Pursuit of Happiness - August 23, 2007

One of the benefits of being a psychologist is the somewhat unique opportunity to see all walks of life on an hour-to-hour basis. I grew up in a fairly homogenized area of central New Jersey (I spent every day with the cast of The Sopranos) and it wasn't until I began graduate training that I began to experience the many variations of the human race.

One particular aspect of diversity that always fascinated me is what people do for pleasure. There seems to be no end to what people do for fun. Normally, this would be a fairly obvious and mostly uninteresting observation. But for a therapist, it is of particular importance. One of, if not the most, common diagnoses seen in mental health is Major Depressive Disorder. Considered by many to be the "common cold" of psychological difficulties, some studies report that 25% of the population will suffer from this condition at least once in his/her lifetime. One of the hallmark symptoms of depression is anhedonia, an inability to experience pleasure. During an initial visit, the astute therapist asks about anhedonia and inquires about what the patient formerly found pleasurable before the depression set in. This information can serve as a rough measure of therapeutic progress: as the patient begins to enjoy what he or she used to find fun, the therapist knows that the treatment is showing efficacy.

I started graduate school in 1996, so in 10 + years I've heard some common and not-so-common pleasures:

drinking
smoking
doing drugs
spending time with family
chewing gum
having sex in dumpsters
reading African-American erotica
looking at people's feet (in a non-sexual way)
looking at people's feet (in a sexual way)
eXtreme knitting
using a ex-lover's credit card number for major purchases
reading "The Secret" over and over
buying lozenges

And so on. Needless to say, when a client begins to re-experience joy by dint of buying lozenges, it is a truly satisfying moment for me.

When clients are stuck and are unable to experience pleasure despite talk therapy, many therapists will employ behavioral measures to pull the client up from the depression. One technique is informally known as "As If." In Alcoholics Anonymous, it is often referred to as "Fake it 'til you Make It." This approach is based on the concept that when one acts in a certain manner, one begins to feel the corresponding emotion. As an example, for a male client with social anxiety, a therapist might have him describe how an interpersonally confident client would behave. Many clients will report actions such as maintaining good eye contact, initiating conversations, smiling, asking questions, etc. Between sessions, the client would be asked to act just like that, even if he is screaming with anxiety inside. Over time, the client begins to feel more confident simply through action.

To highlight the acting "As If" approach, consider my work with Mark, a 48 year- old man who struggled with depression. He took medication, and came to therapy weekly. Over the first 10 weeks, he made good progress (e.g., his sleep pattern returned to normal, his concentration improved, and he reported an overall increase in mood). He has, however, an unusual activity that he enjoys, and was not finding pleasure in it. Mark has a shoe fetish, and despite his therapeutic gains in other areas, he is simply not enjoying the shoe as much as he used to.

Many automatically (and erroneously) assume that a fetish is a psychological disorder. It can be, because of its deviation from what society considers "normal." However, part of the criteria for any psychological condition is "impairment," to either oneself or others. In other words, for something to meet the criteria for a former disorder, it has to cause problems in daily living. In Mark's case, his fetish doesn't interfere with his job, social life or overall happiness. He and his wife use shoes in the bedroom for sexual satisfaction, and he never even considers approaching another woman to engage her in any sort of shoe fantasy. He simply admires their shoes the way another heterosexual man might notice their cleavage. In other words, don't judge the man.

Mark and I sat in session, with his favorite shoe. I walk him through the "As If" approach:

Dr. Dobrenski: Do you what you used to do, what used to be fun. Hold the shoe, caress it, admire it, love it.

Mark (does so): Something doesn't feel right.

Dr. Dobrenski: What's going through your mind as you are one with the shoe?

Mark: That I'm a freak.

Dr. Dobrenski: Define for me a "freak."

Mark: A loser, a weirdo.

Dr. Dobrenski: Well, if I were telling myself that I was a freak, I'd probably not be very happy either. Just because you get turned on shoes you're a loser?

Mark: Yes. Well, no. I guess not.

Dr. Dobrenski: You don't sound convinced.

Mark: I'm not sure I am.

Dr. Dobrenski: Let's switch. I'm you, you're me.

I take the shoe and start to admire it. It's one of those faux-Prada slip on things. Pink and ugly but I imagine the ladies love it.

