Let's say Mr. Jones, a 75-year-old retired teacher with no personal or
family history of depression, comes to you with a classic picture of major
depressive disorder. He tells you that his wife of 50 years died two months
ago. Since then, he has experienced profound depression, a 15-pound weight
loss, early-morning awakening, and inability to
Shouldn't "common sense" tell you that Mr. Jones' depression
was "triggered" by his wife's death and that it simply represents
a "normal" and "proportionate" response to grievous
loss? This, at any rate, is the core of a popular and superficially plausible
thesis advanced by Professors Jerome Wake-field and Alan Horwitz.
But as Brandeis University biochemist Douglas Theobald, Ph.D., has
observed, "common sense" tells us that the Earth is flat, the sun
truly rises and sets, and the Earth is not spinning at more than 1,000 miles
per hour. Medical science is not founded on "common sense," but on
uncommon investigation: on randomized, controlled studies that try to rule out
as many confounding variables as possible.
Psychiatric medicine, too, relies less on common sense than on what the
French call sense clinique—that ineffable blend of knowledge,
experience, and hard-won wisdom that comes from seeing hundreds of patients
over the course of one's career. Your sense clinique is what leads
you to respect Mr. Jones' narrative of bereavement, while also contemplating a
medical workup to rule out a covert malignancy as another possible trigger for
Your clinical sense also tells you that myriad other biopsychosocial
factors may be causally related to Mr. Jones' depressive symptoms. Making an
early calculation that his depression is, or is not, proportionate to any one
putative trigger represents clinical naivete and premature closure.
You may discover several months into psychotherapy that Mr. Jones was not
grieving the death of his wife so much as castigating himself for an
extramarital affair he had 20 years earlier. Similarly, in severely anxious or
traumatized patients, facts may emerge that cast serious doubt on what the
psychiatrist first assumed was the precipitant of the patient's acute
It is the psychiatrist's job to maintain respectful and open-minded
neutrality regarding the cause or causes of a patient's acute disturbance. As
Otto Kernberg has pointed out, therapeutic neutrality is not disgruntled
indifference to the patient's felt experience; rather, it refers to the
therapist's position of "equidistance" from the powerful emotional
forces clashing within the patient.
By analogy, diagnostic neutrality means maintaining a position of
equidistance from the biological, psychological, social, and spiritual forces
impinging on the patient. Diagnostic neutrality is akin to keeping a sailboat
steady in the swirl of shifting cross-winds. Such neutrality is especially
important early in the clinical encounter.
As more information emerges in the context of evaluation and treatment, the
psychiatrist's sense clinique begins to winnow less likely causal
factors in the patient's condition. Often, we never discover the ultimate
cause, or trigger, of the patient's acute anxiety, depression, or psychosis.
But with or without obvious cause, some forms of intense suffering and
incapacity represent disease or disorder.
Furthermore, the possibility that bereavement-related major depressive
symptoms might remit in a few weeks should not deter us from diagnosing a
major depressive disorder, when full criteria for that disorder are
met—nor should we be reluctant to provide professional care in such
The inherent problem in positing a depressive trigger is that we humans are
famous for constructing explanatory narratives, even when the facts of the
situation are not clear. Indeed, in her book, Narrative Gravity,
linguistics professor Rukmini Nair argues that human beings have a genetic
drive to fabricate narratives that serve our emotional needs. Furthermore, Dr.
A.M. Ergis and colleagues have demonstrated that memory in depressed patients
shows a "recall bias" toward recollection of negatively toned
But if the foundational notion of a depressive trigger itself is dubious,
then any calculation regarding the "proportionality" of the
patient's supposed response is necessarily doubtful. Making such calculations
is like trying to measure floor boards while standing atop a scaffold of
This certainly doesn't mean we should dismiss what our patients tell us
when they try to explain "why" they are depressed or anxious. It
does mean that we must use our sense clinique in weighing such
reports as a part of all the available data. Finally, we should base our
judgments regarding disordered mood on observations of the patient's degree
and duration of suffering and incapacity—not on calculations of"
proportionality" derived from facile causal narratives.▪