The Trap of Meaning: Title and subTitle BreakA Public Health Tragedy

Adolf Merckle, the German billionaire whose speculation in volatile Volkswagen stock had pushed his sprawling business empire to the edge of ruin, has committed suicide. . . . “No longer being able to handle the situation . . . he ended his life,” the family said.¹

John Updike, the kaleidoscopically gifted writer . . . died. . . . The cause was cancer.²

Two deaths: one by suicide and one by lung cancer. In the photograph accompanying Updike's obituary, a lighted cigarette dangles from his fingertips. Despite the clear causal link between cigarette smoking and lung cancer, the obituary did not suggest that Updike's death was due to smoking. How different is the reporting of Merckle's death. Despite the lack of a direct causal link between stressful life circumstances and suicide, Merckle's death was attributed to stressful life events. Neither Merckle nor Updike was our patient, so their medical histories, life stories, and causes of death are not known to either author. However, these reports of the deaths of 2 prominent public figures illustrate the ways that individuals, including physicians, think differently about the causes of illness and death depending on the type of illness or death.

There seems to be a universal human tendency to adopt meaningful explanations for behaviors and feelings, including suicide or the depression that often precedes suicide. But such adoption is rare in the case of nonpsychiatric illness, such as lung cancer. When explanations are invoked by patients or their physicians to understand, for example, suicide or depression, those explanations have great appeal in that they have face validity and make sense. Nevertheless, these explanations may not provide the true cause of a patient's behavior or symptoms and may, in the case of depression, contribute to multiyear delays in diagnosis and treatment,³ with life-altering consequences including suicide. Because depression is the leading cause of disability worldwide among high-income countries,⁴ this shared human propensity to provide meaningful explanations is a public health problem of tragic proportions. The problem is what is called the trap of meaning—ie, finding an explanation that seems meaningful and adopting it as causal.

Most treatment for psychiatric conditions in the United States occurs in the primary care setting. In this setting, the accuracy and timeliness of detection and treatment of psychiatric illnesses such as depression, although improving, remain remarkably limited. The likelihood that a primary care physician will detect a mental disorder and begin appropriate treatment is influenced by variables such as the symptom severity, sex, and age of the patient.^{5 - 6} Not surprisingly, accurate diagnosis may also be influenced by the patients' own attributions of their symptoms. Specifically, in a study of 197 primary care patients in 5 practices, Greer et al⁶ found that “ . . . patients' specific beliefs about their presenting symptoms strongly predict the likelihood that physicians identify patients as distressed and recommend mental health interventions . . . a more pragmatic and useful approach for practitioners would be to ask patients directly about their experience of psychological distress. . . . ” When a patient presents to his or her physician with meaningful explanations for behavior and feelings, the physician is likely to accept these meaningful explanations as the cause of the patient's behavior and feelings and, consequently, is less likely to initiate appropriate treatment.

Meaningful explanations are best appreciated as the product of cognitive activity whereby individuals provide psychological explanations for their feelings, thoughts, and behavior, as opposed to applying the disease-oriented causal reasoning typical of medicine to explain nonpsychiatric symptoms. This cognitive process is well articulated by Jaspers:

We sink ourselves into the psychic situation and understand genetically by empathy how one psychic event emerges from another. We find by repeated experience that a number of phenomena are regularly linked together and on this basis we explain causally . . . attacked people become angry . . . cheated persons grow suspicious.⁷

Meaningful explanations are psychologically understood and judged for accuracy based primarily on their face validity; ie, the degree to which they make sense. They are also judged using empathy, which allows individuals to appreciate that they have had or could have a similar experience. In addition, they are judged by verisimilitude; ie, the extent to which the explanation seems plausible. In addition, meaningful explanations are judged as being accurate because they are not only understood but are understood immediately. Meaningful explanations are rarely judged by invoking any form of inductive reasoning, the traditional causal reasoning of science and medicine.

The adaptive value of meaningful explanations is self-evident. Assigning meaning to behavior and feelings almost by definition helps make sense of human lives, often by constructing causal stories about what is happening to an individual; these stories help individuals cope with stressors and adapt. Through empathy, they link individuals to other human beings, promoting the development of culture and social interaction. In the absence of meaningful explanations, lives without meaning may emerge, often leading to demoralization, isolation, and despair.

Despite their power and utility, meaningful explanations provide a challenge to physicians because these explanations need be neither accurate nor causal. In a seminal article, Whitehorn pointed out that meaning and cause are not the same:

The perception of an issue in a patient's life . . . is not infrequently misconstrued as if it were the discovery of the cause of the patient's illness . . . haziness of thinking . . . tends to obscure the distinction between ‘meaning’ and ‘cause’ . . . [they] are not mutually contradictory; but neither are they synonymous.⁸

The trap of meaning contributes heavily to delays in psychiatric care, delays far greater than those that occur with medical problems such as diabetes, heart disease, stroke, and cancer. Because individuals seem prone to use meaningful explanations to explain behavior and feelings, the resulting explanations are difficult for both the patient and his or her physician to ignore. Nevertheless, the meaningful explanations that patients give to symptoms are not always correct and thus may obstruct other more causal explanations. For example, depression is now understood as a disease of the brain⁹ that may cause behavior and feelings that depressed persons seek to understand using meaningful explanations such as life events. Patients may live for years with this incorrect understanding of the cause of their illness. They typically remain in this trap of meaning until their symptoms become overwhelming—even life-threatening—or seriously affect functioning, or until others close to them intervene to help them access appropriate care. Not unexpectedly, patients are often surprised when their behavior changes and symptoms remit after proper treatment, while the life circumstances they considered to be the cause of their problems stay the same.

What can be done to avoid reliance on meaningful explanations and thus falling into the trap of meaning? Psychoanalytic theory played a dominant role in American psychiatry for half a century, and uncovering meaningful explanations with causative roles in pathological feelings and behavior is still viewed by many as central to all psychiatric treatment. However, good psychiatric care distinguishes conditions for which meaning is also causal from those for which it is not and links evidence-based treatments to the nature of the disorder.¹⁰ The trap of meaning is a formidable challenge because it feeds off of an adaptive human predilection. But it clearly affects physician behavior, often to the detriment of patients. To overcome the trap of meaning, physicians should be mindful of the use of meaningful explanations and, with every patient presentation, focus on observations of what the patient is authentically experiencing, rather than doing what comes naturally and using psychological interpretations of patient behavior and feelings, both conscious and unconscious.