Beyond Voice: A project about silence in depression and bipolar

By Dr Dan Degerman and Dr Jae Ryeong Sul, Department of Philosophy, School of Arts

Dr Dan Degerman and Dr Jae Ryeong Sul tell us about their project which seeks to highlight the underappreciated and vital role silence plays in the lives of people with mental illness. In doing so, the project will challenge the denigration of silence in mental health. The project recently received an AHRC Research Development and Engagement Fellowship and runs until June 2025.

When we talk about silence in mental illness, it is nearly always as something harmful that we need to ‘break’. Of course, some silences in and around mental illness should be broken. Think of the silence of someone afraid to talk about their distress because of mental health stigma. Or, think of the silence of someone who wants to share their distress but can’t find the words to make others understand.

However, silence is a diverse experience, as most of us will recognise from our own lives. Silence can be painful, imposed, and disempowering. But it can also be pleasant, chosen, and empowering. While it can feel like a barbed cage that keeps us from saying what we want, it can also feel like an oasis of freedom from other people’s demands.

Why should we think that silence in mental illness is any less diverse? Our AHRC-funded Beyond Voice project suggests there’s good reason not to.

Beyond Voice is a philosophical project that sheds light on the role of silence in the lives of people with depression and bipolar. Our research engages deeply with first-person accounts of people with lived experience of these illnesses from different backgrounds. That involves analysing autobiographical accounts and qualitative research, as well as working with a research advisory group consisting of both experts-by-experience and mental health professionals who provide invaluable guidance on our research.

Mapping the rainbow of silence

So far, our research has shown that many first-person accounts defy common assumptions about silence in depression and bipolar. For one, they suggest that silence can be part of what it means to be depressed. The writer Andrew Solomon, for instance, writes that depression ‘is like going deaf, hearing less and less until a terrible silence is all around you until you cannot make any sound of your own to penetrate the quiet’.

Silence can be painful, imposed, and disempowering. But it can also be pleasant, chosen, and empowering.

By contrast, in the manic episodes that form part of bipolar, the loss of silence can be a source of suffering and longing, as the writer Bassey Ipke suggests in her account of such an episode: ‘The thoughts have started to flood. They tumble and race so quickly that only focusing on [the cab driver] helps slow their circling. … [M]y mind is never quiet’.

These are just two examples of the rainbow of silence experiences – to borrow a metaphor from our advisory group – that people with depression and bipolar report. The first key objective of our 18-month project is to begin to map out that rainbow.

A better understanding of the variety of silences that occur in depression is not simply a matter of dotting some ‘i’s in an otherwise complete picture of depression and bipolar.

A clearer picture of the rainbow of silence will have important practical implications for people with those illnesses and those who want to help them, including friends and family, healthcare professionals, and policymakers. The second and third objectives of Beyond Voice are to draw out those implications.

The implications of silence for mental health

Some implications have already begun to emerge.

Since silence can be a part of what it is to be depressed or a desperate attempt to keep the worst consequences of mania at bay, we need to recognise the potential harm that the blinkered insistence on ‘breaking the silence’ around mental illness can have.

For example, other people’s well-intentioned appeals to share experiences or unsolicited advice can cause more harm than good to an individual whose depression is so severe that they cannot speak and do not even feel the urge to. In such cases, simply sitting with them in silence – honestly acknowledging the depth of their despair and quietly blunting their isolation – may instead be the crucial first step towards providing the appropriate support.

In other words, we must consider how we can help those who want to speak to do so without pathologising and pressurising those who cannot or have good reasons not to.

Our work will continue over the next year and we’d love to hear from you with your own thoughts on and experiences of silence.

Dr Dan Degerman is a Research Fellow in the Department of Philosophy and is interested in issues at the intersection of mental health, emotions, and politics. His first book Political Agency and the Medicalisation of Negative Emotion has just been published in paperback. Dr Jae Ryeong Sul is a Research Associate in the Department of Philosophy with research interests in phenomenology and philosophy of psychiatry. To find out more about the Beyond Voice project, please contact

Representing Evolution

By Professor Samir Okasha, Professor of Philosophy of Science, School of Arts

Professor Samir Okasha tells us about Representing Evolution, a £1.4m ERC Advanced Grant currently underway in the Department of Philosophy. Led by Samir, the five-year research project in the philosophy of science aims to deepen our understanding of how evolution is, has been, and should be represented.

