Psychiatry Rebuilt from First Principles

An unwelcome illness intrudes

The initial response, always in this society, is to try harder, be stronger, be better. But this time, the emotions are overwhelming and relentless. A possibility that would flip cause and effect—could this be psychiatric illness? Now you must turn to psychiatry, one of the fields of medicine you had sympathized with others for needing, with a faint sense of vindication that you did not. That is past. Now is the time to secure the best solutions that society has to offer.

The medical system: hoping that below the surface it isn’t bureaucratic and clumsy

Anyone suddenly dependent on modern medicine understands the World War II GI’s observation that “there are no atheists in foxholes.” When psychiatric symptoms emerge within us or our families, we trust – we have to trust – that experts know how to fix it.

We try to put aside our experience with a medical system that seems more like the DMV than a palace of wisdom. We all experienced the clumsiness of medical decision-making during COVID, when we were told we weren’t allowed to get a vaccine, and then, the next day, told that it was urgent that we get it. Medicine defaults to binary decision-making, while, almost always, nuance is needed. As a result, many, perhaps most, don’t get the treatment that would work best for them. Vincent DeVita, who served as Director of the National Cancer Institute, of the Yale Cancer Center, and as Physician-in-Chief at Memorial Sloan Kettering Cancer Center, estimated that 100,000 cancer patients are lost each year due to refusal to adjust treatment as needed for each individual patient. In psychiatry, a rare realm of medicine in which only the patient can directly assess the effect of treatment, the top-down medical approach is especially wrong-headed.

A first-principles approach that rings true

To be effective, psychiatric treatment must combine all the knowledge that has been amassed by modern psychiatry with the individual’s observations of the symptoms that they are experiencing. Together this information comprises the full map, and the person dealing with the symptoms carries the most important half. They are the one who is expert on their circumstance and it is they who are choosing to work with a supporting team. Calling them patient trivializes their expertise, and instead vests significant information in the medical team. To properly embed the primacy of both their information and their objectives, they properly should be called the client. The client is the deep-sea diver, reporting on the vivid passing scenery; the psychiatric team is on the surface ship, with experience, loyalty, and resources. Only the diver can see directly that which ultimately matters.

Psychiatric symptoms stand out in that only the individual experiencing them has direct access to what needs treatment. The client’s report is the equivalent of the serum chemistry, MRIs, and tracer scans in other medical fields. But in addition, psychiatry also is entangled in the obstacles that Dr. DeVita enumerated in oncology. Psychiatry, too, is distorted by institutional processes, financial incentives, and pursuit of prestige, all of which make it less likely the individual will obtain the treatment that is most likely to cure them.

The key to eliminating symptoms

As in any realm of life, decency requires that people be treated with respect and kindness. But it is a medical necessity in psychiatry, where the person dealing with the symptoms is also the sole reporter on the front line, observing, perceiving, analyzing. To be effective, the treatment system must be built for real-time collaboration, treating their dispatches as the foundation for every decision. Technology, carefully and thoughtfully deployed, makes this possible.

Seeking expert treatment could have been useless, but fortunately, we humans share 99.7% of our DNA, and so among the treatments that work for others are ones that will work for each of us. Good treatment must harvest and organize that knowledge, and share it generously and supportively. When we combine the two halves of the map, that of the client who is directly observing their symptoms, with that of the treatment team who carries knowledge learned from all who have gone before, we can have great confidence that we will eliminate the symptoms.