{"id":1834,"date":"2023-11-27T10:00:09","date_gmt":"2023-11-27T10:00:09","guid":{"rendered":"https:\/\/blogs.cardiff.ac.uk\/openfordebate\/?p=1834"},"modified":"2023-11-24T16:45:03","modified_gmt":"2023-11-24T16:45:03","slug":"suicidal-ideation-or-malingering-a-case-of-testimonial-injustice","status":"publish","type":"post","link":"https:\/\/blogs.cardiff.ac.uk\/openfordebate\/suicidal-ideation-or-malingering-a-case-of-testimonial-injustice\/","title":{"rendered":"Suicidal Ideation or \u2018Malingering\u2019? A case of Testimonial Injustice."},"content":{"rendered":"

Introduction <\/em><\/p>\n

According to the Office for National Statistics, 5,275 suicides were registered in England and Wales in 2022[1]<\/a>. Nevertheless, reports of the intent to kill oneself are not always met with the credibility they deserve, with potentially fatal results. We recognise this as testimonial injustice, whereby a person\u2019s testimony is not taken seriously due to a pervasive identity prejudice attached to the speaker (Fricker 2007). To meet the government\u2019s \u2018zero suicide ambition\u2019 for mental health patients, we need to adopt epistemically just methods of evaluating suicide claims.<\/p>\n

Stigma and Suicide <\/em><\/p>\n

People with suicidal ideation are wrongly perceived to be selfish, incompetent, emotionally weak, and immoral (Sheehan et al, 2017)[2]<\/a>. Although suicide has largely been decriminalised[3]<\/a>, the perception that suicide is morally wrong persists. The immorality attached to suicidal ideation creates a unique form of pathophobia[4]<\/a>[5]<\/a>. On the one hand, the suicide claim may be deemed genuine and immoral due to the harm caused to friends and relations if the person were to end their life. For example, suicidal ideation or attempts may be perceived as emotionally abusive: \u2018The immediate reaction is, \u201cHow dare you do something to me when we are trying so hard to help you?\u201d (Rimkeviciene et al., 2015: 595)[6]<\/a>.\u00a0 On the other hand, the suicide claim may be considered disingenuous and merely a ploy to attain some further goal. The latter is the form of stigma that tracks people with suicidal ideation into the healthcare system. Therefore, rather than dismissed as fallible, suicide claims are more likely to be dismissed as deceitful.<\/p>\n

Testimonial Injustice and Malingering<\/em><\/p>\n

Using conversation analysis, Bergen et al found cases where claims of suicidal ideation had been undermined, questioned and recharacterized by healthcare practitioners (Bergen et al, 2023) [7]<\/a>. Through several different communication practices (such as speaking over the patient, challenging the authenticity of the patient\u2019s suicidal ideation and attempting to confront the patient with inconsistencies in their account), some clinicians demonstrated that they were not sufficiently receptive to their patient\u2019s testimony.<\/p>\n

In addition, Petrea Taylor has developed studies showing that suicide claims from women are particularly likely to be dismissed as attention-seeking and manipulative, as they encounter additional misogynistic identity prejudices:<\/p>\n

Even if you tell [clinicians] you were suicidal, it is not taken seriously. They almost refuse to treat you. They refuse to talk to you. You are just worthless . . . You can come out of [the hospital] feeling three times worse than when you go in with a crisis . . . because [the clinicians] are too judgmental. (Taylor, 2020)[8]<\/a><\/p>\n

\u201cI just said to [psychiatrist], \u201cYou aren\u2019t listening to me!\u201d [Psychiatrist responded], \u201cWell nothing is wrong with you\u201d (Taylor. 2022: 616-617)[9]<\/a>.<\/p>\n

\u201c[the psychiatrist]\u00a0 came\u00a0 in\u00a0 and\u00a0 said,\u00a0 \u201cYou\u00a0 are\u00a0 manipulating\u00a0 the\u00a0 system\u2026\u201d (Taylor, 2022: 617).<\/p>\n

Beyond self-reports, institutionalised testimonial injustice is reflected in the language surrounding suicidal ideation (Frey at al., 2020)[10]<\/a>. The very language implemented in the context of suicidal patients betrays an implicit stigma, as such patients are not referred to as \u2018communicating\u2019 or even \u2018confessing\u2019 suicidal urges but of \u2018threatening suicide\u2019 (ibid). This terminology suggests that the patient is blackmailing the clinician, using the \u2018threat\u2019 of suicide as part of an ultimatum to force them to give in to the patient\u2019s demands. This attitude is reflected in the concept of \u2018malingering\u2019.<\/p>\n

The DSM-5 defines malingering as \u2018the intentional production of false or grossly exaggerated physical or psychological problems\u2019[11]<\/a>. The DSM-5 claims that malingering is not a psychiatric illness. What differentiates malingering from psychiatric disorders whereby the patient feigns, exaggerates or creates illness (e.g. Munchhausen\u2019s Syndrome), is the pursuit of external benefits. This may include drugs, evading criminal prosecution, avoiding work or school, paid leave from employment, or shelter. According to the DSM-5, malingering \u2018should be strongly suspected\u2019 in the following situations:<\/p>\n