A central part of scientific enquiry involves constructing representations of the world, or more accurately of those objects, events and processes in the world that the science in question is concerned with. Representations can take many forms, including diagrams, taxonomies, verbal descriptions, physical models, and abstract mathematical models. Thus a diagram of the solar system, a taxonomy of Alpine flora, a ball-and-stick model of a chemical substance, and a mathematical model of the spread of a disease are all examples of representations. Different though they are, each of these scientific constructs aims to represent some system in the world (the “target system”) and can be assessed for how well they achieve this aim.

The aim of Representing Evolution is to examine how biological evolution has been represented – diagrammatically, verbally and mathematically – in the scientific literature, past and present. A further aim is to examine representations of evolution in the context of pedagogy and science communication. “Biological evolution” is taken to include the process of descent with modification that Darwin described; the mechanisms that drive the evolutionary process such as natural selection; and the products to which the process has given rise, such as organic adaptation and diversity. Scientists have constructed representations of each of these elements in their quest to understand how evolution works. The project will offer a systematic study of these representations, the concepts from which they are built, and the associated inferences, from an overarching philosophical perspective.

The project has six work strands:

  1. The first strand examines diagrammatic representations of evolution, such as trees, landscapes and causal graphs.
  2. The second examines linguistic representations, particularly the use of metaphors and analogies to describe the evolutionary process.
  3. The third examines mathematical representations, as found in the abstract models that evolutionary theorists develop.
  4. The fourth strand examines “ways of thinking” about evolution, that is, fundamental cognitive styles that scientists and laypeople alike use to think and reason about evolutionary phenomena.
  5. The fifth strand considers the communication of evolutionary ideas, in particular how evolution is represented in science education and non-specialist fora.
  6. The sixth strand examines the project of generalizing evolution to the non-biological realm, a project whose feasibility depends in part on which representations of evolution are treated as canonical.

The importance of the project lies in its integrative ambition. The project will bring together philosophical ideas about the nature of representation and idealization, linguistic ideas about metaphor and analogy, psychological ideas about reasoning and cognitive biases, and educational ideas about science communication. By drawing on such a diverse range of ideas, the project will deepen our understanding of how evolution is, has been, and should be represented. The results will be of interest to both philosophers of science and scientific practitioners alike.

Professor Samir Okasha, Department of Philosophy, is Principal Investigator (PI) on the Representing Evolution project. To find out more about Representing Evolution, please visit the project’s website at, or contact Samir directly at

Is illness important to philosophy? A spotlight on project EPIC

By Professor Havi Carel and Assistant Professor Ian James Kidd (University of Nottingham)

To mark World Philosophy Day, Professor Havi Carel and Assistant Professor Ian James Kidd (University of Nottingham) provide an update on their Epistemic Injustice in Health Care (EPIC) project. Havi first introduced us to EPIC back in April and with the project now underway, it’s wonderful to see the progress that has been made.

Serious illness can seem extraordinary in the suffering and pain it inflicts, the losses it causes and its role as a premonition of death. It marks human life as vulnerable, limited, subject to contingency (such as a genetic mutation leading to cancer), and, of course, as finite. Project EPIC, a Wellcome Discovery Award, was launched in September, to study a particular aspect of this vulnerability. It focuses on a set of injustices – called ‘epistemic injustices’ – that can affect ill persons when they are not listened to, ignored, or their needs and wants overlooked. This is an injustice meted out to a person who is already ill and vulnerable, a vulnerability on top of the vulnerability all humans share as flesh and blood creatures whose bodies are susceptible to injury and disease.

Illness is a sign of our mortality and hence a human universal. None of us can avoid it indefinitely and it touches on every human life at some point. Everyone is, was, or will be, ill. Even if, miraculously, one does avoid serious illness, we will experience illness in the lives of those we love and care for. Illness is a fact of our humanity and of our membership in the animal kingdom.

