Chapter 35 Would You Rather?

Julie is cataloging her body parts, deciding which ones to keep.

"Colon? Uterus?" she asks, her eyebrows raised as if telling a joke. "And you're not going to believe this one. Vagina. So basically it comes down to, do I want to be able to shit, have babies, or fuck."

I feel a knot form in my throat. Julie looks different from the way she had at Trader Joe's a few months back, or even from what she'd looked like a few weeks ago, when the doctors said that in order to keep her alive, they'd need to take more of her away. She'd soldiered through the first bout of cancer and the recurrence and the death sentence that ended up with a stay of execution and the pregnancy that gave her hope. But after too many just kiddings, she's done with the cosmic jokes, worn down by it all. Her skin looks thin and lined, her eyes bloodshot. Now sometimes we cry together, and she hugs me when she leaves.

Nobody at Trader Joe's knows that she's sick, and for as long as she can, she wants to keep it that way. She wants them to know her first as a person, not as a cancer patient, which sounds a lot like how we therapists think about our patients: We want to get to know them before we get to know their problems.

"It's like those ‘would you rather' games we played at slumber parties as kids," she says today. "Would you rather die in an airplane crash or a fire? Would you rather be blind or deaf? Would you rather smell bad for the rest of your life or smell bad things for the rest of your life? One time when it was my turn to answer, I said, ‘Neither.' And everyone said, ‘No, you have to choose one,' and I said, ‘Well, I choose neither.' And that kind of blew people's minds, just the concept that when presented with two awful alternatives, maybe neither was an option."

In her high-school yearbook, under her name, they'd written I choose neither.

She'd used this logic in her grown-up life too. When she'd been asked if she'd rather have a prestigious grad-school opportunity with minimal funding or a fully funded position that was far less interesting, everyone had an opinion about which one she should take. But against all advice, she chose neither. It served her well; soon after, she got an even better grad-school offer in a better location in the same city as her sister, and she'd met her husband there.

Once she got sick, though, neither became less of an option: Would you rather have no breasts but live or keep your breasts and die? She chose life. There were many decisions like this, where the answers were difficult yet obvious, and each time, Julie took them in stride. But now, with this particular would-you-rather, this body-part roulette, she didn't know how to choose. She was, after all, still getting over the shock of her recent miscarriage.

Her pregnancy had lasted eight weeks, during which time her younger sister, Nikki, had become pregnant with her second child. Not wanting to announce their news until the end of their first trimesters, the sisters kept each other's secrets, giddily marking the days on a shared online calendar that labeled their progression for twelve weeks. Julie's hash marks were in blue because she guessed she was carrying a boy; she'd nicknamed him BB, for Beautiful Boy. Nikki's were in yellow (nickname: Baby Y), the color she planned to paint the baby's nursery; as with her first pregnancy, she wanted the gender to be a surprise.

At the end of Julie's eighth week, the bleeding started. Her sister was just beginning week six. As Julie was on her way to the ER, a text popped up from Nikki. It was an ultrasound photo with the caption Hey, look, I have a heartbeat! How's my cousin BB? XO, Baby Y.

Baby Y's cousin wasn't doing so well. Baby Y's cousin was no longer viable.

But at least I don't have cancer, Julie thought as she left the hospital she knew so well by then. This time, she'd been there for a "normal" problem for people her age. Lots of people miscarried in those early weeks, her obstetrician explained. Julie's body had been through a lot.

"It's just one of those things," her doctor had said.

And for the first time in her life, Julie, who had always lived in the land of rational explanations, was content with this answer. After all, every time the doctors had a reason for something, the reason was devastating. Fate, bad luck, probability—any of those seemed like a welcome respite from a dismal diagnosis. Now when her computer crashed or a pipe burst in the kitchen, she'd say, It's just one of those things.

The phrase made her smile. It could work both ways, she decided. How many times do good things inexplicably come our way too? Just the other day, she told me, some random person walked into Trader Joe's with a homeless woman who'd been sitting in the parking lot and said to Julie, "See that woman over there? I told her to buy herself some food. When she gets to the register, come find me and I'll pay the bill." Relating the story to Matt after work, Julie shook her head and said, It was just one of those things.

And, in fact, on her next try, Julie got pregnant again. Baby Y was going to have a younger cousin this time. It was just one of those things.

So as not to jinx it, Julie didn't nickname the baby. She sang to it and talked to it and carried around her secret like a diamond that nobody could see. The only people who held the secret with her were Julie's husband, her sister, and me. Even her mother didn't know yet. ("She has trouble keeping good news to herself," Julie said, laughing.) So it was me to whom she reported her progress, me to whom she described the heart-shaped balloon that Matt had brought to their first-heartbeat ultrasound appointment, and me whom she called when, a week later, she miscarried again and tests revealed that Julie's uterus was "inhospitable" due to a fibroid she would need to have removed. Again, a welcome problem because it was so common—and fixable.

