Mark B. Borg, Jr. PhD
Borg, Jr., M. B. (2010). Human Antidepressants and the Old
Song-and-Dance Routine: Zeroing in on the Life-Course
(and Lack Thereof) of Expectations in Clinical Practice.
P. León and N. Tamez (Eds.) The Psychology of Expectations.
Happague, NY: Nova Science Publishers.
I WISH TO FOLLOW UP ON THE STUDY conducted by myself and Leroy Porter (this volume) with a brief clinical vignette to assess the ways that our conceptualization of expectation combined with an assessment of the influence of cultural factors/dynamics might be utilized to inform clinical practice.
Through much clinical and cultural research (cf. Borg et al., 2009), as well as in my work with analytic patients, I have developed a poignant and provocative hypothesis: For generations our (U.S.) culture has been breeding not just manufacturing antidepressants, Human Antidepressants. The term Human Antidepressant (H.A.D.) denotes a dynamic pattern wherein a person has developed a particular interaction pattern a song-and-dance routine that plays out in all significant relationships, a pattern which essentially enacts a stance toward others (as well as the associated expectations at play within and between self and others) in which it is the person's primary task in life to heal others.
It has been suggested that a child's first job in life is to provide a kind of therapy to his/her primary caregiver usually the mother and that the child's very survival is subjectively experienced as being contingent on how well that job is done (cf. Searles, 1975). The familial/cultural etiology of this process goes beyond the scope of this commentary; though the dynamics of H.A.D. are highly associated with our cultural/political/economic "Liberal Individualistic" (vs. community-oriented) environment, which incessantly though unconsciously pits individual rights against the needs of others. This, therefore, makes this a process where expectations (ones which do not, in our terminology, have a life-course) are also cultural artifacts that are developed mutually/reciprocally, are sustained by behavioral intentions that result in habitual roles/behaviors and concomitant interactions patterns, and then lead to repetitive self-defeating dynamics that affect all significant relationships.
Obviously, children are not diagnosticians; so the distinction that the child will register is simply between happy and not-happy (not-happy becomes a catch-all term for "Depression," but at the earliest stage it also includes anything from mild dysthymia to full-blown Major Depression, anxiety states, mood instabilities, and other inconsistencies in affect). The child registers any state in his/her caregiver other than "Happy" as a danger to his/her very existence. So much the worse for the child who grows up with actual depression in his/her primary caregiver, but the desperate need to ensure that the parent is "well" plays out regardless of the actual emotional state/condition of the caregiver. This, therefore, sets up behavioral intentions that are consistent with the role of H.A.D., and the sustains the co-occurring expectancy values a process thought to precede all behaviors: decisions to act or not act that are the result of an assessment of the likelihood of specific outcomes associated with the act along with the subjective value assigned to those outcomes associated with this role.
The H.A.D. exists between the Scylla and Charybdis. Every victory in the realm of the H.A.D. is a pyrrhic one. One the one hand, if we are victorious (as was Pyrrhus in the Trojan War) and we do "cure" our caregiver, then we go on to live in the expectation/delusion that our role as H.A.D. worked that it is our primary task in life to seek other suffering individuals and offer (or impose) our healing powers upon them. On the other hand, if we fail we lose access to the sense of safety and security that our caregivers might otherwise offer and this becomes a trauma that we then attempt to repair in all future relationships. Actually, both success and failure in the role of the H.A.D. is traumatic in the sense that either victory or defeat results in a sense of isolation and an inability to take in and make use of what others have to offer. Either side of the coin therefore set up behavioral/interaction patterns that leave us inaccessible to others and dissociated from our own feeling states leaving the H.A.D. in a state of righteous indignation and chronic resentment. The underlying trauma is repeated/enacted in future relationships where we (viciously) cycle through our habitual expectations expectations devoid of what we (see our chapter in this volume) refer to as a life-course. The following example from my clinical practice will exemplify what this looks like in adult life.
Dr. L is a 42-year-old psychologist who initiated 3 times/week psychoanalysis with me because he himself was considering applying for psychoanalytic training. He expected that his work with me and his training in the analytic program would help him understand and deal with his growing sense that his clinical practice had "bogged down," that he felt "stuck," and "increasingly resentful" because his patients were not only "not getting better," but seemed to be increasingly dependent upon him while simultaneously disparaging him and his efforts. In fact, he was beginning to believe that his patients were "punishing (him) for trying to help them get well."
The dynamics of H.A.D. began to become clear as Dr. L revealed his own history of inhabiting the role of H.A.D. including in his role as a psychotherapist, and his wish/expectation to enhance his abilities in this role. Dr. L was the kind of H.A.D. who was for a long period of time successful in treating/curing his mother's actual depression. He described his parents as "children of the 60's" quite literally children, as they were both 18 when he was born. His mother came from a well-to-do family and his father was "the boy from across the tracks" (and both he and her premarital pregnancy were a profound provocation/insult to his mother's parents). Both parents grew up in what he described as the "Children are to be seen and not heard" (consistent with the dynamics of H.A. D.) generation. His parents were married and his father soon enlisted in the ARMY, was trained as a helicopter pilot, and flew off for the Vietnam War. During the war his mother found Born-Again Christianity and his father found alcohol, heroine and prostitutes. Jesus notwithstanding, his mother was profoundly depressed. As early as he can recall, he remembers developing "song-and-dance routines" to "make her happy." It worked.