Despite that, within philosophy, the profound significance and impact of illness has so far not received its due place. Language, mind and other aspects of human existence are philosophically well-studied. But illness is not. In most cases, illness is seen as a set of pragmatic and scientific questions – about the definition of disease or allocation of healthcare resources. These are the concerns of the sub-fields of philosophy of medicine and philosophy of science, as well as political philosophy and bioethics. But illness raises philosophical concerns that fall outside the scope of those sub-disciplines.

Consider the existential complexities of serious illness. A serious illness is one of the most profound and life-changing events in one’s life. It changes the ill person’s body and agency. Illness alters our ability to do things – from the mundane (carrying your shopping home) to the most significant (being around for your children). Such temporal changes also shape our sense of possibility, finitude, and our sense of the certainty of death.

“Humans seek knowledge, offer testimony, and work to understand their own and others’ experiences. When our epistemic efforts come to be unfairly obstructed, one suffers an epistemic injustice”

We believe that for all these reasons illness ought to be a central topic in philosophy. Moreover, illness cuts across some of its fundamental areas. Ethics, metaphysics, ontology, and social and political philosophy are all importantly informed by the ‘facts of life’ made salient by illness. What are these ‘facts of life’? That we are mortal, embodied, fragile, vulnerable, temporally finite, and existentially self-concerned. Our existence is conditioned by the changing state of our body.

One aspect of illness takes on particular importance: the vulnerability and dependence on others that arise from one’s body or mind being ‘diseased’. Vulnerability is morally relevant. It can be recognised, attended to, and invites care, compassion and protection. Dependence tells us something crucial about human life. We live and develop with others, who can support or obstruct our development. Our connections to others could be nurturing or oppressive. This whole nexus of dependence, connection, and vulnerability ought to guide our philosophising. Many feminist philosophers, for instance, explore these themes in relation to specific issues like justice, fairness, and social inclusion.

Within this nexus, and within the context of illness, one important area to study is that of the relationships within health care. These caring relationships involve multiple dimensions: scientific and biomedical, existential-personal, professional, and institutional-hierarchical. These relationships are often complex and played out during times of great distress and strain on ill persons and their families. They also take place within healthcare institutions, often characterised by their vastness, structural complexity, stubborn institutional constraints (time! Money!), and often changing institutional goals. It is important to note that individual ill persons can get lost within such structures and can find themselves unfairly treated by healthcare professionals or others (for example, social workers, insurance companies, and hospital clerical staff).

These social realities can give rise to what Miranda Fricker named ‘epistemic injustice’, an injustice relating to someone’s epistemic capacity. Humans seek knowledge, offer testimony, and work to understand their own and others’ experiences. When our epistemic efforts come to be unfairly obstructed, one suffers an epistemic injustice. Varieties of epistemic injustice are consistently reported by persons with somatic and psychiatric illnesses. Patients might, for instance, find their testimonies unfairly deflated due to racist biases and stereotypes. Questions about treatment options can be ignored or dismissed. If a patient reports severe pain, their testimony might fail to receive the uptake and response it merits. Fricker also describes kinds of ‘hermeneutical injustice’, unfair and harmful failures of understanding. One needs the right concepts, terms, and language to explain certain experiences. Fricker offers the example of the concept of ‘sexual harassment’. If the necessary concepts and language are either unavailable or ruled out as ‘unacceptable’, one suffers a hermeneutical injustice.

A main theme of contemporary work in the philosophy of illness is the epistemic injustices reported by persons with chronic illnesses. The new project – EPIC: Epistemic Injustice in Health Care will study these injustices. What are their forms, what causes them, how do they aggravate the sufferings of ill persons and what can be done to redress them? These aims combine many kinds of philosophy; there are moral issues of justice and fairness, social and political questions about the proper organisation of our shared world, and epistemological questions about credibility, testimony, understanding and the obstacles to our individual and collective epistemic life. There are topics in the philosophy of science and medicine, too, as well as phenomenological investigation into the experience of somatic and psychiatric illness.

“It is important to note that individual ill persons can get lost within such structures and can find themselves unfairly treated by healthcare professionals or others (for example, social workers, insurance companies, and hospital clerical staff)”

In addition, project EPIC will, for the first time, offer a systematic empirical study of epistemic injustice within a range of health care settings, from maternity care and vaccination programs to mental health and cancer. It will deploy diverse research methods from a variety of disciplines, including medical history, qualitative health research, legal studies, discourse analysis, and philosophy.

