Revolutionary Psychiatry II: Going Batty: Game Theory and Improved Patient Outcomes
Consider an extreme manifestation of interpersonal conflict: one man purposefully and relentlessly harasses another until the second man snaps, striking his provocateur in the head with a baseball bat. The victim—having successfully engineered his own assault—is quietly thrilled by the outcome. The retaliator, meanwhile, is arrested, charged, and sent to jail.
When confronted with a scenario that ends in severe violence and masochistic satisfaction, the immediate societal impulse is to ask: Who is crazy in this situation?
Is it the man who orchestrates his own physical destruction just to win a psychological game? Or is it the man who allows himself to be pushed into throwing his freedom away over a provocateur’s taunts? To understand this dynamic, we must strip away the colloquial use of the word "crazy" and examine the mechanics of the conflict through the roles of Person A (the provocateur) and Person B (the reactor), and look at what happens when an arbitrator steps in to resolve what the individuals could not.
The Symbiosis of Person A and Person B
In this dynamic, Person A and Person B are not acting independently; they are locked in a toxic, symbiotic feedback loop.
Person A weaponizes vulnerability and the rules of social conduct. By harassing Person B without crossing the threshold of physical violence, Person A maintains the technical high ground while applying unbearable psychological pressure. His goal is not to avoid harm, but to manufacture a scenario where Person B becomes the undeniable aggressor. When the bat strikes his head, Person A is happy because his internal narrative has been validated: he has proven that Person B is a monster, and he has successfully manipulated the system into destroying his enemy. Person A sacrifices his physical safety to secure a moral and legal victory.
Person B, conversely, lacks the psychological endurance or emotional regulation to navigate the trap. Exhausted, humiliated, or enraged by the harassment, Person B reaches a breaking point where the immediate release of physical retaliation outweighs the long-term consequences of a felony. Person B trades his future for a single moment of absolute, primal control.
Both individuals are operating outside the bounds of healthy emotional regulation. Person A exhibits a detachment from self-preservation, while Person B exhibits a catastrophic failure of impulse control. Yet, asking "who is crazy" is a trap in itself, because the label of insanity is rarely about clinical diagnosis in these moments—it is about societal utility. In this real life example, both of these individuals had psychiatric diagnoses, but person A “got away with it.”
The Arbitrator and the Culture of Disabling
When a conflict escalates to this level, society can no longer ignore it. An arbitrator—in this case, the legal and penal system—is forced to step in.
The arbitrator does not have the capacity, nor the mandate, to untangle the deep psychological warfare that led to the swinging of the bat. The system operates on objective, physical realities. Person B committed aggravated assault with a deadly weapon; therefore, Person B is labeled the "criminal" (and colloquially, the "crazy" or dangerous one) and is removed from society. Person A suffered physical trauma; therefore, Person A is labeled the "victim."
By imposing these binary labels, the arbitrator participates in a culture of disabling people. Rather than addressing the root dysfunction, the system "disables" the participants to restore order. Person B is physically disabled by incarceration and stripped of his autonomy. Person A is psychologically disabled by the system’s validation; by officially crowning him the victim, the arbitrator shields Person A from having to confront his own severe manipulative pathology.
The label of "crazy" or "criminal" is a tool of convenience for the arbitrator. It creates a neat narrative where the complex, shared responsibility of a toxic dynamic is flattened into a one-sided offense. Society uses these labels to outsource the messy work of human reconciliation.
The Ultility of Mutual Resolution
The tragedy of this extreme scenario is that the violence, the jail time, and the pathologizing labels were all entirely avoidable.
If Person A and Person B possessed the emotional vocabulary and willingness to resolve their conflict interpersonally, the entire framework collapses. If Person A could communicate his underlying grievances or insecurities without resorting to relentless psychological torture, and if Person B could establish boundaries and communicate his limits without resorting to a weapon, the conflict would remain in the realm of normal human friction.
In a space of mutual resolution, neither individual needs to be labeled “crazy.”
