Criticisms That Establishment Psychiatry Can and Cannot Tolerate

For the institutions comprising establishment psychiatry, self-preservation means maintaining legitimacy as a branch of medicine. Thus, any criticism of establishment psychiatry—no matter how harsh—that can also be applied to medicine in general does not threaten its existential legitimacy.

However, criticism that uniquely applies to establishment psychiatry but not to medicine in general does threaten its existential legitimacy, and it is not tolerated. Such criticism is either ignored by most of establishment psychiatry or it is attacked, often viciously so, especially from establishment psychiatrists who promote themselves as being open to criticism.

Before getting to specific criticisms that establishment psychiatry can and cannot tolerate, what are the institutions comprising establishment psychiatry?

In the United States, the most obvious such institution is the American Psychiatric Association (APA), the guild of U.S. psychiatrists, which promotes psychiatry as a legitimate branch of medicine. Another hugely important member of establishment psychiatry is the National Institute of Mental Health (NIMH), which has prioritized funding research on biological psychiatry (Thomas Insel, NIMH director from 2002-2015, famously stated: “I spent 13 years at NIMH really pushing on the neuroscience and genetics of mental disorders, and when I look back on that I realize that while I think I succeeded at getting lots of really cool papers published by cool scientists at fairly large costs—I think $20 billion—I don’t think we moved the needle in reducing suicide, reducing hospitalizations, improving recovery for the tens of millions of people who have mental illness”).

U.S. establishment psychiatry also comprises lesser-known institutions including the American Academy of Child and Adolescent Psychiatry, as well as psychiatry departments in approximately 150 U.S. medical schools. Worldwide, there are parallels to U.S. establishment psychiatry institutions, all of which have in common the belief that emotional suffering and behavioral disturbances, especially serious ones, are medical phenomena.

Establishment psychiatry does acknowledge that emotional suffering and behavioral disturbances—what it calls “mental illnesses”—have biological-psychological-social roots. Such an acknowledgement does not threaten the legitimacy of establishment psychiatry as a branch of medicine because many medical conditions, including cancer, are also accepted as having biological-psychological-social causes. Establishment psychiatry institutions are not threatened by any proposed cause of emotional suffering and behavioral disturbances, as long as the resulting conditions are seen as medical conditions.

Thus, establishment psychiatry is unthreatened by the idea that trauma and adverse childhood experiences are a cause of emotional suffering and behavioral disturbances—as long as these conditions are medicalized. This is why psychiatrist Bessel van der Kolk’s best-selling The Body Keeps the Score, with its “Part Two: This is Your Brain on Trauma,” can safely exist within establishment psychiatry. As long as front and center is the book’s assertion that “the body keeps the score”—in other words, the body is damaged—then emotional suffering and behavioral disturbances resulting from trauma can be seen as a medical phenomenon; and psychiatrists can retain their authority as medical experts who determine whether the resulting condition requires their drugs and other somatic treatments, or can be treated by non-somatic therapies.

In contrast to The Body Keeps the Score, a book that would have threatened establishment psychiatry would have made clear that there are physical correlates not only with trauma but with everything we think, feel, experience, and do; however, physical correlates do not make a phenomenon a medical condition, and viewing the emotional suffering and behavioral disturbances that are the result of psychological and social trauma as a medical condition is, for many individuals, a problematic paradigm.

Criticisms That Establishment Psychiatry Can Tolerate

Establishment psychiatrist defender Awais Aftab has positioned himself as the highest-profile psychiatrist open-minded to criticism of psychiatry, and so he provides a good sense of what establishment psychiatry can and cannot tolerate.

As noted, establishment psychiatrists, including Aftab, can tolerate criticism that can also be applied to medicine in general because this does not threaten its existential legitimacy. Here are some examples.

Misdiagnoses. Since misdiagnoses occur in medicine in general, it is no existential threat for establishment psychiatry to acknowledge that it too is guilty of this. Establishment psychiatry not only acknowledges misdiagnoses, but it actually embraces misdiagnoses to explain their failed theories and failed treatment outcomes.

There are many patients who have been diagnosed with so-called “serious mental illness” (such as so-called “schizophrenia” and “bipolar disorder”) who ultimately reject psychiatric treatment including psychiatric drugs, and become highly functioning. It is not unusual for these ex-patients to then face claims by establishment psychiatrists that they are only able to become highly functioning without psychiatric drugs because they were initially misdiagnosed.

