Psychiatric institutions exert considerable power over patients and service users, including whether or not their account’s are considered credible and what harms are measured and addressed. The use of coercion and force are common in psychiatric hospitals, including forcibly medicating people against
their will and using restraint and seclusion. Yet institutional culture is often one in which patient and service user complaints are dismissed, allowing unhelpful, harmful, and abusive practices to go relatively unchallenged and unchanged within these institutions.
A new article published in PLOS Mental Health calls this pattern “institutional non-learning,” a refusal to acknowledge systemic problems that lead to repeated harm. The authors, led by independent researcher Laurence Cobbaert, argue that psychiatry as a discipline must recognize that patients and service users can be harmed by diagnosis and treatment. They call for these organizations to change institutional practices that result in harm, ignoring patient complaints, and refusing to allow negative patient experiences to influence clinical care and institutional culture. The authors write:
“Psychiatry combines clinical expertise with substantial institutional authority over diagnosis, treatment access, coercion, clinical records and the credibility assigned to people receiving care. This Essay examines how that authority can impede learning from recurrent warnings across professional misconduct, coercive care, diagnostic practices and iatrogenic harm. We propose institutional non-learning as a cross-cutting problem: professional interpretation can shape whose testimony is believed, which harms are measured, how events are recorded and whether reform is evaluated.”
Institutional Failures Result in Harm
News articles have documented numerous repeated institutional failures on psychiatric wards that led to patient harm and death. A 2025 San Francisco Chronicle investigation into for profit psychiatric hospitals in California found that “incidents of violence, neglect and patient self-harm are rampant within many of California’s for-profit psychiatric hospitals.” These for-profit companies capitalized “on lax state regulations to strip their workforces bare, generating massive earnings for investors and owners while exposing patients to erratic care, violence and deadly neglect.”
This problem is not restricted to for-profit institutions. A 2022 Propublica investigation described a “culture of cruelty” at Choate Mental Health and Developmental Center in Illinois. The US department of Justice’s Civil Rights Division cited Choate in 2009 for failing to protect patients from harm. Despite the DOJ declaring that “Illinois officials had made adequate improvements” in 2013, numerous criminal investigations and arrests have been made as a result of patient abuse at this facility through 2022.
While these egregious offenses could be seen as examples of “bad apples,” they can also be seen as a symptom of the psychiatric system as a whole, which relies heavily on coercive practices, forced treatment, and involuntary hospitalization—removing patient autonomy despite research reporting that coercion undermines recovery and results in lower perceived quality of care. Psychiatry has largely ignored patient complaints calling coercive measures “torture” and “assault,” with some studies suggesting these practices are increasing to cover over systematic failings such as poor ward environments and staffing shortages. The UN and WHO agree with patients, and support the call for an end to forced treatment.
Institutional Non-Learning
The authors of the current work argue that psychiatric institutions can often overlook harm when professional authority determines which accounts are believed and which problems receive attention. When patients are harmed as a result of professional misconduct, diagnosis, and treatment, a focus on individual mistakes is insufficient. Instead, psychiatric facilities should examine their own policies, assumptions, reporting procedures, and institutional culture that may prevent learning from mistakes and criticisms. This involves something the authors call “epistemic humility,” recognizing the limits of institutional knowledge and remaining open to correction. The authors also note that acknowledging a problem or mistake without implementing any concrete changes to correct it, demonstrating measurable improvements in safety, and reducing harm is a hollow act that does not demonstrate “institutional learning.”
Psychiatry largely depends on research and clinical trials of interventions to justify treatments, even when patients and service users report harm. The authors present evidence that treatment related harm is likely underreported in research literature. They cite a review of 132 randomized trials of psychiatric interventions where 79% of trials did not report that any harms were monitored and only 3% detailed both harms and the methods used to collect data about those harms. If researchers do not monitor for harms related to treatment, an absence of reported harm is not evidence that the treatment is safe.
The authors also emphasize that research around psychiatric treatment does not apply to all patients and service users. Factors such as cultural background, individual life circumstances, trauma history, and identity can influence how people experience treatment. If certain groups are underrepresented in research, the evidence cannot speak to their specific treatment needs.
