I. The Participatory Shift
A participatory shift is taking place across health research, as the contributions that those affected by research might make to research are beginning to be recognized, and the familiar refrain of “nothing about us without us“ is beginning to be heard.Footnote 1 In mental health research, this growth in consumer/survivor/stakeholder involvement demonstrates an increased receptivity to experiential perspectives and their potential implications for theory and practice. This is an important shift; biomedical psychiatry has historically, and by its own estimates, come up short in producing satisfactory models, evidence, and treatments for its own disorders, and many diagnosed with them have put forth near constant resistance to all facets of mental health systems and knowledge. Beyond a moral case for incorporating the viewpoints and demands of service users, such perspectives would seem to offer epistemic benefits to a field in need of them. This shift toward recognizing that some form of expertise may be on offer from those on the other side of the mental health system raises many questions: How are we to account for the relative benefits and the types of knowledge that might be available from those with lived experience as psy-subjects? What is the basis for the epistemic advantage held by these subjects, if there is one? What implications fall out of the recognition of such an advantage? How are we to theorize the incorporation of perspectives in an area of research from which service users have been historically excluded, even objectified and symptomatized? We hope to make a start on answering some of these questions by applying the lens of feminist standpoint theory to the psy sciences (psychiatry, psychology, psychotherapy, psychoanalysis, and so on).
Below, we seek to build on existing work that has pointed to standpoint theory as grounding for service user involvement and leadership in mental health research,Footnote 2 notably by leading survivor scholars Alison Faulkner and Diana Rose (Rose Reference Rose2014; Faulkner Reference Faulkner2017; Rose Reference Rose2017) as well as philosophical arguments for greater inclusion in the psy sciences (Sadler and Fulford Reference Sadler and Fulford2004; Cooper Reference Cooper, Poland and Tekin2017; Bueter Reference Bueter2019; Tekin Reference Tekin, Nahmlas, Polger and Zhao2020).Footnote 3 Here, we consider how and whether feminist standpoint theory can provide a basis for the inclusion of service users in knowledge projects within the psy sciences. In the next section, we unpack the basic claim of standpoint theory and the meanings of its three components: a marginalized social location, a process of critical engagement, and an epistemic advantage. In the third section, we discuss how this theory might apply to the realm of the psy sciences, and what the components of marginalization and critical engagement might look like in application. The fourth section considers what evidence we have for the claim that standpoints offer an epistemic advantage within the psy sciences, looking to case studies of participatory, survivor, and user-led research, and argue that we have good reason to think that a standpoint offers an epistemic advantage in the psy sciences. Finally, in the fifth and sixth sections, we consider implications of, and objections to, the claim that standpoints in the psy sciences offer an epistemic advantage.
II. Standpoint Theory
Feminist standpoint theory has its roots in the work of Karl Marx, who recognized the way in which knowledge can be significantly shaped by those in positions of power, while at the same time appearing to be entirely inevitable (Harding Reference Harding and Harding2004). In The German Ideology, Marx and Engels observe how “the class which has the means of material production at its disposal, has control at the same time over the means of mental production, so that thereby, generally speaking, the ideas of those who lack the means of mental production are subject to it” (Marx and Engels Reference Marx and Engels1970, 172). Furthermore, they emphasize how, as facts are brought into being by those at the top of the hierarchy, they become embedded in our way of life, and we tend to “detach the ideas of the ruling class from the ruling class itself and attribute to them an independent existence” (173). Anticipating standpoint theory, Marx further argued that the proletariat alone has the potential to recognize this distorted reality from the unique position they hold at the bottom of the social and material hierarchy. Drawing on the insights of Marx, Nancy Hartsock, one of the first standpoint theorists, argued that since women's lives are radically unlike those of men with regard to the social and material conditions within which they exist, women alone have the potential to recognize the partiality and perversity that is contained in the dominant vision of reality produced by men (Hartsock Reference Hartsock, Harding and Hintikka1983). Although many standpoint theorists since Hartsock have moved away from the essentialism implied in her analysis, what has been taken up from her work is the observation that those who are marginalized are uniquely capable of observing the way in which knowledge is shaped in relation to power (Collins Reference Collins1986; Haraway 1994; Harding Reference Harding1995).Footnote 4
Standpoint theorists have since drawn upon and developed the claims of Marx and Hartsock, demonstrating how they rest on both the thesis of socially situated knowledge, which claims that knowledge is shaped by social forces, and the thesis of epistemic advantage, which holds that experiences within some social locations offer advantages when it comes to particular knowledge projects (Haraway Reference Haraway1988). Standpoint theorists have also added an additional component, that of critical reflection, arguing that in order to attain a standpoint, which confers an epistemic advantage, one must both have experienced marginalization and have engaged in a process of critical reflection. This forms the basic claim of standpoint theory: a standpoint is arrived at as a result of two necessary components, a marginalized social location and a process of critical reflection, and once arrived at, a standpoint offers an epistemic advantage over other positions with regard to relevant scientific pursuits (Hartsock Reference Hartsock, Harding and Hintikka1983; Harding Reference Harding1992; Wylie Reference Wylie, Figueroa, Harding and Harding2003; Intemann Reference Intemann2010). In this section, we unpack this claim, by offering an exploration of how standpoint theorists have understood the meanings of a “marginalized social location,” a process of “critical reflection,” and an “epistemic advantage.”
Marginalized Social Locations
A marginalized social location is important to standpoint theory in conjunction with the thesis of socially situated knowledge. This thesis holds that knowledge is at all times formed in relation to the social conditions that provided the environment for its establishment (Haraway Reference Haraway1988; Wylie Reference Wylie, Figueroa, Harding and Harding2003; Harding Reference Harding and Harding2004; Intemann Reference Intemann2010). In Alison Wylie's words, the situated-knowledge thesis states that “social location systematically shapes and limits what we know, including tacit, experiential knowledge as well as explicit understanding, what we take knowledge to be as well as specific epistemic content” (Wylie Reference Wylie, Figueroa, Harding and Harding2003, 31).Footnote 5 Wylie describes a social location as a position in society that is structurally defined; central to such a position are relations of power that individuals exist within that alter the material conditions, the relations of production and reproduction, as well as the conceptual resources available to them (Wylie Reference Wylie, Figueroa, Harding and Harding2003). Kristen Intemann affirms this view, explaining that the social position one occupies draws the boundaries of that which one can possibly know because it inevitably influences the kinds of experiences available to oneself (Intemann Reference Intemann2010). Importantly, the thesis of socially situated knowledge has implications on both individual and societal levels. Though an individual's social location inevitably shapes what one knows and is able to know, structures of power also shape what is known by a society as a whole. As Berta Britz explains, “the language and questions asked by those most embedded in a dominant culture will always contain presuppositions shaped by that dominant culture's values, beliefs, and motivation for maintaining its systems and structure” (Britz Reference Britz2017).
Once the thesis of socially situated knowledge has been established, standpoint theory recognizes that some social locations have a unique epistemic potential that others do not. These locations are those that are marginalized. A marginalized social location is one that holds little power relative to other positions in one or more realms of society. Those who are marginalized are often those who are most stigmatized, who are socioeconomically most disadvantaged, and who are least likely to hold positions that enable them to create or contribute to the dominant collective knowledge (for example, scientists, judges, politicians, academics, and so on). The reason that marginalization leads to unique epistemic potential is that those in positions of power have a vested interest in maintaining the structure of knowledge that exists, whereas those in marginalized positions do not. Furthermore, those marginalized by particular ways of thinking or forms of knowledge are more likely to see the errors or assumptions embedded within them. As Wylie puts it, there is an irony in this: “those who are economically dispossessed, politically oppressed, socially marginalized and are therefore likely to be discredited as epistemic agents—for example, as uneducated, uninformed, unreliable—may actually have a capacity, by virtue of their standpoint, to know things that those occupying privileged positions typically do not know, or are invested in not knowing” (Wylie Reference Wylie, Figueroa, Harding and Harding2003, 32).
