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  • A Case of Major DepressionSome Philosophical Problems in Everyday Clinical Practice
  • Paul B. Lieberman (bio)

Diagnosis, psychiatric ethics, therapeutic alliance

After the publication of third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM III) in 1980, psychiatry no longer characterized psychological problems as 'reactions,' which seemed to assume unproven psychoanalytically derived explanations, and referred to them instead as 'disorders,' which, it was thought, could be identified phenomenologically and without theoretical 'presuppositions.' Since then, psychiatrists have typically made diagnoses without reflecting on the fact that any categorization, including psychiatric diagnosis, exists within a framework of beliefs and practices and will, therefore, have implications and consequences. The fact of making a diagnosis, the act of doing so, the nature of the diagnosis, and the various ways the diagnosis can be used all have implications and consequences whose importance cannot often be clearly discerned. Such effects are frequently a complex mixture of clinical, conceptual, ethical, and sociological features as Dr. Kayali Browne (Browne, 2017) has suggested. Yet the busy and usually philosophically untrained clinician is poorly situated to address these vexing matters during the routine course of his or her practice.

As the following case tries to illustrate, making even the most common clinical diagnosis, that of major depression, can immediately immerse the clinician in a nest of philosophical problems. Philosophy, like therapy, can be helpful in clarifying and sorting things out, but only after the need for clarification is recognized and appreciated will either treatment begin.

Mr. H was a 54-year-old married man who lived with his third wife and her two children, and worked as a school bus driver. He was referred by his endocrinologist to Dr. S, a psychiatrist, for symptoms of depression.

Mr. H presented reluctantly to Dr. S's office, but then provided a clear history of major depression that had developed over the past year. He noted that nothing gave him pleasure anymore. He had trouble getting up for work, but felt lost and unfocused on the weekends. He rarely slept through the night, was tired most days, picked at his food, and lost weight. Usually outgoing and extroverted, he now turned down most social [End Page 215] invitations and, when he did see friends, they noticed that he seemed 'glum' and had little to say. He was irritable with his family, but anxious when by himself. So unbearable was his mood that he seriously considered buying a gun and shooting himself.

As Mr. H and Dr. S talked, it became clear that these changes had started about a year before, when Mr. H had learned that his wife was having an affair. They had been married for 3 years; it was her second marriage, his third. Mr. H's first two marriages had ended in divorces after both wives had left him for other men. This time had seemed to be different and Mr. H, who had no children of his own and very much wanted a family, was happy to be able to support his new wife (who did not work) and her children. He told Dr. S that he had felt 'less than' since childhood and being able to help and to care for others made him feel worthwhile and important. Now all he felt was overwhelming failure at some moments, impotent rage at others.

Mr. H had type 2 diabetes, which had been well-controlled. But he had begun to worry about his vision; it seemed blurry and unclear. He became concerned that he could no longer drive the school bus safely, recalled a few 'near-miss' accidents and began to take time from work because of anxiety. Like his marriage and being 'head of the household,' driving the bus was very important to Mr. H. The responsibility he felt for the children, his spotless record, and the appreciation of parents and the affection of his small passengers all contributed to a well-deserved sense of pride and the knowledge that he was contributing meaningfully to his community. He could not imagine doing anything else.

But now he had started to feel incompetent as a driver and frightened that he might accidentally harm the...