While lived experience expertise and evidence is treated as subjective, psychiatric institutions often look at professional knowledge as objective. However, psychiatric diagnosis is largely a matter of opinion, and publication bias means positive findings for psychiatric treatments are more likely to be published. Rather than uncritically accepting professional or experiential knowledge, the authors argue that both types of evidence should be evaluated fairly while acknowledging the limits of each.
Just as an absence of reported harm is not evidence that a treatment is safe, neither are reported benefits. The authors contend that a simple measure of symptom improvement is not sufficient to establish treatment quality or overall effectiveness. A treatment may improve certain symptoms while also leading to negative experiences, other symptoms or difficulties getting worse, damaging patient and service user trust in healthcare, or other adverse effects. A treatment may also be effective for some people while harming others. Additional problems around research related to treatment safety includes studies rarely assessing long-term outcomes and people that discontinue treatments due to negative experiences being excluded from offering subsequent feedback.
Epistemic injustice means that people with mental health diagnoses are often viewed as unreliable narrators, even when it comes to their own experiences. As a result, patient and service user complaints, including those related to abuse, neglect, and harm as a result of treatment, are often dismissed by mental health workers. The authors identify three institutional patterns that sustain this problem:
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Ignorance culture: Warnings or complaints are minimized, ignored, or blamed on the person who raised them.
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Exclusion culture: People may be denied care because institutions interpret their difficulties as making them unsuitable for help.
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Defensiveness: Instead of investigating complaints, institutions and professionals focus on the complainant’s personality or psychiatric diagnosis
These patterns can become self-reinforcing. For example, the authors describe “diagnostic recursivity” as the tendency of psychiatric institutions and professionals to interpret complaints or criticism of a diagnosis or treatment as further evidence that the diagnosis is correct. A patient complaint that a certain treatment has caused harm is interpreted as evidence of their supposed “illness” rather than as a warning about the treatment. When both agreement and disagreement are interpreted as evidence that the institution is correct in their assessment, patients have little recourse to challenge a clinical decision or treatment plan.
The authors also describe “diagnostic weaponisation,” a situation in which a psychiatric diagnosis is used to discredit patient’s and service user’s testimony and complaints, justify coercion, and restrict their ability to challenge clinical decisions. This can be especially problematic for minorities that are more likely to receive diagnoses that are easily weaponized, such as schizophrenia for black men and borderline personality disorder for women and LGBTQ+ patients and service users.
The authors emphasize that these problems are often structural rather than intentional. A clinician or mental health worker does not need to deliberately mistreat someone for institutional processes and culture to produce harm. For example, diagnosis alone can negatively change the way patients are viewed by friends, family, and medical professionals.
The authors propose “responsibility culture” as a remedy for institutional non-learning. This means organizing mental health systems around the ability to identify harm, investigate it fairly, repair its consequences when possible, and demonstrate improvements over time. Responsibility culture would involve four interconnected baseline requirements:
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Independent scrutiny: Serious or recurring concerns should be reviewed by people in positions to hold the institution accountable. Independent reviewers should also be diverse in terms of how they view psychiatry, as it is possible for external reviewers to share the same biases as the institution they are reviewing.
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Active safety monitoring: Mental health services should collect information related to adverse effects of treatment, negative experiences of treatment, deterioration, and reasons for discontinuing care.
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Meaningful lived-experience governance: People with lived experience of psychological distress and psychiatric diagnosis should be meaningfully involved in setting research priorities, defining harm, and decision about service improvement. This would also involve adequate compensation.
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Remedy, redress, and public accountability: Institutions should correct inaccurate records and inappropriate decisions where warranted, provide appropriate remedies, report what action has been taken, and assess whether changes have improved safety.
The authors conclude:
“Trust should rest on transparent self-correction rather than assurances of good intent. The practical test is whether institutions can recognise when their own practices are implicated, respond to those affected and demonstrate what changed.”
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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). (Link)