David Oaks, co-founder and former long-time executive director of MindFreedom, reports that as a college student he unequivocally had the symptoms that establishment psychiatry uses to diagnose schizophrenia:

“There were times when I thought the CIA was making my teeth grow, or that a UFO was appearing in my living room, or that God was talking to me via the radio, or that the performers on TV were directly talking to me. . . . A dozen psychiatrists diagnosed me as a psychotic. I was told I would have to stay on psychiatric drugs the rest of my life, like a diabetic on insulin.”

However, after David rejected establishment psychiatry’s drug treatments, recovered by other means, and became a highly effective articulate activist, he regularly faced claims by establishment psychiatry and its apologists that he must have been initially misdiagnosed.

This same misdiagnosis justification by establishment psychiatry is currently directed at Laura Delano, the latest high-profile effective articulate activist, who had received a bipolar diagnosis along with other psychiatric diagnoses during an extensive period of her life which she details in her recently published memoir Unshrunk (“I became a professional psychiatric patient between the ages of thirteen and twenty-seven”). However, in his review of Unshrunk, establishment psychiatrist defender Awais Aftab claimed that Delano was misdiagnosed with bipolar disorder, discounting Laura’s own following account that “I was properly diagnosed and medicated according to the American Psychiatric Association’s standard of care.”

So, establishment psychiatry has put David, Laura, and many other ex-psychiatric patients who have been diagnosed with serious mental illnesses in the ridiculous position of having to repeatedly assert that, according to establishment psychiatry’s criteria, they were properly diagnosed.

Iatrogenesis, which is defined as illness or injury caused by medical treatment. Iatrogenesis comprises all conditions for which physicians and other medical professionals, hospitals and other medical facilities, and their treatments are the causes of various types of harm. Again, establishment psychiatry acknowledges that iatrogenesis occurs in psychiatric treatment, which makes psychiatric treatment just like medical treatment in general.

So, Aftab titles his review of Laura Delano’s Unshrunk as “A Memoir for the Iatrogenic Age,” and he tells us that “Delano’s story has much to teach us about the iatrogenic realities of our work.” Aftab distorts the book’s message to be about iatrogenic treatment which occurs throughout medicine when practitioners are mistaken, incompetent, or arrogant. However, the major thrust of Delano’s Unshrunk is that she was damaged not by what establishment psychiatry would consider malpractice or even sub-standard treatment, but by its standard of care delivered by its most prestigious practitioners, and she was damaged by its paradigm of care.

Corruption by pharmaceutical companies. Establishment psychiatry tolerates such criticism because this puts them in the same category as medicine in general. While Marcia Angell, former editor-in-chief of the New England Journal of Medicine, reported on the corruption of establishment psychiatry institutions by drug companies in her The Truth About the Drug Companies (2004), the book details the corruption by drug companies of medicine in general.

To repeat, any criticism that can be applied to medicine in general is not only tolerated but embraced by establishment psychiatry, as such criticism supports what establishment psychiatry cares most about—that it is just like medicine in general. There are other examples of such criticism, but I’ll offer one more to make the point that no matter how horrible the indictment, as long as it can be applied to medicine in general, it can be tolerated because it does not existentially threaten psychiatry.

Nazi embrace. Pretty horrific, right? However, as long as this criticism is applied to medicine in general, establishment psychiatry can tolerate it. So establishment psychiatry is unbothered by Alessandra Colaianni’s 2012 report in the Journal of Medical Ethics that, “More than 7% of all German physicians became members of the Nazi SS during World War II, compared with less than 1% of the general population. . . . By 1945, half of all German physicians had joined the Nazi party.” As horrible an indictment as this is, Colaianni does not single out psychiatry, and so establishment psychiatry is not existentially threatened by a criticism that can be applied to medicine in general.

In contrast, what is existentially threatening to establishment psychiatry is the 2007 Annals of General Psychiatry article, “Psychiatry During the Nazi Era: Ethical Lessons for the Modern Professional” by psychiatrist Rael Strous, who is critical of the contemporary training of psychiatrists. Strous begins by stating:

“It has been acknowledged that the medical profession was profoundly involved in crimes against humanity during this period, with various publications describing this malevolent period of medical history. It is less known, however, that psychiatrists were among the worst transgressors. . . .Their role was central and critical to the success of Nazi policy, plans, and principles.”

