So far, we have defined the sense of self and suggested that meaningful autobiographical narratives, which are often co-constructed, may alter the sense of agency intended as the subjective feeling of being able to carry out what one intends to. For example, an autobiographical narrative may augment or diminish an existing sense of agency, or even cause it to change qualitatively.
It is now time to go back to the notion of epistemic injustice. In what circumstances are people at the receiving end of unjust treatment if their sense of agency is challenged? As we saw, self-narration has been strongly linked with a general sense of agency, which is plausibly included in one’s sense of self. Here, we are interested in how the story that one tells about oneself impacts the sense of oneself as an epistemic agent. The sense of agency (or perceived agency) has been defined in different ways in the psychological literature, where some uses of the phrase are broader, referring to the general tendency to initiate or have control over one’s actions, whilst other uses are more specific, referring to the sense that people initiate or are in control of a particular action. One basic description of the sense of agency is “the experience of controlling one’s own actions, and, through them, events in the outside world” (Haggard and Chambon 2012). People have a sense of agency if they see themselves as the initiators of their actions; they feel in control of their bodies and minds; and they feel they can intervene on their environment (Christensen et al. 2019; Tapal et al. 2017). With respect to thoughts and other mental states, the sense of authorship can also be added to the sense of agency, where people feel that thoughts do not just happen to be “in their heads”, but are also thoughts that they feel they can commit to and give reasons for (Bortolotti & Broome, 2009).
Objective agency is when an agent performs an action, whereas the sense of agency is when the agent feels that they are performing or have performed an action. We find in the literature some fascinating examples of cases in which agents feel in control of some external events, but did not actively intervene on them: people playing dice tend to believe that they can determine what number will come up if they are the ones throwing the dice; people practising voodoo believe that inflicting a pin on a doll will cause pain to some other person in the real world; and pedestrians tend to think that when they press the button at the crossing they cause the green light to appear, although most traffic lights are timed (Moore 2016). Some behaviours that are considered symptoms of mental disorders, such as passivity and thought insertion, are also often mentioned as examples of failure of the sense of agency. These are cases where the person is the initiator of a particular action or the source of a particular thought but do not feel they are and thus attribute the action or the thought to a third party (see for instance Gallagher, 2015; Bortolotti & Broome, 2009; Humpton and Broome 2016).
How do we measure the sense of agency? There are different measures depending on the type of feeling that is studied and the context in which it is studied. Some implicit measures (such as time perception) are more suitable to track the sense of agency that applies to specific actions. Focusing on the explicit measures which are based on people’s reports and can be biased, someone with a strong sense of agency would tend to agree with statements such as “I am in full control of what I do” or “I am completely responsible for everything that results from my actions” and disagree with statements such as “The outcomes of my actions generally surprise me” or “I am just an instrument in the hands of somebody or something else”. Perceived agency in its general sense is related to other constructs such as self-efficacy—described as “a generalized, positive belief in personal competence and ability to organize and execute desired behaviour” (Tapal et al. 2017)—but whereas self-efficacy is manifest in the sense that people can attain their goals, perceived agency is conceptually prior to that as it focuses on the capacity people have to initiate action and control their bodies, their minds, and the surrounding environment to some degree.
Although perceived agency does not coincide with objective agency and can be illusory, perceived agency is important in its own right because the feeling that one is performing an action, and is in control, or has performed an action in the past, and has thus been in control, can impact one’s future capacity to exercise objective agency, as we suggested at the end of the previous section. For instance, in a recent study on how biological models of depression affect people’s sense of agency it was found that “when people are pessimistic about their own prospects of overcoming a disorder or benefitting from treatment—which may be especially likely if they attribute their symptoms to biological causes—their negative outlooks can become self-fulfilling prophecies” (Lebowitz and Ahn 2017, p. 125). The study shows that, when an intervention is developed to educate users about the malleability of biological factors responsible for depression, users’ confidence in their chances to recover from depression increases, thanks to their sense of agency being enhanced. This has positive implications for clinical outcomes. In general, when people have a strong sense of agency, control, and self-efficacy, they enjoy better mental health, avoid experiencing feelings of helplessness after setbacks, and act more like agents, preserving their motivation to pursue their goals in adverse circumstances (Bandura, 1989). As a consequence, people are also more likely to perform satisfactorily and fulfil their goals. They tend to be more productive, more resilient, better at planning, and more effective at problem-solving (e.g., Alicke & Sedikides, 2009; Bortolotti et al., 2019).
