The role of clinicians in the looping effect: epistemic injustices and looping breaks

The debate on whether psychiatric disorders can be studied as natural kinds has raised controversy, reviving socio-constructionist arguments about the influence of social factors on psychiatric categories. A key concept in this discussion is the "looping effect", which describes how individuals change in response to their classifications, necessitating revisions to those classifications. We argue that, until now, the broad discussions around the looping effect have greatly failed to integrate the perspectives surrounding clinicians and patients. We examine more closely the dynamic and unstable nature of psychiatric diagnoses by proposing two key hypotheses: first, that understanding the looping effect requires incorporating both clinician and patient viewpoints, and that when done adequately, such an incorporation can facilitate the work of the clinician by creating feedback loops (i.e., the iterative adjustment of clinical interpretations based on patient responses); and second, that epistemic injustices between clinicians and patients can create disruptions in these feedback loops, which we call "looping breaks", rendering them ineffective. Looping breaks can happen at the clinical level of the relationship between the patient and the clinician or at the nosological level (during the process of revising a classification). We suggest that looping breaks can be caused by a denial or minimization of credibility based on identity prejudice, or due to an epistemic disadvantage, affecting the experiential feedback of patients following the announcement of a diagnosis. To substantiate our claims, we first examine the impact of looping effects in the interaction between patients and clinicians. Second, we investigate the impact of these interactions at the nosological level, on the broader diagnostic framework. We identify epistemic injustices as critical factors that can lead to looping breaks at both levels, thus affecting the stability and validity of psychiatric diagnoses. Our findings underscore the importance of an epistemic approach to the looping effect, emphasizing both knowledge validity and justice in clinician-patient relationships and among clinicians themselves.