Epistemic disadvantage and therapeutic asymmetry in psychiatric care

1. Med Health Care Philos. 2026 Jul 7. doi: 10.1007/s11019-026-10378-8. Online
ahead of print.

Epistemic disadvantage and therapeutic asymmetry in psychiatric care.

Gauld C(1)(2), Espi P(3).

Author information:
(1)Service de Psychopathologie du Développement, Hospices Civils de Lyon, 69000,
Lyon, France. .
(2)S2HEP, Sciences, Société, Historicité, Éducation et Pratiques, Université
Lyon 1, Lyon, France. .
(3)Service de Psychopathologie du Développement, Hospices Civils de Lyon, 69000,
Lyon, France.

In a recent commentary, Alcalay argues that the concept of epistemic
disadvantage provides a useful framework for understanding forms of epistemic
harm that may arise even in the absence of epistemic injustice. We agree that
this concept identifies an important category of harms associated with warranted
asymmetries of expertise and offers valuable insights into both clinical and
nosological practices. However, we suggest that, in some clinical situations,
clinicians may intentionally maintain interpretative distance from a patient’s
explicit narrative while fully recognizing its sincerity, meaning, and
experiential value. We argue that psychiatric care frequently involves what we
call therapeutic asymmetry, i.e., situations in which interpretative distance
forms part of the therapeutic process itself. Using examples based on
suicidality, loyalty conflicts, mania and AI sycophancy, we aim to show that
clinicians may sometimes refrain from accepting patient narratives at face value
because suffering can affect capacities for self-understanding,
self-deliberation and decision-making. Therapeutic asymmetry highlights the role
of alterity, interpretation, and clinical judgment in situations where patients
seek assistance precisely because they struggle to understand, interpret, or
transform aspects of their own experience.

© 2026. The Author(s), under exclusive licence to Springer Nature B.V.

DOI: 10.1007/s11019-026-10378-8
PMID: 42412317

Conflict of interest statement: Declarations. Competing interests: The authors
declare that they have no conflict of interest. Ethical approval and consent to
participate: Not applicable. Consent for publication: Not applicable.

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