When Psychiatry Stops Learning: How Institutional Power Blunts Warnings of Harm

Psychiatry holds a rare combination of powers in modern healthcare. Its practitioners diagnose, decide who may access treatment, authorise involuntary care, write the clinical records that follow people for life and, crucially, determine how much credibility is assigned to the words of those receiving care. A new Essay published in PLOS Mental Health argues that this concentration of interpretive authority creates a systemic vulnerability: the field can fail to learn from repeated warnings about professional misconduct, coercive care, questionable diagnostic practices and harm caused by treatment itself. The authors, led by independent researcher Laurence Cobbaert, call this cross-cutting problem institutional non-learning, and they propose a framework for fixing it that rests on epistemic humility, reciprocal scrutiny and a culture of accountability that can be publicly evaluated.

The core insight is structural rather than about individual bad actors. When a patient reports harm, the same institution that may be implicated in that harm defines what counts as legitimate knowledge, classifies the person making the report, decides what is recorded in the notes and determines whether reform is needed. Philosophers call the resulting wrongs epistemic injustice: harms done to people specifically in their capacity as knowers. In mental healthcare, stereotypes of irrationality, unreliability or manipulation can diminish a patient’s credibility while professional interpretations receive presumptive authority. The authors stress that psychiatry is not monolithic and has genuine traditions of self-critique, supervision and professional disagreement, but they insist that internal reflection alone is not learning. Learning becomes visible only when concerns are detected, reforms implemented, outcomes measured and recurrence reduced.

A central technical contribution of the Essay is a careful dissection of what different kinds of evidence can and cannot show. Qualitative research can rigorously investigate experiences, meanings and processes, but cannot estimate how common a phenomenon is. Epidemiological studies can estimate frequency with appropriate sampling. Randomised trials can estimate causal treatment effects under defined conditions, but applying those results elsewhere requires attention to participants, interventions, outcomes and settings. The authors warn against collapsing these distinct tasks into a single number. An adverse event occurs during treatment without necessarily being caused by it; iatrogenic harm requires an attribution to care. Negative experiences, reliable deterioration and serious adverse events differ in severity and how they are ascertained, and combining them into one prevalence figure would obscure clinically important differences.

The evidence on harm in psychological treatment is striking precisely because harm is so rarely sought. In one review of 132 randomised trials of psychological interventions, 79 per cent gave no indication that harms were monitored at all, and only 3 per cent described both adverse events and the methods used to collect them. Later reviews identify inconsistent definitions and terminology across the field. Reported estimates of clients experiencing at least one negative episode in psychotherapy range from 7 to 96 per cent across studies, with reliable deterioration estimated at 2 to 14 per cent, figures that vary depending on what is counted and how. Limited safety evidence, the authors argue, ultimately constrains clinical guidelines and the informed consent patients can genuinely give. Tools such as a patient-rated scale for positive and negative experiences of psychotherapy offer a starting point for systematic monitoring.

The Essay also challenges the assumption that professional knowledge is a neutral comparator against which patient accounts should be judged. In an experimental diagnostic task, psychiatrists who searched for confirmatory information were more likely to retain an incorrect preliminary diagnosis. A meta-meta-analysis found an association between researcher allegiance and psychotherapy outcomes, meaning the preferred therapy of a research team tends to perform better in that team’s trials. The authors are careful to note that such findings do not establish deliberate distortion, but they support what they call reciprocal reflexivity: lived experience and professional expertise should each be scrutinised, matched to the question at hand and neither presumed infallible nor excluded from evaluating the other’s claims.

Representativeness problems compound the picture. Among articles in a leading American psychiatry journal, only 43 per cent reported the race or ethnicity of participants, and just a quarter acknowledged limited representation as a limitation. In perinatal mental health studies conducted during the COVID-19 pandemic, 76.5 per cent of participants were White; in an eating disorder review, roughly 70 per cent of participants in studies reporting ethnicity were White. A sample containing few or no members of a population cannot provide precise safety estimates for that population, and extrapolation requires explicit justification. The published record itself may misrepresent the research conducted: comparing 74 antidepressant trials with regulatory reviews, 94 per cent appeared positive in the published literature versus 51 per cent in the assessments, and the published effect size was 32 per cent larger overall. Among federally funded psychological treatment trials for depression, nearly a quarter went unpublished, and including available unpublished results reduced the estimated effect by 25 per cent.