It is important to note here that, according to standpoint theory, a marginalized social location is not enough to grant one an epistemic advantage over others within a scientific project. There is no particular knowledge attached to womanhood, to Indigeneity, or to having a diagnosis of bipolar disorder that connects an identity essentially to a scientific question. Rather, the experience of marginalization offers individuals the potential to see particular knowledge projects in a new light, but in order to fulfill this potential, one must engage in a process of critical engagement. In this sense, in Sandra Harding's words, “each oppressed group can learn to identify its distinctive opportunities to turn an oppressive feature of the group's conditions into a source of critical insight about how the dominant society thinks and is structured” (Harding Reference Harding and Harding2004, 7).
Critical Engagement
The second component necessary for achieving a standpoint is critical engagement. As highlighted before, there is no automatic epistemological benefit that arises from simply occupying a particular social location. Many standpoint theorists have pointed to the importance of gaining a standpoint through a conscious effort to understand how knowledge comes to be within the unique material and social conditions that exist within a certain time and place. Wylie argues that standpoints, unlike social locations, are “struggled for, achieved, by epistemic agents who are critically aware of the conditions under which knowledge is produced and authorized” (Wylie Reference Wylie, Figueroa, Harding and Harding2003, 31). Intemann suggests that standpoints are attained “only when there is sufficient scrutiny and critical awareness of how power structures shape or limit knowledge in a particular context” (Intemann Reference Intemann2010, 785). This suggests that it is crucial not only to occupy a marginalized social location that enables one to see the benefits being gained by those outside one's own position, but also to critically examine the way in which social locations relate to knowledge within the community. This critical examination can come in many forms: attending consciousness-raising meetings, getting a degree, spending time with others and reflecting on the ways in which power dynamics are shaped around one's (shared) marginalized identity. Importantly, according to the theory, this critical work must be taken up by those who have experienced oppression in order to truly attain a standpoint and the epistemic advantage that comes with it. Wylie puts it well: “some standpoints (as opposed to locations) have the especially salient advantage that they put the critically conscious knower in a position to grasp the effects of power relations on their own understanding and that of others” (Wylie Reference Wylie, Figueroa, Harding and Harding2003, 34; emphasis in original). As Harding points out, unlike a social location, “a standpoint is an achievement” (Harding Reference Harding and Harding2004, 8).Footnote 6
The Epistemic Advantage
The epistemic advantage that arises from a standpoint has been described in different ways by different theorists, but often the epistemic tasks most emphasized are those of identifying dubious assumptions, developing new hypotheses, or promoting objectivity (Haraway Reference Haraway1988; Harding Reference Harding1992; Wylie Reference Wylie, Figueroa, Harding and Harding2003).Footnote 7 The ability to identify assumptions underlying a knowledge project stems directly from the recognition of how power shapes knowledge that takes place during the period of critical engagement that leads to the attainment of a standpoint. Given that knowledge produced by those in power tends to benefit those in power, there is little motivation for those receiving these benefits, regardless of their awareness of them, to consider alternatives or engage in critique of the dominant paradigm. Such critical engagement, which often involves the identification of hidden premises that underlie theoretical conclusions, or the ways in which problematic values are guiding the direction of research projects, often comes more easily to those who are marginalized in relation to the particular knowledge project. Intemann emphasizes how “scientific communities that include members of oppressed groups with experiences relevant to the research” are often able to “identify problematic background assumptions” that guide the research (Intemann Reference Intemann2010, 789).
Similarly, those who are not invested in maintaining the status quo in terms of what we know are uniquely able to develop alternative hypotheses, consider novel phenomena of study, and develop research programs and methodologies that have not been thought up yet. Their positions away from the center of power enable them to “access a wider range of empirical evidence,” as well as to “generate new hypotheses, models, and explanations” (789). Similarly, those who are marginalized are “capable of conceptualizing phenomena that were heretofore invisible because they start off from outside the dominant paradigms and conceptual schemes” (Harding Reference Harding1992, 344). This is an inevitable result of the thesis of socially situated knowledge, which acknowledges how material, social, and economic conditions affect the ways of seeing and thinking available to individuals and communities.
Additionally, several standpoint theorists have emphasized how standpoints can contribute to increases in objectivity. Most famously, Harding has argued that standpoint theorists gain an epistemic advantage through “strong objectivity,” a term that reclaims objectivity, distancing it from the traditional “view from nowhere“ (Nagel Reference Nagel1989) and instead defining it as involving a sense of reflexivity and awareness of the role of values. Strong objectivity, according to Harding, is constituted by communities of knowers “outside” of a discipline who are able to identify the values and interests embedded in scientific projects, and in which cases those values and interests serve as a help or hindrance to the project at hand (Harding Reference Harding1995, Reference Harding2015). She suggests that “standpoint approaches provide a map, a method, for maximizing a strong objectivity that can function more effectively for knowledge projects faced with the problem of sciences that have been constituted by values and interests of the most powerful social groups” (Harding Reference Harding1992, 346). In this sense, the work of standpoint theory has been to locate the subjectivity of knowledge within all scientific accounts, generating a commitment to reflexivity that enables one to see the values and interests that inevitably shape knowledge-seeking projects, generating a stronger objectivity in the end (Harding Reference Harding1992).
Wylie suggests, alternatively, that objectivity ought to be understood as a “a loosely defined family of epistemic virtues that we expect will be maximized, in some combination, by the claims we authorize as knowledge,” including qualities like empirical adequacy, explanatory power, and inferential robustness (Wylie Reference Wylie, Figueroa, Harding and Harding2003, 33). If we think of objectivity as constituted by these virtues, but changing shape depending on the particular questions being asked and phenomena being investigated, then along with the thesis of socially situated knowledge, it is easy to see how those with standpoints have an advantage within particular epistemic contexts. Others have emphasized the objectivity gained through standpoints as well; Donna Haraway suggests that subjugated standpoints “seem to promise more adequate, sustained, objective, transforming accounts of the world” (Haraway Reference Haraway1988, 584), and Intemann examines how objectivity arises at the level of community, arguing that including diverse voices in scientific projects is of central importance, since “objectivity is promoted by structuring scientific communities in ways that minimize the negative influence of individual biases” (Intemann Reference Intemann2010, 783).
These three epistemic capacities can be pulled apart—the ability to identify problematic assumptions, develop new hypotheses, or access objectivity—but it is important to also note that they are often entangled with and parasitic on each other. As a result of identifying problematic assumptions, one may then seek to fill in the gaps with more promising avenues of research, and by reflecting on the values that tend to shape different research programs and excluding those that are problematic, one is likely to produce more objective knowledge. Finally, it is worth noting that according to standpoint theory, a marginalized social location gives one unique potential for an epistemic advantage in particular knowledge projects, which can be attained through critical engagement and reflection. This does not mean, however, that what might be visible to those who have attained a standpoint is necessarily inaccessible to those without a standpoint; it only suggests that they are less likely to see it.