While Strous is by no means “anti-psychiatry,” he further differentiates psychiatry from medicine in general with regard to psychiatry’s essential nature, arguing that without such a recognition of psychiatry’s particular vulnerability, Nazi Germany atrocities may well be repeated by psychiatry:

“Moreover, psychiatry by nature incorporates contemporary ideology in its approach to the individual and society. . . . The experience of psychiatry during the Nazi era provides an example of how science can be perverted by politics and therefore can become vulnerable to misuse and abuse. An exclusive focus on the monstrous aspects of Nazi medicine enables us to dismiss such events as aberrant and deviant, with a subsequent failure to internalize the inherent and very real dangers of the perversion of science and clinical management by outside political influences. . . .While it would be expected that the involvement of psychiatrists in such a profound manner would be well-known in the field, this is not the case. Little has been published on the subject in mainstream psychiatry journals and even less is part of the formal education process for medical students and psychiatry residents.”

To Strous’s great dismay, psychiatry students go uneducated in this sad chapter in its history.

Criticisms That Establishment Psychiatry Cannot Tolerate

Misdiagnosis, iatrogenesis, corruption, and even a Nazi embrace are horrible indictments, but as long as these criticisms can be applied to medicine in general, establishment psychiatry can tolerate them because they are not existential threats that delegitimize it as distinct from medicine in general.

What makes a criticism of establishment psychiatry intolerable for it has nothing to do with either how horrific the indictment is or the degree of scientific support for it, only whether or not the criticism can also be applied to medicine in general. Here are some criticisms that establishment psychiatry cannot tolerate:

Establishment psychiatry, unlike medicine in general, has made no progress in terms of treatment outcomes.

This reality is so glaring that even some mainstream journalists, when they exit mainstream media, and even some establishment psychiatry institution directors, upon leaving these positions, acknowledge this truth.

In 2021, upon his exit from covering psychiatry for twenty years, New York Times reporter Benedict Carey concluded that psychiatry had done “little to improve the lives of the millions of people living with persistent mental distress.” Carey noted: “Almost every measure of our collective mental health—rates of suicide, anxiety, depression, addiction deaths, psychiatric prescription use—went the wrong direction, even as access to services expanded greatly.”

Unlike medical treatments in general, which can point to improved treatment outcomes in many areas, there is no area of establishment psychiatry treatment in which there has been improved outcomes, as its new treatments have only resulted in differing adverse effects.

Carey’s claim, he assures readers, cannot be seen as a radical one, as he quotes from a pre-publication copy of a book by Thomas Insel, director of the NIMH director from 2002-2015, who acknowledged not only a lack of progress but deterioration in some areas during his reign: the suicide rate had climbed 33 percent, overdose deaths had increased threefold, and people with schizophrenia were still dying 20 years early. In Insel’s 2022 book, Healing, he asks, “Why with more people getting treated and better treatments available are we in the middle of a mental health crisis, with rising death and disability?” To answer this question without offending establishment psychiatry, Insel offers an explanation in which, as I have previously discussed in a 2022 review of his book, his logic escapes me.

Establishment psychiatry’s treatments, unlike medicine in general, have increased suffering, transforming episodic conditions into chronic illnesses.

Establishment psychiatry defenders recognize that this criticism is so existentially threatening that all efforts must be made to marginalize it. Awais Aftab is civil and even agreeable with criticism that can be applied to medicine in general; however, he becomes dishonest and vicious in his condemnation of the highest-profile author of this criticism, journalist Robert Whitaker, who made a case for it in Anatomy of an Epidemic (2010). Aftab denounces Whitaker in this way:

“He noticed some interesting patterns in longitudinal studies and population data pertaining to the use of psychotropic medications, and fleshed out the provocative hypothesis that psychiatric medications are actually making psychiatric patients worse, causing an epidemic of psychiatric disability. His thinking entered the stage of “trapped priors.” When his views were ignored and rejected by the mainstream scientific community, he rapidly developed the anti-epistemology necessary to protect his thesis, according to which the psychiatric community was not receptive to his criticisms because of their sheer corruption and professional insecurity. Spurned by the scientific community, Whitaker made it his mission to directly convince the public—and basically anyone with an axe to grind against psychiatry—of the validity of his views.”