From these threads the authors build a vocabulary of institutional dysfunction. Ignorance culture describes the handling of alarms through silence, minimisation, deflection or blame. Exclusion culture describes practices that make denying or withdrawing care appear clinically appropriate. Defensiveness names the redirection of scrutiny away from a practice and toward the credibility, pathology or emotionality of the person raising the concern. Most provocatively, diagnostic weaponisation denotes the unwarranted extension of diagnostic authority to discredit, exclude, coerce or control, using a label beyond its evidentiary scope or as a substitute for an independently justified decision. Empirical studies lend this concern weight: higher rates of borderline personality disorder diagnosis have been found among lesbian, gay and bisexual patients, and among transgender and gender diverse patients, even after adjustment for relevant clinical correlates, while an experiment showed that a suggested borderline personality disorder label adversely influenced clinicians’ judgements of an unrelated panic disorder beyond equivalent behavioural information.

The consequences of classification ripple outward. A clinician’s account enters the medical record and can shape diagnosis, risk assessment, coercion and access to care; a researcher’s choices determine which outcomes are foregrounded; institutions decide whether complaints become part of safety systems. Accounts from people harmed in care describe withdrawal from services after coercion or invalidation, which removes their perspectives from clinical learning precisely because feedback depends on continued engagement. Qualitative studies of anorexia nervosa care describe treatment experienced as simultaneously life-saving and unsupportive, coercive or enduringly harmful, and interviews with people reporting long-term adverse effects after electroconvulsive therapy describe memory changes, losses of identity and dismissive professional responses. Antidepressant withdrawal tells a similar story: one survey found withdrawal symptoms in 79 per cent of respondents who had attempted discontinuation, though the low response rate limits population inference, and patient accounts document dismissal, misdiagnosis and inadequate tapering support. Uncertainty, the authors argue, calls for better ascertainment, not dismissal of reported experiences.

The proposed remedy is a responsibility culture built on four linked standards. Serious or recurrent concerns require scrutiny sufficiently independent to challenge the institution, including epistemic independence from the shared assumptions and allegiances under examination. Safety surveillance must actively solicit clearly defined harms rather than passively waiting for complaints, since fewer reports may reflect diminished trust rather than safer care. Relevant lived experience expertise needs remunerated decision-making authority over harm definitions, outcomes, priorities and evaluation, not tokenistic participation. And institutions need mechanisms for remedy, redress and public reporting of implementation, because policies, training and commitments are inputs, not evidence that safety has improved. Research transparency, including trial registration, accessible protocols and complete outcome reporting regardless of results, forms part of the surveillance apparatus.

The Essay’s conclusion is a challenge to the field’s self-image. Psychiatric expertise has genuine value, but professional status does not confer epistemic neutrality, and the authority that accompanies it makes reciprocal scrutiny especially important. Trust, the authors argue, should rest on transparent self-correction rather than assurances of good intent. The practical test they set is disarmingly simple: can psychiatric institutions recognise when their own practices are implicated in harm, respond to those affected, and demonstrate publicly what changed and whether safety improved? Until learning is measured in those terms, warnings that recur across misconduct, coercion, diagnosis and iatrogenic harm will continue to be attenuated by the very systems that should be heeding them.

Subject of Research: Institutional non-learning, epistemic injustice and diagnostic weaponisation in psychiatry

Article Title: When psychiatry does not learn: Epistemic humility, ignorance culture, exclusion culture and diagnostic weaponisation

Article References: Cobbaert, L., Elwyn, R., Downs, J., James, S., & Jackman, M. (2026). When psychiatry does not learn: Epistemic humility, ignorance culture, exclusion culture and diagnostic weaponisation. PLOS Mental Health, 3(10), e0000741. https://doi.org/10.1371/journal.pmen.0000741

Image Credits: AI Generated

DOI: 10.1371/journal.pmen.0000741

Keywords: psychiatry, epistemic injustice, institutional non-learning, iatrogenic harm, diagnostic weaponisation, psychotherapy safety, publication bias, lived experience, coercive care, diagnostic bias, epistemic humility, accountability