As anticipated, epistemic agency is concerned with a person’s capacity to produce and share knowledge. People have a sense of epistemic agency if they feel that they enjoy competence, authority and credibility as knowers of their own experiences and feel that they master the conceptual resources necessary to understand their situation. In the philosophical literature (Fricker, 2009), the epistemic domain is one where distinct forms of injustice can occur, where people’s testimony is discredited for non-epistemic reasons (e.g. in testimonial injustice, one’s knowledge may be discounted due to gender or ethnicity) and where, due to non-epistemic factors, people lack the conceptual resources to interpret their own situation (e.g. in hermeneutical injustice, one may be excluded from a technical discussion regarding medication).
Recently, there has been some interest in applying epistemic injustice to the medical and especially the mental health context (e.g., Byrne, 2020; Crichton et al., 2017; Dotson, 2012). Our interest is in understanding the relationship between epistemic agency and epistemic injustice in the experiences of a group of people who may have their views discounted due to multiple reasons including illness, youth, ethnicity, poverty, and gender. How can social interactions, and more specifically interactions during clinical encounters, support or undermine a person’s sense of agency? The attitude people take towards each other has wide-ranging effects on their experiences of themselves and the world.
By our very attitude to one another we help to shape one another’s world. By our attitude to the other person we help to determine the scope and hue of his or her world; we make it large or small, bright or drab, rich or dull, threatening or secure. We help to shape his or her world not by theories and views but by our very attitude toward him or her (Løgstrup, 1997, p. 18)
The general approach a clinician takes to the young person they are working with (their ‘attitude’) can affect young people’s experience of themselves and their surroundings. Conversation analysis has already been applied successfully to interactions between clinicians and people experiencing psychotic symptoms. With conversation analysis we can explore the epistemic dimension of the clinical encounter: what is known, how it is known, who has the right to know it. The method consists in studying verbal and non-verbal communication, and reflecting on factors such as interruptions, tone, emphasis, and gaze, as well as on the content of the exchange (McCabe et al., 2002).
Some of the evidence on clinical encounters gathered by using conversation analysis offers a good insight into exchanges that have the potential to adversely affect people’s sense of agency. In exchanges between a psychiatrist and users with psychotic symptoms, for instance, users actively describe their experiences but often the doctor provides no response and avoids direct questions that users might have about their experiences. This suggests to the users—and to a neutral observer—that there is no engagement: the psychiatrist does not explain or discuss the relevant experiences despite these being important to the users and users seeking to know more about them.
[Patients with psychotic symptoms] clearly attempted to discuss their psychotic symptoms and actively sought information during the consultation about the nature of these experiences and their illness. When patients attempted to present their psychotic symptoms as a topic of conversation, the doctors hesitated and avoided answering the patients' questions, indicating reluctance to engage with these concerns. (McCabe et al. 2002, p. 1150)
As McCabe and colleagues notice, in the course of the conversation with the psychiatrist when a carer is also present, and users express concern about their experiences or ask for explanations (such as “why don’t people believe me when I say I am God?”), the psychiatrist often responds with hesitation (“hmm”), with another question (“what should I say now?”) or with a smile or laughter. This makes users feel that they are not taken seriously, and their concerns are not addressed.
Such exchanges in the clinical encounter point to the risk of testimonial injustice: the doctor fails to engage with the users’ account of their own experiences. Engagement does not require or imply an endorsement of the unusual experiences or of the unusual beliefs, but simply an acknowledgement that users share information about their experiences that is important to them and that their contributions and concerns matter to the success of the encounter.
There is also potential evidence of hermeneutical injustice because users are denied the conceptual resources to understand their own experiences—they ask questions that the doctor does not answer. As we saw, McCabe and colleagues notice that, in this form of exchange, although users actively attempt to talk about the content of their symptoms and ask about them, their questions are avoided. One effect of the psychiatrist not commenting or not answering the questions is that users do not feel that their reports are valued as meaningful contributions to the conversation. Another effect is that a different understanding of their experiences that could be encouraged by the psychiatrist is not made available to them.