Dr. Dobrenski: I'm into the shoe now. It's sexy. I'm telling myself "this is fun, this brings me pleasure. My wife wears these and it turns me on." Mark, how do I look?

Mark: You look like some tool holding a woman's shoe.

Dr. Dobrenski: No, how do you think I feel holding the shoe.

Mark: You look happy. A little weird, but happy.

Dr. Dobrenski: Right, I'm happy. So what if I'm a little weird, I'm not hurting myself or anyone else.

Mark: Give me the shoe back.

Dr. Dobrenski: Why?

Mark: Just give it back.

Is this a therapeutic opening?

Dr. Dobrenski: Hmmm...no.

Mark: Give it back!

Dr. Dobrenski: Why should I? I'm enjoying it.

Mark: Because it's mine and I want to hold it.

Dr. Dobrenski: I'm not finished yet.

Mark (getting up and yanking the shoe away): Yes you are!

Dr. Dobrenski (smiling): Mark, how do you feel?

Mark: A little embarrassed that I'm jealous.

Dr. Dobrenski: That's okay. In fact, it's more than okay. It's your shoe, and I got the sense that you could see the pleasure it used to bring you.

Mark: I did. I feel better. What if it doesn't last though?

Dr. Dobrenski: To be honest, it probably won't last. You'll have to practice. You'll have to continue to be with the shoe, to challenge yourself when you berate yourself for having an unusual pleasure, and to act "As If," that you're enjoying yourself, even if it feels mechanical for awhile. Remember, change your behaviors and your emotions will follow.

Mark: Tell me, honestly: did you enjoy the shoe?

Dr. Dobrenski: We're out of time, so I'm going to give you the short answer: no.

Over the next few weeks, the As If approach began to stick, and his ability to experience pleasure returned. He tapered off of his medication, and his treatment was considered a success by both of us. And for those who still think Mark is a freak for his shoe fetish, consider: he and his wife (and her shoes) still have an amazing sex life after 25 years of marriage. How many couples can say that?

Posted by Rob Dobrenski at 1:37 PM

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Comments

Great posting!

Posted by: john at August 23, 2007 03:22 PM

Always good to see something go right, especially in your field of work. Especially when it has something to do with depression.

Posted by: Jason at August 24, 2007 02:21 AM

this isn't so much a comment as a suggestion, but perhaps you should have an "ask a question" section where week by week you answer a question regarding psychological issues and whatnot, im sure even a slight amount of insight into certain issues could be beneficial to those who are not willing to seek professional help, or who have friends who they would like to help.

Posted by: Pete at August 24, 2007 12:48 PM

I'm sure the last thing a shrink wants to do is invite a load of questions onto himself through a website that is suppose to be an escape for him and provide others with humor. Not saying I wouldn't enjoy picking his brain, but I enjoy how light this blog is while still having its focus on very serious conditions.

Posted by: Charles at August 24, 2007 03:08 PM

Very good.

Posted by: Wayland at August 24, 2007 05:12 PM

My new favorite RM site! I really hope you can keep updating once a week! *mutters curses in philalawyer's direction*

Posted by: Napsterbater at August 24, 2007 10:55 PM

i did have a giggle at the "give me the shoe back" exchange. but it's so cool that you can help people regain their interest in shoes, or knitting, or whatever. i wish i could do that.

Posted by: missmephy at August 25, 2007 08:00 PM

I used to think psychiatrists were like witch doctors. This site makes me appreciate what you and others in your profession practice1

Posted by: Dave at August 31, 2007 02:41 AM

Whoa. Extremely entertaining entry, thumbs up for the writing. But the 'as if' thing struck me as rather questionable - don't get me wrong, I'm of course no therapist (more likely in search of one) and wouln't judge a professional's methods, but it still feels kinda wrong.
You see, someone very close to me (who is still suffering of episodes of light depression during winter), used to have, before I knew him, some serious psychological problems. The inability to genuinely feel any positive emotion was also part of the problem, but by playing along society's expactions and training to act as how he was supposed to in certain situations he could hide it for years, until he finally went into therapy (upon someones advice, who realized what was up I believe). So in this context, it just made everything worse - even if I see, that under the direction of a therapist it's a whole differen thing, it just feels somewhat suspicious to me.

Eva

Posted by: Eva at October 24, 2007 02:06 PM

man,I need some of those shoes now.

Posted by: :yb detsoP at December 19, 2007 05:19 PM