"But at least I don't have cancer," Julie said. That had been her and Matt's other refrain. No matter what happened—all the daily annoyances big and small that people tended to complain about—as long as Julie didn't have cancer, all was right with the world. Julie just needed a minor surgery to get rid of the fibroid, and then she could try to get pregnant again.

"Another surgery?" Matt had said.

He worried that Julie's body had gone through enough. Maybe, he suggested, they should adopt or use a surrogate to carry the baby with the embryos they'd frozen. Matt was just as risk-averse as Julie—this had been a point of commonality when they met. With all of her miscarriages, wasn't that a safer idea? Besides, if they went the surrogate route, they had the perfect person in mind.

On the way to the ER during her recent miscarriage, Julie had called Emma, a coworker at Trader Joe's, to see if she could cover Julie's shift. Unbeknownst to Julie, Emma had just signed up with a surrogate agency so that she could pay for college. Emma was a twenty-nine-year-old married mom who wanted to get a college degree, and she loved the idea of giving a family their dream as a way to make her own educational dreams come true. When Julie confided in Emma about her uterus problem, Emma instantly offered her services. Earlier, Julie had encouraged her to go back to school, even helping her with college applications. She and Emma had worked side by side for months and it never occurred to Julie that Emma might one day be pregnant with her child. But if her question in life had always been Why?, this time she asked herself, Why not?

So Julie and Matt came up with a new plan, as they'd had to do so many times since the beginning of their marriage. She would get her fibroid removed and attempt one more pregnancy. If that didn't work out, they'd ask Emma to carry their baby. And if that didn't work out, they'd try to become parents through adoption.

"At least I don't have cancer," Julie had said in my office after she finished explaining the baby setback and the plan forward. Except that while preparing for her fibroid removal, Julie's doctors discovered the fibroid wasn't the only issue. Her cancer was back, and spreading. There was nothing they could do. No more miracle drugs. If she wanted, they would do what they could to prolong her life as long as possible, but she would have to give up a lot along the way.

She was going to have to figure out what she could live with—and without—and for how long.

When the doctors first presented this news, Julie and Matt, sitting side by side in vinyl chairs in a doctor's office, burst out laughing. They laughed at the earnest gynecologist, and then the next day they laughed at the solemn oncologist. By the end of the week, they had laughed at the gastroenterologist, the urologist, and the two surgeons they consulted for second opinions.

Even before they saw the doctors, they were giggling. Whenever the nurses, escorting them to an examination room, asked rhetorically, "How are you two today?" Julie would reply nonchalantly, "Well, I'm dying. And how are you?" The nurses never knew what to say.

She and Matt found this hilarious.

They laughed, too, when presented with the possibility of removing body parts where the cancer might grow most aggressively.

"We have no use for a uterus now," Matt said casually while sitting with Julie in one doctor's office. "Personally, I'd vote for keeping the vagina and losing the colon, but I'll leave the colon and vagina up to her."

"‘I'll leave the colon and vagina up to her'!" Julie guffawed. "He's so sweet, isn't he?"

At another appointment, Julie said, "I don't know, Doc. What's the point of keeping my vagina if we remove my colon and I've got a bag of poop attached to my body? Not exactly an aphrodisiac." Matt and Julie laughed then too.

The surgeon explained that he could create a vagina out of other tissue, and Julie burst out laughing again. "A custom vagina!" she said to Matt. "How about that?"

They laughed and laughed and laughed.

And then they cried. They cried as hard as they'd laughed.

When Julie told me this, I remembered how I had burst out laughing when Boyfriend said he didn't want to live with a kid under his roof for another ten years. I remembered the patient who laughed hysterically when her beloved mother died, and another who laughed when he learned that his wife had multiple sclerosis. And then I remembered sobbing in Wendell's office for entire sessions, the way my patients had and the way Julie had for the past few weeks.

This was grief: You laugh. You cry. Repeat.

"I'm leaning toward keeping my vagina but dumping the colon," Julie says today, shrugging, as if we're having a normal conversation. "I mean, I just got fake breasts. With a fake vagina, there won't be much difference between me and a Barbie doll."

She's been figuring out how much has to be taken away before she's no longer herself. What constitutes life even if you're alive? I think about how people barely talk about this with their elderly parents, all the would-you-rathers that they'd rather not contemplate. Besides, it's all a thought experiment until you're there. What are your deal-breakers? When your mobility goes? When your mind does? How much mobility? How much cognition? Will it still be a deal-breaker when it actually happens?

Here were Julie's deal-breakers: She'd rather die if she could no longer eat regular food or if the cancer spread to her brain and she couldn't form coherent thoughts. She used to believe that she'd rather die if she had poop traveling through a hole in her abdomen, but now, she just worries about the colostomy bag.

"Matt's going to be repulsed by this, isn't he?"

The first time I saw a colostomy in medical school, I was surprised by how unobtrusive it was. There's even a line of fashionable bag covers adorned with flowers, butterflies, peace signs, hearts, jewels. A lingerie designer dubbed them "Victoria's Other Secret."

"Have you asked him?" I say.

"Yes, but he's afraid of hurting my feelings. I want to know. Do you think he'll find it repulsive?"