Evidence for Standpoint Theory
Evidence for standpoint theory has been given primarily through accounts of shifts that have taken place in epistemic landscapes after individuals who had achieved a standpoint entered the scene. These accounts document how individuals from marginalized social locations (often women) who have attained a standpoint are able to uncover biases, assumptions, and faulty reasoning within a scientific domain, develop novel research pathways, and to offer more objective accounts of the world. Harding outlines a number of assumptions guiding scientific work that were identified only once feminist critics entered various disciplines. Such assumptions included beliefs that reproduction was inherently pathological, that hunters not gatherers were the primary “breadwinners“ among our ancestors, and that politics and work could take place only outside the home. In place of these assumptions, new theories were developed, mapping the unique contributions that gatherers made within history and the previously unrecognized forms of labor that take place within a household (Harding Reference Harding2015).
In Primate Visions, Haraway describes the faulty assumptions that ran through primatology when the discipline was dominated by men and became apparent when women began to examine the same data, as well as how these women pioneered new methodologies that reshaped the field (Haraway Reference Haraway1989). Patricia Hill Collins documents the rich body of scholarship that developed when Black women entered the domain of sociology, and began to write about the intersectional nature of their oppression, which had been left out of White feminist scholarship (Collins Reference Collins1986). Wylie argues that standpoint theory offers a frame for the “hard-won shift in collective understanding” of women's underrepresentation in the academy, and the sciences in particular, “that was mobilized by insights from the margins” (Wylie Reference Wylie and E2011). After decades of explanations focused on women's innate lack of capacity and productivity, marginalized voices began to document how the unsupportive climates in these contexts provide an alternate explanation for such underrepresentation.
Research documenting how critical, marginalized voices have led to the identification of problematic assumptions within scientific projects, and the development of more promising lines of inquiry in place of them, offers evidence that standpoints can contribute to greater objectivity within science. Crucially, these three components of an epistemic advantage are not easy to disentangle. Although not always characterized as a standpoint project, the work of Carol Gilligan offers a useful example with which to understand how a critical and marginalized knower can have a significant impact on a research program. After working as a research assistant for Lawrence Kohlberg and collecting data from children to score them according to the Kohlberg scale of moral development, Gilligan was struck by how the young boys she spoke to, who often thought of ethical considerations in terms of rules, consistently scored higher on the moral scale than the girls she interviewed, who tended to focus on relationships. This led Gilligan to reject the scale developed by Kohlberg, which privileged some forms of moral reasoning over others, and develop a research program examining ethical deliberation centered around the notion of care (Gilligan Reference Gilligan1982). This demonstrates how the epistemic advantages of identifying assumptions, developing new theories, and attaining a greater stance of objectivity are likely to be bound up together in cases of standpoints shaping scientific projects.Footnote 8
III. Standpoint Theory in the Psy Sciences
This section explores the question of who might be considered to have attained a standpoint in relation to research in the psy sciences. We suggest that the two conditions of having a marginalized social location and engaging in critical reflection are both necessary and sufficient for having a standpoint related to the psy sciences, and we consider how those conditions are fulfilled on a practical level. The following section considers what evidence there is to support the claim that such a standpoint confers an epistemic advantage in the realm of the psy sciences.
A Marginalized Social Location in Mental Health Services
A marginalized social location in the realm of mental health can take many forms. In many cases, such a location will arise from having lived experience of receiving a psychiatric diagnosis and experiencing the mental health system as a service user.Footnote 9 In some, but not all such cases, individuals may experience stigma, discrimination, paternalism, forced treatment, and/or a denial of one's agency, all of which involve taking power away from the individual and contribute to the marginalization of their social position. These effects may be mediated by existing identities and their intersections, including, but not limited to, class, race, gender, sexuality, and perceived disability. As expressed by Mary O'Hagan, the experience of being diagnosed as disordered can have a significant impact on one's sense of agency:
Once I was labeled with “mental illness“ I was seen as a helpless bundle of needs without competence and rationality. I was handed over to experts who colonized my story of suffering and condemned me to a predetermined pathway of recurring or deteriorating illness. They had exclusive rights to administer powerful treatments and to remove my freedom if they perceived me as a danger to myself or others. All they required of me was my passivity and compliance. I knew this regime was the logical consequence of the mental illness label and the belief system that underpinned it. (O'Hagan Reference O'Hagan2015, 115)
The marginalizing effects of diagnosis and experiences with the mental health system are produced in relationship to an associated set of defining features and stereotypes. These stereotypes include irrationality, unpredictability, and a lack of self-awareness as a priori aspects of those seen as disordered. Violence, unmotivated behavior, ineptitude, and dependency are often thought to follow.Footnote 10 These stereotypes are rooted in sources spanning public media and political discourse to personal and second-hand experiences, as well as conceptual associations with the notion of “mental illness“ itselfFootnote 11 (Varshney et al. Reference Varshney, Mahapatra, Krishnan, Gupta and Deb2016).
Stereotypes related to the agentive and cognitive capacities of those labeled “mentally ill“ lead directly to damages to social recognition, as a diagnosis often immediately leads one to be considered less capable of knowing and speaking for oneself. Miranda Fricker's concept of epistemic injustice, in which stereotypes lead to individuals and groups being deemed to lack credibility and the ability to speak as legitimate knowers, offers a productive framework for understanding these effects (Fricker Reference Fricker2007). One particularly applicable form of Fricker's concept is testimonial injustice, in which the capacity of individuals to impart knowledge is undermined by the hearer's prejudice and subsequent judgment of credibility, such as when one's words are characterized as mere symptoms of illness rather than a meaningful attempt at communication (Fricker Reference Fricker2007, 28).Footnote 12
Stephanie LeBlanc and Elizabeth Kinsella have traced this social construction of mad people as illegitimate knowers to sanism or the systematic discrimination and oppression of those who have, or are perceived to have, a psychiatric diagnosis (LeBlanc and Kinsella Reference LeBlanc and Kinsella2016). Maria Liegghio further characterized these delegitimizing structural forces as epistemic violence in which existent subjectivities and identities are erased and replaced with stigmatized social and professional constructions (Liegghio Reference Liegghio, LeFrançois, Menzies and Reaume2013). This form of systematic discrimination results in neglect, silencing, and erasure, in which an agentive subject is reconstructed as an object hijacked by irrationality. Thus the marginalized social location that is often experienced by those diagnosed with “mental disorders“ is inherently linked to a denial of rationality and agency. Such forms of disempowerment around mental health may then shape one's degree of access to economic, material, or emotional resources, as well as social or political recognition, further marginalizing individuals beyond the stigma of their experiences. Importantly, this disempowerment is also used to exclude those with lived experience from participating in knowledge practices for which they are the subjects and presumed beneficiaries. As Jan Wallcraft describes it, “many of us have suffered from the misunderstanding of our needs by people who have been taught to see us as by definition incapable of rational thought” (Wallcraft Reference Wallcraft, Sweeney, Beresford, Faulkner, Nettle and Rose2009).
It is worth noting that these are by no means experiences of marginalization shared by all individuals who have come face to face with a system of mental health care, and many express gratitude for their time in care. Additionally, some may recognize their position as marginalized and accept this marginality as a necessary, if undesirable, corollary to receiving mental health care, disability payments, institutional accommodations, and housing (Estroff Reference Estroff1981; Estroff et al. Reference Estroff, Lachicotte, Illingworth and Johnston1991). It may also be seen as the underside of the social recognition and attitudes perceived as helpful that being labeled “mentally ill“ can afford. In other words, marginalization does not accompany only negative experiences, but may be experienced as a necessary evil or comforting form of recognition and erasure simultaneously.
