Psychiatry Cannot Learn While it Pathologises Diversity and Dissent

What is it about?

Psychiatric diagnosis is meant to help people understand their distress and access appropriate care. But psychiatry also has considerable power over how people’s experiences are interpreted. Sometimes, challenging a diagnosis can be treated as evidence that a person is mentally ill and “lacks insight”. Saying that treatment is not helping, or is causing harm, can be reframed as resistance, non-compliance, treatment-interfering behaviour, or as a sign of psychopathology. This creates a troubling Catch-22: accept the psychiatric interpretation and the diagnosis stands; challenge it, and your disagreement may be used to reinforce it. We call this diagnostic recursivity: when questioning a diagnosis or treatment becomes evidence for the very diagnostic interpretation or clinical practices being questioned. In our PLOS Mental Health essay, we describe how this can contribute to institutional non-learning: services may receive repeated warnings that their diagnostic constructs or treatments are causing harm, including iatrogenic harm, yet fail to make the changes needed to prevent those problems from recurring and to repair the harm already done. A related problem is diagnostic weaponisation, where the power attached to a psychiatric diagnosis is used beyond what the evidence justifies to dismiss, discredit, exclude, punish, or control someone. This matters because psychiatry has a documented history of pathologising racialised people, homosexuality, gender diversity, and nonconformity to Eurocentric, patriarchal social norms. Diagnosis does not take place outside culture, prejudice, or power. Treatment itself also needs scrutiny. A therapy can help someone in one way and harm them in another. Yet psychotherapy research has often focused on very specific treatment outcomes, such as improvement in narrow symptom categories, without adequately measuring possible harms. Someone might improve on a symptom questionnaire while leaving treatment traumatised, losing trust in services, or becoming afraid to seek help again. If these outcomes are not measured, research can record the benefit while missing the harm. Responsible care requires demonstrating that potential benefits outweigh the risks. We also question claims that treatments work universally when many groups have been poorly represented in clinical trials. Findings from one population cannot automatically be assumed to apply across different cultures, identities, life experiences, and ways of thinking, communicating and experiencing the world. We argue for moving from an ignorance culture, where warnings can be dismissed, denied, minimised, or deflected back onto patients as somehow being their fault, towards a responsibility culture grounded in genuine accountability. This means actively monitoring and transparently reporting iatrogenic harm, taking lived experience expertise seriously, sharing decision-making power, providing meaningful ways to put things right when harm occurs, and publicly demonstrating what has changed and whether those changes have actually improved care. A mental health system capable of learning must be able to hear criticism without defensively pathologising the person raising it. When it causes harm, it must be capable not only of acknowledging that harm, but also of accepting accountability, learning from it, repairing what can be repaired, and changing.

Featured Image

Photo by Marija Zaric on Unsplash

Photo by Marija Zaric on Unsplash

Why is it important?

Psychiatry has enormous influence over how distress is understood, whose accounts are believed, and what forms of care people receive. Yet systems intended to help people can struggle to recognise when their own diagnoses, treatments, or institutional practices cause harm. This matters because criticism can be reinterpreted as illness, treatment harms remain inadequately monitored and are not transparently communicated, and people whose experiences fall outside dominant clinical assumptions may be especially likely to be unheard and silenced. Our article brings these problems together through the concepts of institutional non-learning, diagnostic recursivity, diagnostic weaponisation, ignorance culture, and responsibility culture. Rather than treating individual instances of harm or dismissal as isolated failures, we examine the systems that allow the same problems to recur. We argue that meaningful improvement requires more than listening or consultation: it requires accountability, transparent monitoring of iatrogenic harm, genuine decision-making power for people with lived experience expertise, and demonstrable changes in practice.