When I was training as a psychotherapist, my supervisor (an M.D. psychoanalyst) told me an interesting tale: Researchers had a group of psychoanalysts and psychiatrists review histories and perform diagnostic interviews for every member of the first-year class at a famous medical school. They rendered a diagnosis, where appropriate, and noted the prognosis. Researchers followed these students for 15 or 20 years, to see how accurate the evaluations had been. The result? Guess!
The prognoses were uniformly pessimistic. The students were better adjusted than expected, both as a group (meaning, the percentage of correct diagnoses and prognoses was lower than assessed) but also individually (meaning, severity of dysfunction was generally lower). In other words, both the group and the individual people turned out better than expected, over all.
Fans of a certain sort of critique of mental health may scoff at the whole enterprise, perhaps with some reason. I, too, have read Szasz, and, to a considerable extent, I think he’s onto something important about mental health as a cultural practice. But notice that the prognoses in our moral tale were operating on their own terms. In other words, the relative success of the assessments were judged by the same criteria as the original diagnoses: Were these students “clinical” or not? Apparently, not as often as they looked.
The psychoanalysts and psychiatrists who evaluated the students were among the best in their field, so there was no lack of clinical acumen or expertise. The students were — students: They were clearly smart and motivated, and they had quirks, aspirations, inclinations toward self-cultivation strangely mixed with self-destructive impulses. In a word, they were people.
So, what happened? Where did the pessimism come from?
There are many ways to respond to this question, but I want to highlight one particularly important lesson. What did all these psychoanalysts and psychiatrists have in common? They were all disposed to look for dysfunction. For a start, that’s how they make a living — but it’s more than that. It was a finely-honed sensitivity to what goes wrong in living human lives, a sensitivity driven by at least some desire to help make those lives better.
This is a peculiar irony: the desire to improve lives is surely praiseworthy — and much needed — but the downside of sensitivity to what goes wrong is that it focuses one’s attention on what goes wrong. And that leads us to consider the role of expectations in therapy and teaching (and in living human lives).
Here’s yet another thought experiment. Picture the first day of a new class, and the professor says to the students: “Most of you are not developmentally or intellectually or emotionally ready to take this class, and therefore, most of you will not succeed.”
Are you appalled? Why? Might it not be that the professor’s assessment is reasonable? Let’s assume no malice: the professor is merely issuing fair warning. Some of you will probably find this plausible, and others might respond, “How can a professor know in advance what these particular individual students are or are not capable of?” Remember: the prognosis is always up front.
Now suppose we factor in student expectations: Suppose a student is not confident; suppose his or her self-talk is negative, even self-defeating. How will that student’s inner narrative interact with the professor’s “fair warning”? Fundamentally, the question I want to raise is this: Can a student make a fair and accurate assessment of her “prognosis” in this situation?
Now consider this alternative scenario: Same day, same professor, same students. The prof welcomes the students and proceeds to explain the syllabus — but the syllabus, course design, assignments, approach to grading — in short, everything about teaching that course — is suffused with this assessment: “Most of these students are not developmentally or intellectually or emotionally ready to take this class, and therefore, most of them will not succeed.”
In the first scenario, the professor has affirmed and announced a failure program: Most of you aren’t going to make it. But what about the second? The expectations are no different, just the packaging.
Now, before you rush to object that we can surely have negative expectations that turn out to be true, let me say this: You are absolutely right. Sometimes, when we see clinical depression, it’s because we’re interacting with people who are clinically depressed.
On the other hand, expectations have power, and they inform our interactions in ways that are both visible and invisible. It’s as if, in every interaction, there are two dialogues at once: One one the surface, composed of words and gestures, and one hidden, expectations wrestling each other for power.
This, incidentally, is precisely why we like double-blind studies in empirical science. The tricky thing about expectations is that they can distort the judgment even of experts, and expert expectations are the quickest way to distort the judgment of recipients.
Teaching (and therapy) are vocations literally constituted by a very large pile of small interactions on a path toward a goal, steeped in expectations. (In fact, tending as I do to Heraclitus, I’m tempted to say that people become students by being “studented” by someone with the right powers and expectations. But I’ll leave that conversation for another day.)
