Curtis walks into the office and plops into the couch, letting the worn leather take him in. This forty-eight year old man has done well professionally, with a successful law practice and some political ambitions. But, under the surface, he's in turmoil.
As his psychiatrist, I watch and listen for something…some pain…some connection…a story.
…Instead, I hear a deep sigh.
Curtis looks away and I realize that we have been here before.
No one can help him. Or, so he thinks….
Curtis has a history of depression that has responded, if only partially, to anti-depressant medications. Some days he’s in a completely normal mood, and some days it’s like this. Complicating the story is a history of binge drinking, serial marriages and risky real estate ventures.
He tells me that he's felt “empty” since grade school.
Classic depression tends to present with a consistent down experience. While you can argue that Curtis is self-medicating a longstanding depression, something else is going on.
Some might label Curtis an Addict or someone with serious attachment issues. While you can make a case for many diagnostic approaches to this man, it often strikes me how some people lack the capacity to enjoy life’s simple pleasures, while for others, everyday life is endlessly fascinating.
Grace is a twenty-six year old woman who feels empty much of the time, but not when she's shopping and spending money she doesn't have. And then there are her boyfriends. It's a classic pattern of excitement, hurt and abandonment. There's a compulsive quality to how Grace somehow finds these disrespectul men, almost like a non-stop merry-go-round of drama. Yet, under the drama is a depressed person. Without incessant shopping, overspending and relationship issues, life seems drab to this young woman.
When in the room with men and women like Curtis and Grace, I often wonder what’s happened to their basic ability to find happiness in everyday things; a sunrise, the smile of a baby, the ripple of water on a lake, the brilliant white of newly fallen snow, the pleasure of a job well done at work.
Anhedonia is a condition in which a person lacks the capacity to experience pleasure. Yet, both Curtis and Grace can experience pleasure; it’s the dosing that’s the problem.
I would argue that a certain kind of thrill can be found in everyday life. And, people like Grace or Curtis have either lost their capacity to be enthralled by the moment, or have never truly learned the pleasure of the here and now.
High Stimulus Pleasure:
As you may imagine, Grace is not the first person I’ve treated with whose life drama overshadows real emptiness. (The bills are also piling up.) What gets Curtis going? Binge drinking does the job, as well as sex with attractive new women (he bores easily) and risky real estate ventures with unrealiable characters. Curtis has been married or engaged four times; it doesn't stick.
It’s as if the only way that Curtis and Grace can feel alive is with a powerful charge of excitement.
Addicts often suffer from this conundrum. They long for their drug, be it cocaine, shopping, sex, gambling or booze. And, they feel an enduring emptiness without their fix. They are intolerant of boredom, of quiet moments.
A Pallet for Pleasure:
The truth is that life is filled with opportunities to be entertained and delighted.
Each season has its own colors, smells, textures and lighting. For those of us who have a pallet for enjoying life, there are great pleasures available every day, with very little effort. They can be found in literature, in music, in our everyday relationships and in nature.
Some people can be endlessly entertained all on their lonesome.
After decades of practicing psychiatry, I am still saddened by this kind of patient.
Sometimes the primary diagnosis is depression, sometimes an addiction, sometimes it’s a story of trauma, and sometimes a chronic medical disorder like unremitting bowel disease or headaches. I ask myself…and them…about their capacity to find pleasure.
Most of these patients have suffered from psychological pain for years. And, without doubt, pain of any kind will wear a person down, and make him or her self-preoccupied.
Try slamming your toe, and then pay attention to anything other than the pain. It’s hard to do.
So, it’s a chicken and egg problem. We can’t really know if the incapacity to enjoy the small pleasures in this world is a child development issue that predisposes to developing addictions or depression. Or, did the mood problem, abuse history or addiction disorder steal away the patient’s love of the small moment? I ask this question often. And often hear both points of view. In fact, if the patient has lost the capacity for pleasure, I’ll feel a bit more optimistic.
What was once there can be regained - while something that was never there has to be learned from scratch.
Capacity for Pleasure:
With these patients I’ll monitor their capacity for pleasure, almost as a marker of health. For some, it’s a new angle to appreciate what they’re going through. For others, a small sense of curiosity may be sparked. I have had patients consider visiting museums, hike in the mountains, accompany a child on a field trip, go to a gym or yoga class, participate in a weekend workshop or take a ball room dancing class.
Sometimes, a trip to the zoo is an interesting assignment.
This may sound too directive to many. But, in my opinion, a patient’s weak capacity to enjoy life’s small pleasures leads inevitably to the necessity to feel something at any cost. And, these field trips are useful in therapy. The patient reports back what they experienced and sometimes has an uptick in their overall mood.
And, if the experience is just another burden, we may have to double down on the treatment for depression, or make sure they attend their 12 step program, because they are at risk. Life offers many hardships to us all. If we can’t enjoy the things that are in front of us, then something deeply sustaining is not available to such suffering souls. This is a good marker of more work that needs to be done.
Next week I may introduce Grace or Curtis to Mindfulness Meditation. We will see if the landscape of the inner mind is of interest to these restless souls. John Kabat-Zinn gave us a wonderful gift with his mindful approach to living. We will see if Grace or Curtis can widen some appreciation for each moment, at least in the office.
The good news is that they're game for trying something new.
Small Pleasures Count:
Addressing a patient’s capacity for pleasure is often part of a good psychiatric assessment.
Why? Because, without the ability to enjoy small things, a patients like these are compelled to the danger of high stimulus pleasures and the destruction they may bring.
For now, Curtis cannot stay in a commited relationship because it gets old. And, Grace loses interest in her many purchases moments after they're completed. But an attractive new woman, or a pretty (and expensive) new dress? They are always of interest. It's a way to feel alive.
I think you get the point. Curtis and Grace do as well.
When they begin to enjoy the small pleasures, it’ll be a good sign, like the budding of crocuses and daffodils in the early spring.
Take a small inventory. Do you enjoy the world as you would like? Or do you need to spend a lot of money or do radical things just to feel okay? Trust me; the real pleasures of this life happen every day and right in front of us. Can you take some of them in?
Here’s to the blessing of everyday ecstasy.
For more from Dr. Banschick:
The Intelligent Divorce - Taking Care of Your Children
The Intelligent Divorce - Taking Care of Yourself
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