Ultimately, nobody in this dynamic is inherently "crazy." They are two people who failed to manage a deeply broken interaction, relying instead on an extreme escalation to do the work of boundary-setting for them.
The label “crazy” comes into play only when the third party, in this case the penal system is introduced. If instead this conflict could be resolved without escalation, neither party would require labeling or disabling.
“The game of finger pointing in psychiatry in fact increases diagnostic labeling. Let's all eat the shared meal.” K. Dana Moran
In game theory, interpersonal conflict functions as a strategic interaction where the ultimate payoff—autonomy versus institutionalization—depends entirely on whether the players choose mutual resolution or escalation. By modeling Person A and Person B as players in a non-zero-sum game, we can see how the failure to cooperate forces the introduction of a third party, which fundamentally changes the rules and the diagnostic outcomes for everyone involved.
The Payoff Matrix: Resolution vs. Escalation
In a standard conflict scenario, Person A and Person B have two primary strategies: Cooperate (de-escalate, set boundaries, walk away) or Defect (harass, retaliate, escalate).
* Mutual Cooperation (Internal Resolution): If both parties cooperate, they absorb the short-term discomfort of compromising or walking away. The payoff is maximum autonomy. The conflict remains a private matter of human friction. Because no third party is summoned, no external diagnostic labels are required.
* Mutual Defection (The Escalation Trap): Person A chooses to relentlessly harass, and Person B chooses physical retaliation. This mutual defection guarantees a catastrophic negative payoff. They exhaust their own capacity to manage the interaction, forcing a third-party arbitrator—the penal or psychiatric system—to step in and forcefully end the game.
The Game of Finger Pointing in Psychiatry
The label of “crazy” does not exist in a vacuum; it is a mechanism of state and institutional arbitration. When Person A and Person B defect and force the system to intervene, they trigger the game of finger pointing in psychiatry.
Arbitrators—whether judges, police, or institutional psychiatrists—require efficiency to restore order. They do not have the resources to untangle a complex, symbiotic web of mutual psychological abuse. Instead, the system uses psychiatric and legal labels as sorting mechanisms. It looks for the most visible breach of the social contract (the swing of the bat) and points the finger.
In this game, the system diagnoses Person B with a pathology—such as intermittent explosive disorder or antisocial personality trait—to justify stripping him of his freedom. Meanwhile, Person A is diagnosed purely as a victim of trauma, effectively masking his severe manipulative pathology. The diagnostic outcome is inaccurate for both: Person B is reduced to a mindless aggressor, and Person A’s dangerous instigation is medically and legally absolved. The psychiatric finger-pointing serves the institution's need for a clear perpetrator and victim, rather than reflecting the true, shared psychological dysfunction of the event.
Why Conflict Resolution Yields Better Diagnostic Outcomes
A "diagnostic outcome" is not just a medical label; it is the definitive story society tells about a person's mental state. When conflict is resolved internally, the diagnostic outcome is vastly superior because it prevents pathologizing altogether.
When Person A and Person B resolve their friction without escalation, they retain control over their own narratives. They might view each other as difficult, annoying, or incompatible, but they remain within the spectrum of normal human behavior. Neither party requires labeling, and neither party is subjected to the disabling effects of institutional intervention.
Better diagnostic outcomes are achieved through conflict resolution because resolution starves the arbitrator of jurisdiction. By managing their own triggers and establishing boundaries, individuals bypass the game of finger pointing entirely. They prove that they possess the emotional regulation necessary to exist in society, rendering the labels of "criminal" or "crazy" obsolete.
Analyzing institutional psychiatry through the lens of game theory reveals how systemic power dynamics can trap providers and patients in adversarial, zero-sum loops—and how restructuring the "rules of the game" can shift this to a cooperative, positive-sum model.