At the background of this project are also existential questions about what it means to live a human life, what it means to understand and connect meaningfully with other human beings. What starts as reflections on the kinds of epistemic injustice reported by ill persons within healthcare institutions and the social world can inform our thinking about the human condition itself—mortal creatures whose life is conditioned by contingency, vulnerability and dependence.

Professor Havi Carel, Department of Philosophy, is Principal Investigator (PI) on project EPIC. Assistant Professor Ian James Kidd, University of Nottingham, is a co-Investigator (co-I). To find out more about the work of project EPIC, please email the project manager Charlotte Withers ( 

‘It’s hard to think…’: Introducing the EPIC project studying better ways to hear patient voices

By Professor Havi Carel, Department of Philosophy

A fellow patient was talking about a consultation that followed an examination, when she was still wearing the hospital gown. She felt that it was hard for her to offer her opinions, say what she wanted, and ask questions about her condition, because, as she poignantly put it, ‘it’s hard to think without your pants on!’. 

How do we think, speak, ask questions and convey our views in different situations? This brief account opens questions about how patients are listened to, and how we can work together with health professionals to ensure that they are not only listened to but that what they say plays a key role in decision making processes in healthcare contexts. 

Some patients have reported that their testimonies and perspectives are ignored, dismissed, or explained away by the healthcare profession. These experiences are classified by philosophers as ‘epistemic injustices’ because, in some cases, they are based on prejudice and can jeopardize patient care and undermine trust in healthcare staff and systems.  

A new project I am leading with collaborators from the universities of Nottingham, Birmingham, and Swansea – ‘epistemic injustice in healthcare’ (EPIC) – will study this problem is its general form: why some patient voices are ignored and what healthcare systems can do to overcome this problem. The project is funded by a Wellcome Discovery Award, and will run for six years, with a budget of £2.6 million. 

The project will include case studies from a range of illnesses, theoretical research, events, focus groups, the creation of a network with patients and health professionals, postdoctoral positions, summer schools, and publications. The project aims to identify practical measures for the benefit of patients and healthcare practitioners alike. 

The core team also includes Professor Sheelagh McGuinness (Bristol), an authority on gender and the law in relation to healthcare, Professor Lisa Bortolotti (Birmingham), an expert in philosophy and psychiatry, Professor Matthew Broome (Birmingham), an academic NHS psychiatrist, and Dr Ian James Kidd (Nottingham) whose joint work with me pioneered the study of epistemic injustices in healthcare. 

The EPIC team will be completed by eight postdoctoral researchers and a range of other researchers and collaborators from Swansea, City and Aston Universities, and the Universities of Bologna and Ferrara in Italy, making a team of around 30 researchers. 

The six case studies will include labour pain, vaccination in immigrant children, young people and mental health, neurodiversity, cancer and depression, and dementia. 

Professor Broome will lead a case study on youth mental health. He said: “This project will help young people with psychosis develop better relationships with clinicians, and to gain agency in determining their treatment, and ultimately improve outcomes.” 

EPIC will also work closely with patients and service users. Professor Bortolotti added: “It is especially important for people with a mental health diagnosis to contribute to shared knowledge concerning their symptoms and treatment. We will challenge the assumption that they are irrational or disconnected from reality, and so not worthy of being listened to.” 

Dr Kidd said: “EPIC will also involve theoretical work elaborating on the concept of epistemic injustice. We have greatly expanded resources for conceptualising the variety of epistemic injustices. EPIC will contribute to that enrichment as well as benefitting from it.” 

The project will begin in September 2023 and we wish Havi and the rest of the team every success.

Professor Havi Carel, Department of Philosophy, is a philosopher of medicine and an expert on the experience of illness. 