Critical Engagement with the Psy Sciences
The second component necessary for attaining a standpoint, after occupying a marginalized social location, entails critically engaging with the relationship between power and knowledge. For those with experiences of mental health diagnosis, services, or hospitalization, attaining a standpoint in the psy sciences may mean engaging with how institutional and social structures shape knowledge regarding their own construction as “objects“ in the psy sciences and as “mentally ill“ subjects in society. In this sense, critical reflection helps individuals attain a more critical understanding of the structural forces that render their social existence and subject positions. As a mode of reflection, critical engagement can occur on one's own or in community, whether a formal institutional setting (for example, a university) or a more informal one (for example, a support group).
Critical engagement that occurs on one's own may be preceded by experiences of disempowerment and/or harm within mental health services, or a more conceptual disjuncture between firsthand experiences and conventional psychiatric knowledge (Chamberlin Reference Chamberlin1978; Shimrat Reference Shimrat1997; O'Hagan Reference O'Hagan2015). Numerous examples describe traumatic or alienating experiences of treatment followed by a subsequent search for literature that challenges status-quo mental health discourses and reflects one's existing concerns. In her memoir Madness Made Me, O'Hagan describes how, while mobilizing a “middle-class“ sense of personal security and nonconformity, she developed an awareness of the value of madness after years of psychiatric services. Subsequently reading the work of Thomas Szasz, Michel Foucault, and R. D. Laing helped her look critically at the social and historical construction of mental illness and to ultimately see the medicalization of her experiences as a sort of colonization (O'Hagan Reference O'Hagan2015, 116). Similarly, Laura Delano speaks to how thirteen years of disillusionment, despair, and labeling in psychiatric treatment ended when she read Whitaker's Anatomy of an Epidemic: “All it took was an openness, and a readiness, to try out a different way of thinking,” namely the liberating notion that her experiences might be seen not as symptoms of an organic disease, but a rational response to experiences (Whitaker Reference Whitaker2011; Delano Reference Delano2013). In both cases, individual experiences of marginalization and oppression necessitated critical engagement as a means of both survival and curiosity, with the aid of liberatory texts. The impetus to develop these new perspectives stemmed from the very consequences of not doing so, of leaving one's social position unexamined.
Critical engagement can also occur in group settings where consciousness-raising is taking place (Chamberlin Reference Chamberlin1978; Zinman, Howie the Harp, and Budd Reference Zinman and Budd1987). Judi Chamberlin, cofounder of Boston's Mental Patient Liberation Front, noted that “many patients were still into the head-trip of feeling that they deserved what happened to them—they were ‘psychologized‘ into believing it” (Chamberlin Reference Chamberlin1978, 82). She describes how former patients gained a markedly new strength and self-respect through consciousness-raising groups, while sharing previously undiscussed negative experiences in psychiatric hospitals, engaging in discussions that linked mental health systems to broader functions of social control, and offering one another insights into alternative forms of support. For Chamberlin, these critical discussions and the development of novel practices of support are entangled. She notes that “along with the recognition of the antitherapeutic nature of much psychiatric treatment comes the formulation of what does make a good place for a person to come to in times of emotional distress” (186). Tehseen Noorani describes how collective knowledge is built in service user communities: “experiences become more ‘weighty‘ as they collectivise over time, that is, as self-helpers identify similarities and differences in stories they share with one another, about their respective engagement with their distress and the effects of their distress” (Noorani Reference Noorani2013, 62). This process, Noorani suggests, grounds the notion of experiential authority in service user communities.
Beyond individual and group settings, critical engagement can occur within more formalized research contexts. Researchers Robyn Brown and Nev Jones note the problem, exemplified in conventional psychiatric research, that such formal engagements seek to correct:
the consenting research subject at once symbolically concedes “understanding“ of his or her disorder to the academic researcher while at the same time reifying his or her position as an informant or provider of data that will only become “externally valid“ once it has been combined with dozens of other narratives, reports or data points and “transformed“ by expert clinical scientists. (Jones and Brown Reference Jones and Brown2013)
Survivor-led research, a participatory research framework led by those with experiences of madness, distress, and/or treatment, is an example of such formal critical engagement, one that seeks to correct the systematic exclusion of those who have lived experiences in the production of knowledge about those very experiences by centering their voices, priorities, and perspectives (Sweeney et al. Reference Sweeney, Peter Beresford, Nettle and Rose2009; Russo and Sweeney Reference Russo and Sweeney2016). Speaking to the critical engagement required for such research, Alison Faulkner, drawing on Jasna Russo and Diana Rose, acknowledges that “for survivor research to transform knowledge, those involved need more than the experience of being mad or of using services” (Faulkner Reference Faulkner2017, 513). Such an experience, according to Rose, must be complemented by “a political dimension that derives from other social movements” or, according to Russo, a shift away from clinical research and the strengthening of alternative methodologies and theories (Rose Reference Rose2014; Russo Reference Russo2014; Faulkner Reference Faulkner2017, 513).
IV. Evidence for Standpoint Theory in the Psy Sciences
Following traditional discussions of standpoint theory, we propose that the best evidence for an epistemic advantage in the psy sciences will be found in examples of problematic assumptions being displaced and promising theories being developed by those who have attained a standpoint within the domain.Footnote 13 Before offering several such examples below, two caveats are in order. First, though we outline below some significant contributions that individuals who have attained a standpoint have made to the psy sciences, these contributions are only a small portion of the contributions made by those with such standpoints. Knowledge is constantly created and extended in mad communities, and most of this knowledge will never reach the psy sciences. All forms of knowledge-generation and sharing in communities of service users or by individuals with standpoints is important and worthy of further discussion, but we focus here on contributions that have had some impact within the psy sciences, because of the history of standpoint theory and because of the immense power held within these disciplines with regard to funding, policies, and care for those deemed within their purview.
Second, the majority of the examples below are taken from the context of the Global North. In part, this is the result of our limited language abilities and our unfortunate ignorance of global efforts related to the psy sciences. The focus also stems from the different ways in which the psy sciences are known and make themselves known outside of the Global North. In many low- and middle-income countries (LMICs), resources for the psy sciences and their associated interventions are limited, so care for those in crisis is often sought within the community (for example, with traditional healers; at church) as opposed to within formal health care institutions (Luhrmann and Marrow Reference Luhrmann and Marrow2016).Footnote 14 As a result, mad advocacy and knowledge-production taking place in these contexts often focuses on preventing human rights abuses, ensuring the Convention on the Rights of Persons with Disabilities is respected, and building community-centered forms of care (MindFreedom Ghana 2011; Minkowitz Reference Minkowitz2012; Grech and Soldatic Reference Grech and Soldatic2016).Footnote 15 This affects the terminology used to describe service user efforts across the globe, which varies significantly (Beresford Reference Beresford2020). As Jayasree Kalathil and Nev Jones have pointed out, “both user/survivor research and ‘mad theory‘ remain Euro-American phenomena” (Kalathil and Jones Reference Kalathil and Jones2016). A Statement of Purpose from the Trans Asian Strategy Group on Persons with Psycho-Social Disabilities points out that “where there are no services, there are no ‘Users’ or ‘Survivors’ of services, as found in large parts of Asia” (Trans Asian Strategy Group 2014), and in 2008 the Pan African Network of Users and Survivors of Psychiatry changed its name to The Pan African Network of People with Psychosocial Disabilities, recognizing that “users and survivors of psychiatry“ “does not adequately reflect representation and the lived reality of this voiceless group in Africa” (Robb Reference Robb2008). Given these differences, knowledge-production and activism related to mental health in LMICs, though important and impactful, may have less of a direct influence on the psy sciences, whose power is consolidated largely in wealthy nations, and the impact that they do have may be less likely to be recorded in scholarly works that are visible to researchers in the Global North.Footnote 16
Identifying Assumptions
Cases of the identification of problematic assumptions within the psy sciences by individuals or communities that have attained a standpoint are not hard to find. One significant contribution that service users have made within this domain is to challenge the assumption, deeply embedded within the field, that well-being is equivalent to symptom-reduction (Friesen Reference Friesen2019). Service users have long pointed toward the vast distance between the goal of simply reducing symptoms and the goal of living an engaging, meaningful life as defined by the individual living it (Deegan Reference Deegan1997; Young and Ensing Reference Young and Ensing1999; Mead and Copeland Reference Mead and Copeland2000). As Vanessa Jackson puts it, the experience of “being continuously asked about symptoms but never about her life” is not an unusual one (Jackson Reference Jackson2003). What a narrow focus on symptom-reduction as the goal of treatment neglects, however, are a number of aspects that many consider central to a good life, and do not always co-occur with symptom-reduction. These include social support, meaningful involvement, and a life free from debilitating side effects. Those involved in user-led research, the recovery movement, and patient-run initiatives have pushed toward closing this gap and developing both mental health services and supports that help individuals to attain more than an asymptomatic state, as well as research that focuses on measuring well-being in its more expansive forms (Anthony Reference Anthony1993; Del Vecchio and Blyler Reference Del Vecchio, Blyler, Amering, Schrank, Wallcraft and Chichester2009).