First glaring Aftab dishonesty: “His views were ignored and rejected by the mainstream scientific community.” While Anatomy of an Epidemic was rejected by establishment psychiatry, this book won the 2010 Investigative Reporters and Editors Association book award for best investigative journalism, and Whitaker has long been held in high esteem by the scientific community, as he is a past winner of the George Polk Award for Medical Writing and a winner of the National Association for Science Writers’ Award for best magazine article.

As previously noted, New York Times reporter Carey, who covered psychiatry for 20 years, concluded that outcomes, with greater access to treatment, have gone in the “wrong direction,” quoting a former NIMH director to support this. Correlation, as any scientist knows, does not necessarily mean causation, so increased psychiatric treatment is not necessarily the cause of worsening outcomes; however, any genuine scientist would want to investigate the source of this correlation and examine all of Whitaker’s supporting evidence for his hypothesis as to why this is occurring.

This leads to Aftab’s next dishonesty. Anyone who has read Anatomy of an Epidemic, as Aftab has, recognizes that Whitaker does not simply offer “some interesting patterns in longitudinal studies and population data” for support for this hypothesis.

Whitaker makes clear that correlation is not equivalent to causation, and that increasing mental illness disability rates corresponding with increased psychiatric drug treatment is not proof of his hypothesis, but rather should provoke scientific inquiry. Such inquiry reveals a great deal more evidence including: (1) World Health Organization cross-cultural studies which show that compared to the U.S. and so-called “developed” countries, there are far better outcomes for individuals diagnosed with schizophrenia in so-called “undeveloped” countries in which antipsychotic drugs may have been used for acute psychotic episodes but not used chronically as is the case in the U.S. and other “developed” countries; (2) a 1994 Harvard study that determined that recovery rates for schizophrenia patients in modern times had declined over the past 15 years; (3) a long-term NIMH-funded study of patients originally diagnosed with schizophrenia which found that “four years later and continually until the twenty-year follow-ups, patients with schizophrenia not prescribed antipsychotics had significantly better work functioning”; (4) in mood disorders, long-term superior outcomes with no treatment as compared to antidepressant treatment; and (5) several physiological reasons for the counterproductive effects of long-term drug treatment, including: dopamine supersensitivity which makes individuals more biologically vulnerable to psychosis, debilitating adverse effects of these drugs, and severe withdrawal effects which routinely get misdiagnosed as “mental illness relapse.”

Moreover, since the publication of Anatomy of an Epidemic in 2010, there has been even more evidence for Whitaker’s hypothesis, not the least of which is a randomized controlled trial (RCT) published in 2013 in JAMA Psychiatry that found at the end of seven years, the recovery rate for those individuals diagnosed as psychotic who had discontinued/reduced antipsychotic drugs was twice the recovery rate as those individuals who were maintained on their antipsychotic drugs.

Yet despite all of this (and other evidence), Aftab accuses Whitaker of “entering the stage of trapped priors” which, as defined by Aftab’s link, means not believing one is wrong even after having been proven wrong beyond a shadow of a doubt; and he accuses Whitaker of having “rapidly developed the anti-epistemology necessary to protect his thesis,” with anti-epistemology being a jargon term for not respecting the rules of reasoning.

Instead of simply insulting Whitaker, perhaps Aftab has somewhere provided an alternate hypothesis for why outcomes have gone in the “wrong direction” with increased treatment, but I haven’t found it.

Psychiatric drugs, unlike many of the drugs used in medicine, do not correct any abnormal state or underlying condition, but rather induce an abnormal (or altered state), and psychiatric drugs should be seen as in the same category as cannabis and alcohol rather than in the same category as insulin or blood pressure medications.