World Philosophy Day 2020 – Marvellous mysteries and the unity of science

According to the United Nations, philosophy is ‘the study of the nature of reality and existence, of what is possible to know, and of right and wrong behaviour. It is one of the most important fields of human thought as it aspires to get at the very meaning of life.’ Today we are celebrating World Philosophy Day by sharing a post written by Francesca Bellazzi, a PhD student on the ERC-funded MetaScience Project*, which delves into marvellous mysteries and the unity of science…

‘But what vast gaps there were, what blank spaces, she thought leaning back in her chair, in her knowledge! How little she knew about anything. Take this cup for instance; she held it out in front of her. What was it made of? Atoms? And what were atoms, and how did they stick together? The smooth hard surface of the china with its red flowers seemed to her for a second a marvellous mystery.’ (Virginia Woolf, The Years)

So reflects Eleanor in Virginia Woolf’s The Years. How can this china with red flowers be made of atoms that somehow stick together? Many solutions to this marvellous mystery have been offered, and these are the kinds of questions that the MetaScience philosophy project addresses.

The world, like the cup, seems to be composed of different levels, one clustered beneath the other. Different disciplines study these different levels. Each of them focusses on a specific level of inquiry: physics at the physical one, chemistry at the chemical one, economics at the economical one, and so forth. However, how these levels relate to each other is not obvious. They are not isolated clusters such that the things happening in the ‘biological’ and ‘physical’ clusters are completely independent from each other, nor do they seem easily reducible to the one unique level of physical particles.

In light of this, two extremes have been debated within philosophy. Some philosophers are in favour of what is known as ‘strict identity-based reductionism’, arguing that phenomena at the higher level – such as biological phenomena – are strictly identical to phenomena at the physical level. Such a view might lead to ‘eliminativism’, which essentially says that if all higher-level entities are identical to their lower-level components, then we should stop speaking or even worrying about the higher-level stuff. The only fundamental level is then the physical one, and all the sciences have to be reduced to that. However, this is now an ‘old dream’ – the world is way too complex to be pinned down by identity relations.

Against this reductive dream stand those that argue for the disunity of science. Often called Diagram titled 'An Old Reductive Dream' showing the levels‘pluralism’, this position argues that the physical, chemical, biological and social realms can all equally understand the world on their own. However, this route also appears too extreme, as it disregards important interactions between levels and the growing exchanges between disciplines. 

In the MetaScience project we are investigating how to achieve the unity of the sciences by saving the unity of the world itself without being an identity reductionist. Our project studies how the different levels can interact via a variety of dependency relations, such as ‘multiple realisation’ and ‘multiple determination’. Multiple realisation means that a higher level can be realised by different lower-level phenomena. An example is colour, where different microphysical phenomena can realise the same shade. Different surfaces (composed of different microphysical particles) can reflect the same wavelength. Multiple determination goes the other way around: the same lower level can determine different higher-level properties, such as moonlight proteins that play different functions in different environments. Our aim is to use these – and other – dependency relations to find out whether the sciences can be effectively unified.

Let us try now to be a bit more concrete and go back to the china cup: how can its smooth surface be composed of atoms?

Illustration of a china cup decorated in a flower pattern
Illustration by Francesca Moro

The strict reductionist would say that the cup is nothing more than the result of physical stuff interacting with each other following the laws of physics. The pluralist, on the other hand, would say that any of chemistry, physics or psychology can give us an equally valid story about the cup. However, both options seem to take the wrong direction. There is no 1:1 correspondence between the colour red of the flowers and some underlying microphysical phenomena; as we saw earlier, colour is an instance of multiple realisation. However, there are some relations between the colour level and the microphysical one; these are not self-isolated clusters.

Possibly, the truth lies in the middle. Pursuing philosophical enquiry, MetaScience studies the possibility that within one cup, all sorts of different properties can be found and that this is not mysterious. One and the same china cup can be described by different disciplines that consider different properties: its material composition can be studied by chemistry, its solidity by physics, its geometrical form by mathematics, its colour by the interaction between optics and neurophysiology, its function by psychology and sociology. Nevertheless, this does not imply that this single cup is nothing but atoms or that the different descriptions of the cup are self-standing and detached. Rather, it means that the existent cup is only one and yet is complex. It is composed of many levels studied by different disciplines that all help to understand how the compositional parts of the cup are related. The mystery might be solved without taking away the marvellous. Thanks to the interaction between sciences and philosophy, we are able to formulate a unified view of the one china cup with its red flowers.

by Francesca Bellazzi,

PhD Student in the ERC-funded Project MetaScience (771509)

*The MetaScience project has received funding from the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation programme (Grant agreement No. 771509).