When his father returned (complete with alcoholism and Posttraumatic Stress Disorder), things immediately fell apart. His mother dreamed that she could "fix" her husband, but all of her efforts failed and he left. This set off a process wherein Dr. L increased his H.A.D. efforts becoming a living H.A.D. and maniacally doing his "routine" anywhere and everywhere he could. It often worked; he was the "class clown" throughout all the many years of his education. People liked him and he was popular, but he never felt connected in any significant way to those around him. In this role, his expectations were secure and intractable. He would do his routine and those around him felt better; he could efficiently plan and predict the outcome of his social endeavors. However, there was one glitch: He was unable to establish anything like intimacy with anyone. In fact, it seemed that the closer he became to a person (especially a woman who he had romantic interests in), the more resentful he became. And this was a two-way street. The feedback he received at the termination of a relationship was just about always the same: "I have no value for you."
The example of this par excellence was his (now, ex-) wife. Dr. L met his wife in graduate school and, unlike all of the others, she not only loved his routine, it also seemed to work she got better. She made no claims or demands upon him for her own significance (her own H.A.D. performance); she simply accepted the treatment. It turned out, however, that she had been the victim of a terrible trauma when she was 11 (the same time that Dr. L's routine stopped being effective in the treatment of his mother). Others perceived his wife as "cold and sexless" (in fact, sex with her was a painful duty for Dr. L), but his "routine" worked he could make her smile and laugh (and he experienced the same thrill that an infant might when able to provide joy to/for a primary caregiver, simply expressed as a smile).
The underlying expectation associated with H.A.D. finally became clear to Dr. L when he himself experienced a significant trauma in his own life a couple of years into the marriage. He was in treatment at this time, and we were able to piece together the dynamics and dysfunction associated with his H.A.D. role. When Dr. L turned to his wife for care and empathy to deal with the trauma, she was not there (at first, emotionally; and then, all together). The bottom fell out of his world; she revealed her own "analytic discovery": She was a lesbian. It was at this point that the whole H.A.D. pattern his "successful" but isolating and stultifying "song-and-dance" routines, the chronic isolation, resentment and inaccessibility revealed itself to Dr. L and his analyst. It was there and then that he began the long and arduous process of working through his history of being a living and breathing Human Antidepressant.
It turned out that there was a high back-loaded cost associated with Dr. L's self-perpetuating H.A.D. expectation (and its manifestation in his professional role) that his patients in their resistance to it finally brought home to him. It was as if his patients had a group (transferential) reaction protest to his H.A.D. function/technique and all of its associated expectations (that were then revealed to him, and to us, in his own treatment). Dr. L's own countertransference reaction to this was to feel insulted, injured, and resentful, as well as ineffective and lonely. Through his analysis, however, he was able to excavate the most primary expectation that undergirded his H.A.D. song-and-dance routine (that was implemented against his mother, his wife, and his patients): "You will get well and get out and take your madness with you!" His H.A.D. routine (and its implicit expectation/message) worked against his mother (when he was 11 she met and married a man and he took over as her H.A.D.), and against his wife (through her own analysis she discovered her repressed homosexuality); but irony of all irony (considering being a therapist seemed to him to be a legitimate stage to perform his routine) it totally back-fired against him in his own clinical practice. However, it turned out that this back-firing ultimately allowed Dr, L to confront the defensive and futile nature of his H.A.D. role/technique (especially in his clinical work) and to reengage more realistic expectations for himself in the context of his work and his personal life and, at that point, Dr. L's expectations reinitiated a life-course that had been long derailed. He could finally experience the fact that the expectation underlying his H.A.D. role was a dead one that merely repeated his earlier trauma of having been left with a severely depressed mother who, while she did respond to his song-and-dance routine, did so at the price of leaving him alone and disconnected from his own needs and desires caught up in a repetitive cycle that would only distance himself further and further from himself and from others.
Dr. L's chronic and habitual expectations (caught up in the H.A.D. dynamics) were devoid of a life-course. These expectations, however, allowed him to have a standard set of operating procedures that made the world appear to be predictable and under his own control. Yet it turned out that he had to reclaim his own previously dissociated experience (the traumata that sustained his H.A.D. pattern) in order for his expectations to develop a life-course. Expectations that have their own life-courses require a tolerance for a certain level of anxiety that is part and parcel of any movement that we make that brings us into new and novel experience. Also involved is evidence that when the behavioral intentions associated with expectations become disconnected from the implementation intentions that sustain them ("I will be well when you are well" became "you will be well and leave me alone"), expectations are doomed to repeat old patterns and derail the process long before goal attainment is achieved (he had lost all sense of being or getting "well" himself, and was solely focused on the "wellness" of others). However, having survived and worked through the chronic despair and trauma that he experienced during the death of chronic/habitual expectations (underlying his H.A.D. role/defense), Dr, L was able to engage in reciprocal relationships with others (including his analyst), to understand realistically what he could expect from and offer to his patients, to allow others to contribute to him and his well-being, and to end his forlorn sense of isolation.
Borg, M. B., Jr., Garrod, E., Dalla, M. R. & McCarroll, J. (2009). Can psychoanalysis exist outside the consulting room? In B., Willock, R., Curtis, & L. Bohm (Eds.) Taboo or not taboo: Forbidden thoughts, forbidden acts in psychoanalysis (180195). Madison, CT: International Universities Press.
Searles, H. (1975). The patient as therapist to his analyst. In P. Giovacchini (Ed.) Tactics and techniques in psychoanalytic therapy, volume II: Countertransference (pp. 95151). New York: Jason Aronson.