This “drug-centered” model of psychiatric drugs as distinct from a “disease-centered” model of most of the other drugs used in medicine is detailed by dissident psychiatrist Joanna Moncrieff in her 2008 book The Myth of the Chemical Cure (she summarized this distinction in 2013). For making this distinction between psychiatric drugs and most other drugs in medicine, Moncrieff has been demonized by establishment psychiatry, including Aftab, even though Moncrieff makes clear that she is not anti-drug, and that she prescribes psychiatric drugs in some instances. She is simply saying that psychiatric drugs are in a different category than most of the other drugs in medicine. Specifically, Moncrieff states:

“Psychiatric drugs are psychoactive substances, like alcohol and heroin. Psychoactive substances modify the way the brain functions and by doing so produce alterations in thinking, feeling and behaviour. Psychoactive drugs exert their effects in anyone who takes them regardless of whether or not they have a mental condition. Different psychoactive substances produce different effects, however. The drug-centred model suggests that the psychoactive effects produced by some drugs can be useful therapeutically in some situations. They don’t do this in the way the disease-centred model suggests by normalising brain function. They do it by creating an abnormal or altered brain state that suppresses or replaces the manifestations of mental and behavioural problems.”

Despite Moncrieff stating here and elsewhere that “the psychoactive effects produced by some drugs can be useful therapeutically in some situations,” Aftab has attacked Moncrieff as having anti-drug views in his 2025 “Anatomy of Moncrieff’s Anti-Medication Playbook.”

What appears to especially enrage Aftab is Moncrieff’s point, “If you give someone with depression a dose of a mind-altering drug, like heroin, they would most likely feel less depressed for a while,” and she adds that while antidepressants are not the same as heroin, by numbing the emotions, antidepressants might reduce depression scores.  Aftab reacts to this with a frequently used tactic by establishment psychiatry: the ad hominem attack of “guilt by association” in which the psychiatry critic is associated with a person who is abhorrent or polarizing in order not to have to deal with merits of the criticism. Specifically, Aftab states, “It doesn’t seem coincidental that RFK Jr. also brought up a comparison between antidepressants and heroin in his confirmation hearing.”

The application of establishment psychiatry’s medical model of emotional suffering and behavioral disturbances, unlike the application of this model in medicine in general, has been unhelpful and damaging for many individuals.

Psychiatry’s medical model, in common practice, consists of “diagnosing” a person with a mental illness if the person has been assessed to have enough qualifying behaviors termed by psychiatry as “symptoms,” and “treatment” consisting of eradicating as quickly as possible these symptoms. In psychiatry’s medical model, attention deficit hyperactivity disorder (ADHD) and schizophrenia are seen as diseases like gonorrhea and cancer, and medical treatment consists of eradicating the condition, with the idealized goal being the eradication of the cause of the pathology, and the practiced goal of eradication of its symptoms.

In medicine in general, this medical model has in many instances effectively reduced suffering, and in some instances, actually eradicated the cause of suffering. However, when it comes to emotional suffering and behavioral disturbances, psychiatry’s medical model has been itself injurious for many individuals. Specifically, by terming phenomena such as anxiety, depressed mood, inattention, and voice hearing as “symptoms of illness” rather than informative and meaningful “human reactions,” many individuals develop a mental patient identity, become disempowered, and stop searching for what their reactions are trying to inform them of.

To be clear, there are psychiatric patients who state that acquiring a psychiatric diagnosis helps them feel better; and for some of these individuals, drug and other somatic treatments can numb their pain or function as a placebo that fulfills their expectations of pain relief. And so for some individuals, this model can help them feel better, at least initially (though even for many of these individuals, the long-term adverse physical and psychological effects begin to outweigh the benefits).

Thus, abolishing psychiatry’s medical model is unfair to those individuals who have found it to benefit them. However, it is also unfair to force this model on individuals who have found it damaging.

Establishment psychiatrists, unlike physicians in medicine in general, have no experience or expertise in major areas critical to their patients’ well-being, and so these professionals are routinely less helpful and more harmful than many nonprofessionals who have greater experience and expertise in these areas.

One of the clearest examples of this is helping individuals who want to reduce or eliminate their psychiatric drugs. Dissident psychiatrist James Greenblatt’s 2024 article “Antidepressant Withdrawal: A Brief History” describes the recent history of how establishment psychiatry denied the phenomenon and then minimized it:

“As providers started to recognize the problem, the published research—almost all of which was sponsored by the pharmaceutical industry—started to downplay the phenomenon by using the term “discontinuation syndrome” over withdrawal. . . . minimizing withdrawal symptoms, claiming they were rare and that they only lasted a few weeks . . . . However, as the research continued, it became clear that withdrawal was a real phenomenon that could have devastating effects.”