Survivor-led research has also identified problems with standard methodologies used in research in the psy sciences. When a group of service users conducted a systematic review of electroconvulsive therapy (ECT)—but rather than following the standard model of such reviews, they chose to include qualitative data and gray literature—the results differed substantially from what had been found in previous systematic reviews. The researchers found that a smaller proportion of recipients of ECT felt that they had benefited from the treatment than previously reported, and that issues related to informed consent and memory loss were of central importance to participants, concerns that had been neglected in the previous reviews (Rose et al. Reference Rose, Fleischmann, Wykes, Leese and Bindman2003; Rose, Fleischmann, and Wykes Reference Rose, Fleischmann and Wykes2004; Rose et al. Reference Rose, Wykes, Bindman and Fleischmann2005).
Service users have also played a significant role in documenting the role the pharmaceutical industry has played in shaping knowledge in the psy sciences (Faulkner Reference Faulkner2017). Although patient advocacy groups are certainly not strangers to pharmaceutical funding, those deemed patients have also sought to expose such alliances (McCoy et al. Reference McCoy, Carniol, Chockley, Urwin, Emanuel and Schmidt2017; Batt et al. Reference Batt, Judy Butler and Fugh-Berman2020). In a detailed series of articles, Sera Davidow has documented the conflicts of interest deeply embedded within the National Alliance on Mental Illness (NAMI), which calls itself the “largest grassroots mental health organization” in the United States (NAMI n.d.; Davidow Reference Davidow2014; Reference Davidow2017; Reference Davidow2019). Speaking from India, Bhargavi Davar has also noted the presence of pharmaceutical interests in the push toward global mental health, which is likely to lead to a much larger market for pharmaceutical products (Mills and Davar Reference Mills, Davar, Grech and Soldatic2016; Davar Reference Davar, Grech and Soldatic2014).
Another assumption that has been challenged by those entering the psy sciences from a position of oppression is that madness should always be construed as pathological. Individuals with lived experience who have thought deeply and critically about the psy sciences have suggested that rather than viewing “mental disorders“ as such, they might be better thought of as “dangerous gifts“ (DuBrul Reference DuBrul2014), or experiences that can ground “mad pride“ (Schrader, Jones, and Shattell Reference Schrader, Jones and Shattell2013; Beazer Reference Beazer2017; Hoffman Reference Hoffman, Cratsley and Radden2019). The neurodiversity movement, which has grown out of self-advocacy by autistic people, has questioned medicine's tendency to pathologize and attempt to cure experiences that may be better thought of as differences worth accommodating (Graby Reference Graby, Spandler, Anderson and Sapey2015). Critical disability studies, including the social model of disability, which seeks to counteract the exclusive focus on individual “impairments“ through an examination of how structural forces shape experiences of disability, has also proved useful in highlighting the source of our dis-ease with madness (Lewis Reference Lewis and Davis2006; Beresford, Nettle, and Perring Reference Beresford, Nettle and Perring2010; Castrodale Reference Castrodale2017). Others have documented the links between madness and creativity, including poetry, music, and art, and highlighted how much can be gained from experiences of madness (Jamison Reference Jamison1996; Chadwick Reference Chadwick1997; Jamison Reference Jamison2011; Hankir et al. Reference Hankir, Holloway, Agius and Zaman2012). The peer-run organization Intentional Peer Support is guided by the notion of “crisis as opportunity,” and increasing evidence documents the potential for post-traumatic growth following experiences of psychosis (Jordan, Malla, and Iyer Reference Jordan, Malla and Iyer2019; Mead Reference Meadn.d.).Footnote 17 As Davar has put it, “if living life from a non-rational creative space is ‘insanity,’ I accept that as a gift and a blessing” (Davar Reference Davar, Davar and Sundari Ravindran2015).
Developing Novel Tools and Theories
Similarly, ample evidence suggests that those who have attained a standpoint in the psy sciences are capable of developing novel avenues of research, promising theories and hypotheses, and new tools for support. In direct response to the resistance to defining well-being as merely an improvement on a symptom scale, survivor-led research has sought to balance such research with more expansive knowledge projects. Inspired by the voices of service users demanding research that maps onto what is meaningful to them, service user-led research has spurred countless research programs seeking to understand the many factors that contribute to well-being on a wider scale. In just the realm of research involving treatments and support for those who have experienced psychosis and/or received a diagnosis of schizophrenia, research has been taken up that examines the important but often neglected role of factors like side effects, peer support, self-esteem, exercise, personal agency, and goal attainment in contributing to quality of life (Ritsner et al. Reference Ritsner, Kurs, Gibel, Hirschmann, Shinkarenko and Ratner2003; Resnick, Rosenheck, and Lehman Reference Resnick, Rosenheck and Lehman2004; Morrison et al. Reference Morrison, Shryane, Beck, Heffernan, Law, McCusker and Bentall2013).
Similarly, topics that are significant to service users but that are rarely taken up in mainstream psychiatry, such as involuntary treatment, coercion, and police brutality, have been examined in detail in anthologies, zines, and other works written and compiled by survivors (Wallcraft, Read, and Sweeney Reference Wallcraft, Read and Sweeney2003; Sweeney et al. Reference Sweeney, Peter Beresford, Nettle and Rose2009; LeFrançois, Menzies, and Reaume Reference LeFrançois, Menzies and Reaume2013; Cuijpers Reference Cuijpers2019; Green and Ubozoh Reference Green and Ubozoh2019). It is worth noting that much of this literature points away from the individual, who is often the focus within the psy sciences, as both of the source of, and solution to, their suffering. Rather than examining each individual as a site of symptoms and treatments, many who have attained a standpoint in the psy sciences look beyond the individual and toward broader structural issues related to trauma, neoliberalism, various forms of oppression, stereotypes, and the loss of agency that can accompany diagnosis (Beresford and Menzies Reference Beresford, Menzies, Burstow, LeFrancois and Diamond2014; Davar Reference Davar, Davar and Sundari Ravindran2015; Kalathil and Faulkner Reference Kalathil and Faulkner2015; Voronka Reference Voronka2019).