People are usually taken to be credible and authoritative when they report the content of their own experiences and beliefs, that is, people are expected to know what their experiences and beliefs are and to report them accurately unless they have a reason to deceive. That does not mean that those experiences and beliefs can always be understood or shared by others, but that people are typically considered to be in a better position than anybody else to describe such experiences and beliefs. However, when people report unusual experiences and beliefs, the credibility and authority of their reports are no longer taken for granted due to the possibility of a substantial gap between how people take things to be and how things really are.
It is primarily because they report unusual experiences and beliefs that the epistemic agency of users with psychotic symptoms is questioned. But is questioning epistemic agency justified or is it an instance of epistemic injustice? That will depend on what triggers the challenge or the lack of response: if the attitude of the psychiatrist is determined by the person’s identity as a user of services with psychotic symptoms, then there does not seem to be a legitimate reason for epistemic agency to be undermined overall, because we should not assume that the epistemic agency of people with unusual experiences and beliefs is compromised by default. There are very good reasons to reject the assumption that rationality is globally affected by the presence of psychotic symptoms, and indeed we should treat cases in which reports of people’s experiences are not engaged with, but challenged or dismissed, as genuine cases, we would venture to say textbook cases, of epistemic injustice.
In their paper on epistemic injustice and the assessment of delusions, Sanati and Kyratsous (2015) present two cases of people who were experiencing distress and reported beliefs that were judged as delusional by their clinical team. Such beliefs turned out to be true and not to related to their delusions.
We think that the patients are not given the same credibility as a non-patient on the basis of having an illness that is so often associated with attributions of irrationality, bizarreness and incomprehensibility. The type of prejudice that these people are shown to be suffering is related with their social identity and has been persistently and diachronically featuring in social representations of schizophrenia and conceptions of delusions. It is also relevant that the lack of an integrative clinical model of understanding delusions, which does not focus so much on the experience of the person, is one main factor that makes these prejudices salient, interfering in the assessment of such mental states. (Sanati and Kyratsous, p. 483).
Further, in recent inquiries into the potential protective role of some delusional beliefs (e.g., Catone et al. 2015, 2017; Gunn & Bortolotti, 2018; Gunn & Larkin, 2020; Moffa et al. 2017), it is found that the delusion is not an incomprehensible speech act and can make reference to actual life events. It can arise after trauma or an otherwise significant event that has emotionally affected the person, such as abuse or bullying, and reflects the need for the person to respond to such disruptive experiences—it is meaningful and ‘makes narrative sense’.
[…] the delusion is not just a glitch, but its content relates powerfully to significant events in the person’s life and, at the time when it is first adopted, relieves the person of some heavy psychological burden. In particular, in at least some cases, delusion formation can be seen as a short-term protective response to disruptive and traumatising life events. (Gunn and Bortolotti 2018, p. 830).
Such contributions to the literature on delusions suggest that challenging or dismissing users’ reports of their own experiences without engagement is both an instance of epistemic injustice, and a missed opportunity to understand at least in part what they are going through and how best they can be helped. The idea that mental illness and in particular psychotic symptoms are evidence of global irrationality is culturally well-entrenched but very poorly supported by the evidence available to us. More to the point, given our focus here, challenging or dismissing users’ reports without engagement has significant risks for their sense of agency at a time when their sense of agency is already potentially undermined by their mental health struggles.
There are factors specific to young adults which make them especially susceptible to epistemic injustice during the clinical encounter. First, the clinician may have an unconscious bias related to youth, assuming that young people lack clear insight, or that what motivates them is not health-promoting, as when they are thought to prioritise respect from peers to good psychotherapeutic outcomes. Second, there are some harmful societal narratives about young people. As was flagged earlier, there are narratives about young people which—if unchallenged—could lead to see them as being overly sensitive, not knowing what they want, or being unwilling to work hard to achieve what they want. Third, as the young person’s sense of self is still forming, it is more susceptible to external assessment, in that it is more readily shaped by the opinions of others who are perceived as experts in some domain. To state this in terms of the narrative conception of the self, the interaction with the clinician may lead young people to alter the story that they tell about themselves for the worse, inferring from unsuccessful clinical encounters that their contributions are worthless and not worth engaging with. As was discussed earlier, a self-narrative can sensitize people to certain kinds of possibilities. The environment surrounding many clinical encounters is experienced in such a way as to consolidate a particular perception of the self, where one’s experience is not important, should not be trusted, and can be dismissed without significant loss.