Due to establishment psychiatry’s ignoring the realities of psychiatric drug tolerance and dependence, and its denial and minimizing of the suffering caused by psychiatric drug withdrawal, it routinely labeled this phenomenon as “mental illness relapse.” And even after establishment psychiatry no longer denied withdrawal suffering, it has remained uninformed about the science behind safe tapering, which is detailed by dissident psychiatrists such as Mark Horowitz (see his video Antidepressant Withdrawal Effects and How to Safely Stop Them).

Even at present, the New York Times reported (March 17, 2025) that psychiatrist Jonathan E. Alpert, chairman of the American Psychiatric Association’s Council on Research, acknowledges that the APA has yet to issue its own de-prescribing guide (claiming the APA has plans to do so).

So, given this void of both information and support, online peer groups emerged, and Laura Delano and Cooper Davis launched Inner Compass Initiative, which provides information and support for that large group of individuals who want to reduce or eliminate their psychiatric drugs, but who lack any useful information and support from their doctors. Predictably, Inner Compass Initiative has been attacked by establishment psychiatry.

Alpert at the APA, the New York Times reported, “reviewed Inner Compass’s resources and described them as ‘biased and ‘frightening.’ He said online peer communities risk becoming ‘echo chambers,’ since they tend to attract people who have had bad experiences with medical treatment.”

The New York Times also reported that establishment psychiatrist Gerard Sanacora, director of the Yale Depression Research Program, was also critical of peer support because he claimed that it took trained clinicians and licensed practitioner to guarantee “some level of minimum competency” to determine whether a patient is experiencing drug withdrawal or mental illness relapse of underlying conditions.

Establishment psychiatry and its mainstream media apologists neglect the reality that for the last several decades most establishment psychiatrists have routinely been labeling all suffering following drug withdrawal as relapse of the underlying condition; and such labeling has created chronic psychiatric patients.

The Issues are Pluralism and Tolerance, Not Pro- and Anti-Psychiatry

Virtually every critic of establishment psychiatry makes clear that they are not anti-psychiatry, however, establishment psychiatry defenders, including psychiatrist Ronald Pies (interviewed in 2020 by Aftab), label as a member of the anti-psychiatry movement anyone who voices criticism that establishment psychiatry cannot tolerate.

Aftab claims to dislike the anti-psychiatry label, however, similar to Pies, in Aftab’s “The ‘Antipsychiatry’ Dilemma,” he states that this term is suitable for critics who want to “delegitimize” psychiatry. Aftab makes no distinction between delegitimizing the monopolistic authority of establishment psychiatry, which many psychiatry critics desire, versus attempting to abolish psychiatry, which virtually no critics are seeking.

One would hope that this distinction would now be clear to Aftab after interviewing Cooper Davis, Executive Director of Inner Compass Initiative, who told him in 2025:

“We are not ‘anti-psychiatry,’ ‘anti-drug,’ or ‘anti-diagnosis.’ What we are for is providing people with straightforward, factual information about psychiatric treatments, the diagnostic paradigm, and alternatives to them. If, after getting that information, some people find solace in medicalizing their pain and seeking the guidance of a clinician, we are unreserved in our appreciation for mental health professionals and treatments being there for those who want them.”

Davis made clear to Aftab that he is not seeking a “replacement for our current mental health system,” but rather his goal is a mutual-aid, nonhierarchical parallel “built outside of that framework . . . to function as a second beacon of light for people finding themselves lost at sea and looking for safe harbor. . . . I think that any truly effective model ultimately needs to find itself working outside of any medical or clinical context.”

While establishment psychiatry defenders attempt to make the conflict one of “pro-psychiatry” vs. “anti-psychiatry,” the conflict is really one of pluralism versus monopoly.

Pluralism is a political philosophy which holds that autonomy should be enjoyed by various groups within society. Pluralists maintain that diversity is beneficial to a society, and that there can be peaceful coexistence between groups of people with different beliefs, convictions, and lifestyles.

Throughout history, there has been a conflict between those who favor tolerance and pluralism versus those who believe that singularity is the only way a society can function and thus are intolerant of differences. Tolerance and pluralism were key Enlightenment values, and radical Enlightenment thinkers such as Baruch Spinoza (1632-1677) and his friends faced persecution from religious authorities for being uncompromising in their belief in tolerance and pluralism.

This historical conflict has not disappeared, but simply taken on a different shape.