Toward Systems Psychiatry and Precision Medicine

Why is Psychiatry So Disconnected From Neurology, Physiology, and Biomedical Informatics?

The fragmented conceptual models that constitute much of psychopathological theory–and that inform related discourse about, and treatment of, psychiatric disorders–, seem to prescribe a bounded solution set to a ‘problem’ that the very discourse itself, partly produces. In characterizing these problems in such a categorical way–steeped in assumptions about the existence of binaries across and within the “health” versus “disease”–we do little to help ourselves by failing to see the more fundamental biophysical-phenomenological mechanisms of co-emergence that may be in play at every level of analysis. The fundamental nature of our suffering seems anything but clear; however, a tradition of explanatory reductionism (wherever you look in healthcare, be that your mainstream “western medicine”, your “integrative medicine”, your “natural medicine” etc.)  appears to have normalized a discourse that creates this illusion of explanatory depth: we mistakenly believe that professionals fully understand a complex mechanism of action by which some structures and processes result in eventual disease . Many people today–practitioners, clients, and the broader public–uncritically accept and conflate these explanatory, pathological ‘maps’ with their ‘territories’. Many seem happy to believe in the idea that somebody–some entity–understands the nature of their problems; and by association, the nature of their “solutions”.

In order to get a sense of whether or not this faith is based in reality, it may be helpful to take a look at some public health patterns. With respect to matters that are considered to be “of the mind & brain”, we see treatment inefficacy, perpetuation of disease & disorder, attrition and barriers to engagement, power imbalances, risk deflection, blame, rising costs, etc. To be clear, we think that this reflects a significant failure. Moreover, we feel that the failure is a responsibility of all of us. We also do not intend to imply that the scientific knowledge and biopsychosocial technical tools that have been developed thus far are useless; these technologies are deeply valued and utilized by some people in some situations. However, there has been appalling stagnation in this space–particularly with respect to disorders entailing chronic cognitive disorganization, perceptual anomalies, altered states of consciousness, the inability to selectively attend to sensory information, psychosis, etc–since the 60s!!! (. We speculate that a fundamental part of the problem relates to the socio-structural features of healthcare: the stifling, overwrought, inflexible ecology that we call ‘the mental health system’ renders clients and providers alike unable to easily access those potentially useful technologies that do exist, in an autonomous & streamlined way. This system design, we argue, just reinforces paternalism, a culture of blame, and oadministrative risk deflection (as opposed to autonomy, symmetrical risk sharing, and inter-relational collaboration, respectively). The failure of the institutional practice of psychiatry and the allied health professions (and really healthcare writ large) warrants immediate attention and action from all stakeholders involved. **We focus here on the failure of the practice as opposed to theoretical or explanatory endeavors, though the two are inexorably connected. For the purposes of this discussion, we take the theoretical endeavor to be of value insofar as it has implications for technologies that could be developed (also known as the process of biomedical engineering) in order to address unmet health needs.

      The language and other signaling that we use, implicitly reflects our judgments about, and epistemic orientations toward, the theories to which we subscribe. Much of ‘psychiatry’ as we know it, seems flawed not only in practice, but in many of the conceptual assumptions (and ways of thinking or not thinking about these assumptions) upon which it is inspired.

When we buy into theoretical frameworks with an epistemic attitude of certainty and arrogance, it is likely that we cause more harm than if we were to subscribe to those same theoretical frameworks with an epistemic attitude openness and skepticism, void of value judgements. This is one of the central features of the value framework within which “doing science” is understood.

So what is a “belief” versus a “theory”? In the latter, we essentially mostly think that an explanatory model is based in sound evidence, follows from reasonable premises, and stands up to the test of time, but we hold this view with a constant awareness of its potential fallibility . We’re not married to our theories. We’re always open and always ready to prioritize or de-prioritize these ideas in lock-step with incoming information.  As “professionals”, when we believe something about ideas, or ourselves, or others; when we believe that clients are of “lower” epistemic value in all interactions, not based on the contents of their communications, but based upon a perception of social position and associated intellect, everyone loses.

We are all probably merely observers and as such, at any given time and in any given context, we all have the potential to produce some viable propositions, some psychotic propositions, and some ideas that fall somewhere in between.

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