The Zero-Sum Trap: How Adversarial Systems "Disable"
In game theory, a zero-sum game means one player’s gain is mathematically balanced by another’s exact loss. When psychiatric systems operate under rigid, coercive, or highly liability-driven frameworks, they often force a zero-sum dynamic regarding agency and control.
* The Players: The System/Provider and the Patient.
* The Finite Resource: Autonomy.
* The Payoff Matrix: In a risk-averse medical model, the system prioritizes compliance and symptom suppression to minimize liability and institutional disruption. To achieve this "win," the system often employs restrictive measures (e.g., involuntary holds, forced medication, diagnostic labeling). The patient "loses" their agency, civil liberties, and self-efficacy—which can lead to long-term dependency or a "disabling" loss of functional independence.
* The Suboptimal Nash Equilibrium: Both parties adopt defensive strategies. The provider expects non-compliance and acts coercively; the patient expects coercion and acts defensively (or withdraws entirely). Neither can change their strategy without risking a worse outcome under the current rules, resulting in a stable but mutually damaging stalemate.
Shifting to a Positive-Sum Game (Win-Win)
To resolve conflict and improve outcomes, the structure of the game must be changed from a zero-sum battle for control to a positive-sum (cooperative) game, where both individuals can increase their payoffs simultaneously.
Using game theory, this transformation requires three structural shifts:
1. Redefining the Payoff Matrix (Shared Goals)
In the zero-sum model, the provider's goal is compliance and the patient's goal is escape/autonomy. To create a win-win, the game must be restructured around a shared, overarching payoff: the patient's quality of life and functional recovery.
* If the provider's "win" is redefined from managing risk to facilitating the patient's self-determined goals, their incentives align.
* When the patient succeeds in integrating into the community, the patient wins (autonomy/health) and the provider wins (successful clinical outcome/reduced systemic burden).
2. Eliminating Information Asymmetry
Many conflicts in healthcare resemble the Prisoner's Dilemma, where a lack of transparent communication breeds paranoia and defection.
* The Fix: Moving from a game of imperfect information to perfect information. Transparency. By transparently sharing the risks, legal constraints, and treatment options without paternalism, both individuals can make rational, cooperative choices rather than defensive ones.
3. Iterated Play and "Tit-for-Tat" Trust Building
A single, high-stakes encounter (like an acute crisis intervention) often defaults to a zero-sum power struggle. However, game theory proves that in iterated (repeated) games, cooperative strategies mathematically outcompete aggressive ones.
* The Fix: Providers must initiate cooperative moves (granting agency, listening to preferences) and consistently reciprocate the patient's cooperative moves. Over multiple interactions, this builds trust. The patient learns that sharing their true internal state will result in support rather than punishment (coercion), breaking the defensive Nash Equilibrium.
The Outcome: Cooperative Conflict Resolution
When a conflict arises between a patient and provider under a positive-sum framework, they do not fight over who gets to dictate the outcome. Instead, they engage in bargaining.
For example, if a patient wants to stop a medication due to side effects, a zero-sum approach results in the provider labeling them "non-compliant" (system wins, patient loses). A game-theoretic win-win approach involves the provider offering a safe tapering schedule in exchange for the patient agreeing to monitor specific warning signs.( Through programs of CBTp, patients can realise how to monitor symptoms and generally reduce the need for medication.) Both preserve their core interests—the provider maintains clinical safety, and the patient reclaims their bodily autonomy.
A hopeful future for psychiatry is one in which institutionalisation is a last resort (costly and ineffective), medication is used sparingly (it is disabling itself), CBT or CBTp is used often (with direct honest communication), family therapy is used over displacement of sufferers, patients work with healthcare teams for their care (empowerment and transparency), and patients preserve bodily autonomy.
Help instead of disable, honest punishment enables respect and reform (but remember everyone is a little weird), dignity in direct communication equals respect, allow patients to control what go
es into their bodies (if they're not criminal), like a little food 🥑
If person A and person B sat down and shared a meal and a civil conversation maybe no one would be diagnosed and even if they were, at least they might have a better support network ❤️
