so could this stigmatisation then lead to epistemic injustice?

Patrick Sullivan (2019) proposes that this population group experience both TI and HI. Patients experience TI, as they are often placed under false and negative stereotypes, such as being seen as someone who is “just” attention seeking (p. 354). Moving to HI, Sullivan argues that it is the way in which a diagnosis of NSSI is formulated and diagnosed that reduces the space to incorporate patient experience. NSSI patients often feel that the diagnostic process is “unhelpful and leaves them without any adequate means of expressing the reality of their distress.” (p. 355). This suggests that clinicians perhaps rely too heavily on diagnostic protocols when they are engaging with patients.

It is somewhat surprising then, that Sullivan appears to be in favour of harm minimisation techniques (HMT) as one way of continuing to support patients engaging in NSSI. Some examples of HMTs can be found here. In general medicine, a clinician's role is to minimise harm and suffering, not to encourage it. Sullivan’s argument, however, is that by denying the patient the opportunity to self-injure you are causing more ‘net harm’ (more harm overall). This is where EI comes in. By facilitating conversations about self-harm in recovery plans, according to Sullivan, clinicians are more accepting of patient’s account and willing to provide them with the tools to discuss self-injury freely in times of distress.

Is implementing this approach realistic, however, in all healthcare settings? I would say that Sullivan’s argument is failing to consider the deeper context surrounding why a patient self-injures. In his paper, Sullivan has only focused on the broad reasons why patients self-harm (to cope with distress) and argued that clinicians facilitating this action will allow them to feel heard and in turn, aid their recovery. Pickard and Pearce (2017) offer an alternative interpretation. They suggest that people often self-harm due to feelings of low self-worth, shame and self-hatred and thus, by facilitating self-injury in a care setting,
practitioners are reinforcing those beliefs e.g.: ‘We won’t stop you from hurting yourself because you are not worth it’. (p.2).

So instead of relieving the TI and HI felt by patients, Pickard and Pearce argue that HMTs only serve to reinforce the disabling phenomena. In conclusion, despite the evidence from Sullivan regarding HMTs improving clinician-patient relationships, given the risk of mental health deterioration (as demonstrated by Pickard & Pearce), I would conclude that HMTs are not the way forward.

1 comment:

  1. Great blog post, Lauren. I think I'm in agreement that harm minimization techniques fundamentally don't work, but I do feel that the language in academia when it comes to self harm doesn't reflect the reality of self harm presentation in acute settings. I also worry that we underestimate what the self harmer understands about their own condition and reasons for harming, which does support the notion of epistemic injustice, and will often invalidate mental health service involvement anyway because they don't have a mental health problem. This then unlocks a very big rabbit hole.

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