This is especially the case in service user communities in the Global South, where colonial histories and the material conditions of poverty impose themselves frequently, making them harder to sweep them under the rug. As the Cape Town Declaration of the Pan African Network of People with Psychosocial Disabilities states, “The history of psychiatry haunts our present. Our people remain chained and shackled in institutions and by ideas which our colonisers brought to our continent” (Pan African Network 2011). The Trans Asian Strategy Group on Persons with Psycho-Social Disabilities asserts that it is essential to look beyond issues related to medical treatment and to focus on “social security and inclusion, safety, self-dignity and the fulfillment of human rights, liberty and freedoms, education, independent living, employment” (Trans Asian Strategy Group 2014).
The Hearing Voices Network (HVN) is one of the best-known examples of a new theory and research program stemming from the lived experiences of service users (HVN 2020). Aligning with those who sought to push against the view that an experience of mental distress is necessarily harmful and pathological, the HVN takes a step back and views experiences of voice-hearing through a much wider lens than the psy sciences typically do. Seeking to understand the role that traumatic experiences play in contributing to experiences of voice-hearing, and working actively to develop ways in which one can improve the relationships they have with the voices they hear, this network challenges the status quo in theories of psychosis and auditory hallucinations, and has had an enormous impact (Ruddle, Mason, and Wykes Reference Ruddle, Mason and Wykes2011; Oakland and Berry Reference Oakland and Berry2015; Longden, Read, and Dillon Reference Longden, Read and Dillon2018). Not only has the movement produced novel research programs, theories, tools, and communities of support all over the globe, but it has been felt deep within the academy, and is reshaping the questions asked, and the forms of expertise acknowledged, within research related to voice hearing (Kay, Kendall, and Dark Reference Kay, Kendall and Dark2017; Powers, Bien, and Corlett Reference Powers, Bien and Corlett2018; Tate Reference Tate2018).
Countless tools for support have been developed by service users, drawing on their experiences of suffering and mistreatment in order to construct options for others that look different. Dialectical Behavior Therapy, widely accepted as one of the most promising tools of support for those thinking about suicide or diagnosed with Borderline Personality Disorder, was developed by Marsha Linehan in light of her own experiences as a service user (van den Bosch et al. Reference van den Bosch, Koeter, Stijnen, Verheul and van den Brink2005; McCauley et al. Reference McCauley, Berk, Asarnow, Adrian, Cohen, Korslund, Avina, Hughes, Harned, Gallop and Linehan2018). Recounting her early experiences in seclusion, she says “I was in hell. And I made a vow: when I get out, I'm going to come back and get others out of here” (Carey Reference Carey2011). Mary Ellen Copeland created the Wellness Recovery Action Plan, which helps individuals identify their early warning signs, what things look like when they are breaking down, and a crisis plan, so that they can dictate what happens to them if they are in need of support (Advocates for Human Potential n.d.; Cook et al. Reference Cook, Copeland, Jonikas, Hamilton, Razzano and Grey2011). In Pune, India, survivor Bhargavi Davar has established the Bapu Trust, which runs the Seher program, a form of local support that aims to create conversations about well-being with those in low-income communities (Mills and Davar Reference Mills, Davar, Grech and Soldatic2016), as well as Sanchit, an oral history archive of individuals diagnosed with mental illnesses and collection of resources related to survivor experiences (Davar Reference Davar, Davar and Sundari Ravindran2015).
The Icarus Project, a support and education project developed by and for service users, has created support groups all over the world and released multiple tools to help those in crisis. These include a collective document called Friends Make the Best Medicine: A Guide to Creating Community Mental Health Support Networks (Icarus Project 2013) as well as Mad Maps, documents inspired by advance directives that enable individuals to reflect on their challenges, gifts, and triggers in order to develop “strategies for self-determined well-being” (DuBrul Reference DuBrul2014; Fireweed Collective 2015). Over fifty collaborators from within the Occupy Wall Street movement, including many mental health activists, collectively wrote the booklet Mindful Occupation: Rising Up without Burning Out, a manual for organizers focused on maintaining well-being, offering support, and healing from the harms that can be caused by participating in protests and experiencing police violence (Mindful Occupation 2012).Footnote 18 In order to support those hoping to withdraw from psychiatric medications, the Freedom Center, in collaboration with the Icarus Project, released the Harm Reduction Guide for Coming off Psychiatric Drugs, far in advance of the current clinical acknowledgement of the importance of tapering (Hall Reference Hall2007).
Objectivity
These examples, while only a small sample of the many that are out there, offer evidence of the important role that individuals with standpoints can play in identifying problematic assumptions and developing novel tools and theories within the psy sciences. This suggests that user involvement in the psy sciences is likely to contribute to a more objective view of mental health and distress, as the values and assumptions that have long guided the field are uncovered and rejected, and as novel research programs and interventions are developed to better support those in crisis or receiving services. These contributions, in which assumptions are identified and new research programs are developed, can also help those within the field to reflect on how values have shaped the psy sciences over time, leading to greater reflexivity, and in turn, strong objectivity (Harding Reference Harding1992). Furthermore, the diversification of the field, occurring through the expansion of who are permitted to take part in knowledge projects, is likely to bring to light biases that are present, which can then, ideally, be expunged (Intemann Reference Intemann2010).
Taken together, this evidence substantiates the claim that arriving at a standpoint gives one an epistemic advantage within the psy sciences. In the next section, we consider some implications that might follow from this claim.
V. Implications
If it is the case that critically reflecting on one's experience of marginalization within the psy sciences offers one an epistemic advantage in relation to knowledge projects in this domain, then what follows? First and foremost, the psy sciences ought to incorporate the views, skills, and expertise of those who have attained standpoints in all stages and domains of research.Footnote 19 There are already good ethical reasons to involve service users in mental health research (Beresford Reference Beresford2002; Friesen et al. Reference Friesen, Lignou, Sheehan and Singh2019), and the evidence for standpoint theory in the psy sciences offers an additional and compelling epistemic reason for such involvement. If those who have attained a standpoint in the psy sciences have a unique epistemic potential with regard to identifying problematic assumptions plaguing the field, developing promising avenues of research, and contributing to the objectivity of ongoing research, serious efforts should be made to increase the amount of service user-cled and participatory research taking place. What this involvement should look like is a complex and multifaceted question. A promising first step in answering it is to consider the substantial barriers and challenges that have been encountered in efforts to date. Although participatory methods have been taken up in some domains of the psy sciences more than others (for example, qualitative research, but not clinical trials), and in some countries more than others (for example, the United Kingdom compared to the United States), there are challenges across the board (Kalathil and Jones Reference Kalathil and Jones2016).
In places like the United Kingdom, where service user involvement in mental-health research and decision-making is commonplace, since it is required by major funding bodies, issues related to tokenism, role confusion, and harmful instances of participation are common (Department of Health 2009; Kalathil Reference Kalathil2010). Examples abound of investigators failing to reflect on what and how service users might contribute to their research before bringing them to the table, strategically selecting service users who already agree with the directions of the research, or dismissing the input of participants with reference to their diagnoses (Lewis Reference Lewis2009; Brett et al. Reference Brett, Sophie Staniszewska, Sandra Herron-Marx, Tysall and Suleman2012; Jones et al. Reference Jones, Jay Harrison, Munro, Nelson, Kloos and Ornelas2014; Russell et al. Reference Russell, Sandy Starr, Rodogno and Singh2018). This suggests that the involvement of those who have attained a standpoint in research needs to be well thought through and not merely a box-ticking exercise. This also points to the importance of sharing authority with those who have a standpoint, engaging in co-production, funding user-led research, and delegating spaces for clear contributions within traditional research projects.
