Beyond testimonial consent: a negotiated model for epistemic justice and co-expertise in clinical mental health care

Introduction

While there has been an increasing recognition of lived experience in mental health care, clinical practices remain anchored in a paternalistic subject-object dichotomy. In this hierarchy, the patient is frequently positioned as the ‘known’ who embodies certain symptoms, rather than as a ‘knower’ possessing unique interoceptive expertise. Epistemological stance is a social construct with the potential to disempower those whose knowledge is not considered valid, which is the patient in this context. This ‘epistemic injustice’ marginalises patients by discounting their testimony and depriving them of the shared conceptual resources needed to validate their experiences. Powerful frameworks have emerged in the literature addressing this, but mainly in the context of diagnostic validity. There remains a paucity of research focused on the longitudinal clinical encounter itself. Addressing this gap, this study identifies the redesign of structural aspects of the therapeutic alliance as an opportunity for creating a shared, co-constructed epistemic base.

Aims

This study aims to identify how contemporary clinical practices perpetuate testimonial and hermeneutical injustice (two key forms of epistemic injustice), despite the discourse on lived experience. It further investigates how the exclusion of a patient’s interoceptive expertise impacts the predictive and therapeutic validity of the clinical record. Ultimately, the research proposes a Negotiated Model of Co-Expertise that transitions the therapeutic relationship from epistemic tokenism to a meaningful epistemic partnership through the formalised co-creation of knowledge.

Methods

This research employs a critical interpretative synthesis of existing literature, including peer-reviewed articles from PubMed and NIHR databases. Grounded in Fricker’s epistemic injustice framework [1] and the bioethical principles of Beauchamp and Childress [2], it builds on the critical perspectives provided by the Power Threat Meaning Framework [3], Post-psychiatry paradigm [4], and the Hearing Voices Network movement [5] to determine the structural shifts needed to redistribute power and restore epistemic justice in clinical settings.

Summary of Results: The synthesis identifies a critical epistemic gap that prioritises clinical symptomatology over interoceptive context, creating an impoverished database that lacks long-term therapeutic validity. Furthermore, structural silencing occurs as patient narratives are often seen as lacking insight, hence barring the individual from the construction of their own record. To resolve these ethical breaches, this research proposes a shared epistemic base, a structural mechanism formalised through a ‘Joint Sign-Off’ protocol. This ensures the clinical record is only considered valid and ethically sound when co-authored and verified by both clinician and service user as equal experts.

Conclusions

Epistemic justice in mental health requires a structural redesign in how clinical data is produced and legitimised. Transitioning from a unilaterally constructed, hegemonic enquiry to a negotiated, bilaterally co-created interaction enables the addition of hermeneutical knowledge to the shared epistemological database. This model ensures that interoceptive intuition and lived experience are foundational requirements for clinical validity, ultimately upholding the dignity, agency, and fundamental human rights of the individual within the psychiatric system.

References

1. Fricker, M., 2007. Epistemic Injustice: Power and the Ethics of Knowing, First Ed. Oxford University Press, Oxford. Available from: https://doi.org/10.1093/acprof:oso/9780198237907.001.0001 [Accessed: 08 April 2026].
2. Beauchamp, T. L., & Childress, J. F. ,2013. Principles of biomedical ethics, Eighth Ed. Oxford University Press, Oxford. Available from: https://global.oup.com/ukhe/product/principles-of-biomedical-ethics-9780190640873?cc=gb&lang=en& [Accessed: 08 April 2026].
3. Johnstone, L., 2022. General patterns in the Power Threat Meaning Framework—principles and practice. Journal of Constructivist Psychology, 35(1), 16–26. Available from: https://doi.org/10.1080/10720537.2020.1773358 [Accessed: 08 April 2026].
4. Bracken, P., & Thomas, P., 2001. Post psychiatry: a new direction for mental health. BMJ (Clinical research ed.), 322(7288), 724–727. Available from: https://doi.org/10.1136/bmj.322.7288.724 [Accessed: 08 April 2026].
5. Longden, E., Corstens, D., Bowe, S., Pyle, M., Emsley, R., Peters, S., Branitsky, A., Chauhan, N., Dehmahdi, N., Jones, W., Holden, N., Larkin, A., Miners, A., Murphy, E., Steele, A., & Morrison, A. P., 2022. A psychological intervention for engaging dialogically with auditory hallucinations (Talking With Voices): A single-site, randomised controlled feasibility trial. Schizophrenia research, 250, 172–179. Available from: https://doi.org/10.1016/j.schres.2022.11.007 [Accessed: 08 April 2026].