Pushback against the notion of a “professionalized” participant is also interesting to reflect upon (Brett et al. Reference Brett, Sophie Staniszewska, Sandra Herron-Marx, Tysall and Suleman2012). Many moans can be heard in discussions of public and patient involvement (PPI) about the number of mental-health service users who partake in research regularly; concerns that they have lost their “lay“ or “community member“ status are common. These worries about professionalism reflect a paradox that arises for many who have attained a standpoint in the psy sciences. If they are not well-versed in research methods and familiar with the contours of participatory projects, they are thought to lack credibility, but if they are experienced in and familiar with research settings, they are considered to be too “professionalized“ and no longer representative of other service users. This creates a lose-lose situation for many. Importantly, however, involving those with standpoints in the psy sciences is different from involving anyone with lived experience of receiving mental health services. Because those who have attained a standpoint have engaged in a period of critical reflection on the power structures that shape the psy sciences, they are not merely patient representatives, but experts on how knowledge is shaped and can affect experiences within mental health services. Thus, the involvement of those who have attained a standpoint does not mean that all service users are represented within a project; it means that someone with a unique ability to understand the psy sciences is involved in the project. In a discussion of the “double identity” of those who are both researchers and community members, Rose notes that “I do not define a ‘user researcher’ as someone who is a researcher and just happens to have received mental health services. A ‘service user researcher’ is someone who uses their experience of being in receipt of services to inform their research practice from start to finish” (Rose Reference Rose2014, 154).
A related worry concerns co-optation. The ways in which the recovery movement and peer support initiatives have been co-opted by neoliberal institutions have been widely recognized within service user communities and beyond (Morrow and Weisser Reference Morrow and Weisser2012; Morrow Reference Morrow2013; Beresford and Russo Reference Beresford and Russo2016; Penney and Prescott Reference Penney, Prescott, Russo and Sweeney2016). Erik Eriksson describes the way in which organizations engaged in service user involvement used processes of bonding, framing the activities, and controlling the activities to restrict the influence of users involved in their projects. Although service users resisted these forms of cooptation, this resistance was limited by the boundaries of involvement laid out by the organizations, resulting in a “sanctioned resistance” that both pushed against and supported the existing institutional logic (Eriksson Reference Eriksson2018). Lucy Costa and colleagues describe another form of co-optation that occurs frequently within involvement initiatives:
It is now commonplace for mental health organizations to solicit personal stories from clients—typically, about their fall into and subsequent recovery from mental illness. These stories function to garner support from authority figures such as politicians and philanthropists, to build the organizational “brand” regardless of program quality, and to raise operating funds during times of economic constraint. (Costa et al. Reference Costa, Voronka, Landry, Reid, Mcfarlane, Reville and Church2012)
These examples should serve as warnings of the risk of virtue signaling through participatory approaches or what could be called “involvement washing,” in a time when projects and organizations are increasingly rewarded for highlighting the ways in which they take up the views of service users in their work.
Placing in leadership positions in research those who have attained a standpoint will require facilitating opportunities for more individuals to receive training that will prepare them for such positions. Nev Jones and Robyn Brown's discussion of the lack of c/s/x (consumer, survivor, ex-patient) voices in academia highlights a variety of barriers that appear in this domain (Jones and Brown Reference Jones and Brown2013). Stereotypes about those who have received a mental health diagnosis loom large, including fears that individuals with lived experience might be biased, “too close” to research, incapable, or irrational. The authors discuss a recent survey of graduate admissions directors for a psychology program in which “disclosures of personal mental health issues [came to be known] as a ‘kiss of death’ in the admissions process” (Appleby and Appleby Reference Appleby and Appleby2006, cited in Jones and Brown Reference Jones and Brown2013). Additional difficulties for those seeking to attain a standpoint through academic pathways include accommodations, mentoring, climate, and discrimination (Jones and Brown Reference Jones and Brown2013). This suggests that working toward appropriate and deserved inclusion in institutions engaged in the psy sciences will be a long and transformative process. Given these barriers, Bonnie Burstow has reflected on how adult education could be revised to better support psychiatric survivors, including building in safety and advocacy, allowing for sporadic attendance, and learning about and connecting with resistance efforts (Burstow Reference Burstow2003).
Importantly, recognizing the epistemic advantages that those with standpoints have to offer to the psy sciences will mean revising research significantly. Although it is clear that in most domains of health research, democratization is taking place and lived experience is being recognized as a valuable foundation for knowledge, participatory research projects still often resemble the status quo with a slight “twist.” As we have seen, however, the insights provided by standpoints have the potential to help identify problematic assumptions that may be deeply embedded in a field and develop new research programs that were previously unexplored. In order to ensure that the benefits of these standpoints are captured within research, the participatory shift cannot be merely a gesture of recognition, but must also involve shifts in power. It is crucial to have those who have attained a standpoint leading research projects and running centers, so that the field can evolve toward more fruitful lines of inquiry (Russo Reference Russo2012).
VI. Objections
Whose Values?
An objection one might raise in response to our claim that lived experience of marginalization and critical engagement with the psy sciences leads to an epistemic advantage within relevant knowledge projects is that standpoint theory appears to favor some values (those of the oppressed) over others, but hasn't made an argument in favor of those particular values. This critique stems from Susan Hekman, who argues that standpoint theorists successfully make the case that all knowledge is socially situated, but fail to demonstrate that there is one standpoint that is better than others (Hekman Reference Hekman1997). This concern is linked to the shift toward feminist empiricism taken up by some standpoint theorists, as a result of the bias paradox (Antony Reference Antony, Antony and Witt1993; Intemann Reference Intemann2010).Footnote 20 An extension of this objection is the worry that the oppressed are likely to enter into scientific investigations with their own biases and values that may also distort research.Footnote 21
However, standpoint theory does not involve a privileging of particular values, but rather a recognition that the capacity to identify problematic assumptions and develop novel theories guiding the production of knowledge, a capacity that arises along with the attainment of a standpoint, is valuable. An objection often posed in response to feminist empiricism, which holds that all values, no matter how morally or politically problematic (for example, those of the neo-Nazis) ought to be given consideration,Footnote 22 is not relevant to standpoint theory, which explicitly highlights the link between oppression and the ability to think through how power shapes knowledge (Hicks Reference Hicks2011). Those with standpoints are certain to have biases and values, as the thesis of socially situated knowledge holds that there is no neutral, objective view from nowhere, but what's important is that such a standpoint offers one the ability to see the dominant paradigm in a different light. Importantly, the values and interests of those with a standpoint are currently not well represented, and so objectivity will be strengthened through their representation. As Wylie argues:
it is the political commitment that feminists bring to diverse fields that motivates them to focus attention on lines of evidence others have not sought out or thought important; to discern patterns others have ignored; to question androcentric or sexist framework assumptions that have gone unnoticed and unchallenged; and, sometimes, to significantly reframe the research agenda of their discipline in light of different questions, or an expanded repertoire of explanatory hypotheses. (Wylie Reference Wylie, Figueroa, Harding and Harding2003, 38)
Assuming Essentialism?
A second objection one might raise is that standpoint theory as applied to the psy sciences assumes that there is a shared perspective to be found among all consumer/survivors/ex-patients, when no such perspective exists. Indeed, the risks of essentialism that arise from claims that “those with lived experience” have experiential authority and can represent all of those within the experiential category has been well explicated by Jijian Voronka (Voronka Reference Voronka2016). However, alignment or agreement between those with lived experience is neither expected nor necessary for standpoint theory to pertain to the psy sciences (Jones and Kelly Reference Jones, Kelly, Spandler, Anderson and Sapey2015). Individual standpoints will look different depending on unique intersecting identities, and these differences will further contribute to the advancement of knowledge. A person of colour who has accessed mental health services may well have had different kinds of experiences than a White person, and these differences will contribute to their potential to contribute to epistemic projects related to the psy sciences; this means that involving those with varying intersectional identities and diverse experiences of marginalization will further contribute to advancing knowledge projects (Kalathil Reference Kalathil2008; Kalathil and Faulkner Reference Kalathil and Faulkner2015; Beresford Reference Beresford2020). Importantly, standpoint theory is not aligned with claims about essential knowledge that is derived from a particular social location. Rather, one's social location shapes one's own particular knowledge, and critical engagement hones that knowledge in order to help one develop an epistemic capacity in the domain in which one has experienced marginalization. Important also is that this does not mean that someone with a particular diagnosis or experience can be expected to/should be asked to speak for all others who share that diagnosis or experience (Davis Reference Davis2016; Voronka Reference Voronka2016).
A Distinct Knowledge Project?
Another objection holds that there is no sense in asking who has an epistemic advantage within the psy sciences, since those working within the dominant medical model and those within communities of service users are engaged in two distinct knowledge projects within two meta-epistemological frameworks. What counts as a successful instance of research in one domain is unlikely to count as successful in another, since different values shape what questions, methodologies, and research formats count. In line with this, one might suggest that what arises from standpoints in the psy sciences is simply an “alternative form of knowledge” (Weedon Reference Weedon1987). However, in the psy sciences, the goal in either domain is arguably to improve the well-being of those experiencing mental distress. Crucially, how to go about achieving this task can only be answered with reference to the subjectivity of individuals with lived experience of that mental distress. Although this is the case in all health sciences, it is especially important in the psy sciences because there are no biomarkers through which clinicians can avoid such subjectivity (for example, as with a diagnostic test for tuberculosis). This suggests that projects taking place in the dominant research paradigm and service user communities cannot be disentangled. Furthermore, this indicates that an epistemic advantage in the psy sciences is an epistemic advantage in either of these knowledge projects.
Is This Relativism?
Standpoint theory is often objected to with claims that it is relativistic. Relativism holds that there is no view that is better than another, since each perspective is unique, and we have no tools with which to evaluate one over the other. However, this objection is misplaced and stems from conflating the thesis of socially situated knowledge, a starting point for standpoint theory, with relativism (Wylie Reference Wylie, Figueroa, Harding and Harding2003). However, the thesis of socially situated knowledge is merely a descriptive claim about how people come to know what they know, emphasizing the social aspect of this process, but it does not claim that each viewpoint is equal. On the contrary, standpoint theory explicitly claims that some viewpoints, resulting from different social situations, are better than others, in that they lead to the potential to develop a standpoint, which offers an epistemic advantage with regard to particular knowledge projects. This normative component of standpoint theory draws upon experiences of power and oppression, and how these can lend themselves to unique insights, but never makes a relativistic claim with regard to knowledge. As Harding points out, the onus is on the objector to show why relativism is a threat to this theory: “Standpoint theory provides arguments for the claim that some social situations are scientifically better than others as places from which to start off knowledge projects, and those arguments must be defeated if the charge of relativism is to gain plausibility” (Harding Reference Harding1992, 131).
Taking Standpoints into Account?
Another objection that might be raised is whether the argument that's been put forward truly justifies the conclusion. Indeed, one reviewer for this manuscript wondered whether some individuals with a standpoint may be less epistemically trustworthy in connection with their lived experience, because irrationality may be part and parcel of a mental disorder, and another expressed concern that many who have attained a standpoint may not have sufficient research skills to contribute to the psy sciences. As a result, they suggested, it may be preferable for those within the academy to continue to do this work, but from the point of view of, or with guidance from, those with a standpoint. This would be a more efficient way to ensure that their epistemic insights are considered and would not require such a radical reconstruction of how we've set up our institutions of knowledge.
First, with regard to the epistemic trustworthiness of those who have attained a standpoint, although it is the case that some extreme states can lead to a loss of one's ability to contribute to a research project, the simple association of madness and unreason is far too easy. As evidenced above, individuals who have attained a standpoint are capable of making significant contributions to the psy sciences. Some will, of course, require additional training before being able to conduct particular kinds of research, and this is why reducing the barriers to access for those with lived experience, as discussed above, is so important. It is worth acknowledging that research involving service users may well include unexpected pauses and challenges, if an individual is struggling to contribute to the project at a given time (Jones and Shattell Reference Jones and Shattell2016). Of course, such roadblocks are not exclusive to research that involves those with a standpoint, and probably most projects would be better off if they built accommodations for well-being into their research plans from the start.
What about the suggestion of merely taking standpoints into account, so that these extra challenges could be avoided? As mentioned above, it isn't the case that only those who have attained a standpoint are able to see the problematic assumptions underlying the psy sciences, develop new tools and theories, and contribute to (strong) objectivity within the field, but that those with a standpoint are likely to have an epistemic advantage over others when it comes to these activities. It is an open question as to whether those who have lived outside of such experiences would be able to successfully take on such a point of view, but given the limits of our imaginations (Mackenzie and Scully Reference Mackenzie and Scully2007), such a route risks maintaining current power structures and is likely to lead to further harms. Beyond the epistemic reasons we have offered to include those who have attained a standpoint in knowledge practices in the psy sciences, there are many compelling ethical reasons to share power with those who are the subjects of those knowledge practices. These include an enduring history of human rights abuses committed within the psy sciences, the many ways in which these knowledge practices have been and continue to be used as tools of oppression (for example, classifying homosexuality and drapetomania as mental disorders), and the frequency with which assessments of incapacity have been used to justify coercion and paternalism in the treatment of those considered mad (Friesen et al. Reference Friesen, Lignou, Sheehan and Singh2019). Merely speaking for those with standpoints, while maintaining the status quo in terms of how power is distributed, is likely to reinforce stereotypes, produce epistemic injustice, and ensure the continued silence those who have long lacked a voice.
VII. Takeaways
In light of an examination of the intersection between feminist standpoint theory and the psy sciences, we have argued that individuals who have lived experience of the mental health system from a position of marginalization, and who have thought critically about knowledge-production within the field, are likely to have attained a standpoint that provides them with an epistemic advantage within the psy sciences. This argument rests upon evidence that demonstrates a positive impact on these sciences as a result of the involvement and critical work of service users and survivors. This impact involves contributions to identifying problematic assumptions, building up new methodologies and research questions, and therefore contributing to stronger objectivity within the field. The implications of this argument are significant: those who have attained a standpoint within the psy sciences ought to be included in research in this domain and given the tools and funding to develop research programs. However, we must be wary of risks of cooptation, essentialization, and tokenization that come with the act of privileging such firsthand experience.
Acknowledgments
Many thanks to audience members who offered helpful feedback on early versions of this article, presented in 2017 at the annual meeting of the Association for the Advancement of Philosophy of Psychiatry, the conference of the Canadian Society for Women in Philosophy, the Knowledges in Contact conference at Rutgers University, and at Early Career Day at the Hastings Center. More recently, the article benefited from lively discussions with the Philosophy Department at McGill University in 2020 and the Philosophy of Psychiatry webinar series in 2021. And of course, the article draws heavily on work conducted by many who have attained a standpoint in the psy sciences; for their work, we are very grateful.
Phoebe Friesen is an Assistant Professor in the Biomedical Ethics Unit and Department of Social Studies of Medicine at McGill University. Her work engages with ethical and epistemic issues related to the production and implementation of knowledge in the health sciences, drawing on feminist philosophy of science, ethics scholarship, and methodologies from the social sciences.
Jordan Goldstein has worked as a peer specialist and in peer-run initiatives for several years. He also holds a Master's degree in medical anthropology from Southern Methodist University.
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