"I don't think he'll find it repulsive," I say, realizing that I'm being careful with her feelings too. "But he may have to get used to it."

"He's had to get used to a lot," she says.

She tells me about a fight they had a few nights ago. Matt was watching a show, but Julie wanted to talk. Matt was uh-huh-ing her, pretending to listen, and Julie got upset. Look what I found on the internet, maybe we can ask the doctors, she said, and Matt said, Not tonight, I'll look tomorrow, and Julie said, But this is important and we don't have a lot of time, and Matt looked at her with an anger she'd never seen in him before.

"Can't we have one night off from cancer?" Matt yelled. It was the first time he had been anything but kind and supportive, and Julie, taken aback, snapped at him. "I don't get a night off!" she said. "Do you know what I'd give for a night off from cancer?" She fled to the bedroom and closed the door, and a minute later, Matt followed, apologizing for his outburst. I'm stressed, he said. This is very stressful for me. But not as stressful as what you're going through, so I'm sorry. I was insensitive. Show me the thing on the internet. But his words shook her. She knew that it wasn't just her quality of life that was changing. Matt's was, too. And she hadn't been paying attention to that.

"I didn't tell him about the thing on the internet," Julie says. "I felt so selfish. He should get a night off from cancer. This isn't what he signed up for when he married me either."

I give her a look.

"Well, sure, the vows say ‘in sickness and health' and ‘for better or worse' and all that, but that's kind of like clicking okay to the terms and conditions when you download an app or sign up for a credit card. You don't think any of that is going to apply to you. Or if you do, you don't expect it to happen right after your honeymoon, before you've even had a chance to be married."

I'm glad that Julie is thinking about the impact of her cancer on Matt. It's something she's avoided talking about by changing the subject whenever I mentioned that maybe it was hard for Matt to go through this too.

Julie would shake her head. "Yeah, he's amazing," she'd say. "He's so solid, so there for me. Anyway . . ."

If Julie had any awareness of the depth of Matt's pain, she hadn't been ready to face it. But something shifted with Matt's outburst, forcing her to acknowledge a difficult tension: their togetherness on this unfortunate journey, but also their separateness.

Julie is crying now. "He kept wanting to take back what he'd said, but it was already out there, hanging between us. I understand why he wants a night off from cancer." She pauses. "I'll bet he wishes that I would just die already."

I'll bet sometimes he does, I think for a second. It's hard enough in a marriage to do the give-and-take of putting one's wants and needs aside for another, but here the scales are tipped, the imbalance unrelenting. Yet I also know it's much more complicated than that. I imagine that Matt feels trapped in time, newly married, young, wanting to live a normal life and start a family, all the while knowing that what he has left with Julie is temporary. He sees his future as a widower, then as a father in his forties rather than his thirties. He probably hopes that this doesn't go on for another five years, five years at the prime of his life spent in hospitals, caretaking his young wife whose body is being cut apart. At the same time, I'll bet that he is touched to his core by this experience, that in some ways it makes him feel, as one man told me in the months before his wife of thirty years died, "forever changed and paradoxically alive." I'd wager that, like that man, Matt wouldn't choose to go back in time and marry a different person. But Matt's at a life stage when everyone else is moving forward; the thirties are a decade of building the foundation of the future. He's out of sync with his peers, and in his own way, in his own grief, he probably feels completely alone.

I don't think it would be helpful for Julie to know every detail, but I believe that their time together will be richer if there's space for Matt to show more of his humanity during this process. And if they can have a deeper experience of each other in the time that they have left together, Julie will live more fully within Matt after she's gone.

"What do you think Matt meant by wanting the night off from cancer?" I ask.

Julie sighs. "All the doctor appointments, the lost pregnancies, everything I want a night off from too. He wants to talk about how his research is going and the new taco place down the street and . . . you know, the normal things people our age talk about. The whole time I've been going through this, all we cared about was finding a way for me to live. But now, he can't make plans with me for even a year from now, and he can't go meet someone else. The only way he can move forward is if I die."

I hear what she's getting at. Underlying their ordeal is a fundamental truth: For all of the ways that Matt's life has changed, it will eventually return to some kind of normal. And that, I suspect, pisses Julie off. I ask if she's angry with Matt, envious.

"Yes," she whispers, as though she's sharing a shameful secret. I tell her it's okay. How could she not be envious of the fact that he gets to live?

Julie nods. "I feel guilty for putting him through this and jealous that he gets a future," she says, adjusting a pillow behind her back. "And then I feel guilty for being jealous."

I think about how common it is, even in everyday situations, to be jealous of a spouse and how taboo it is to talk about that. Aren't we supposed to be happy for their good fortune? Isn't that what love is about?

In one couple I saw, the wife got her dream job on the same day that her husband was let go from his, which made for extreme awkwardness every night at the dinner table. How much should she share of her days without inadvertently making her husband feel bad? How could he manage his envy without raining on her parade? How noble can people reasonably be expected to be when their partners get something they desperately want but can't have?

"Matt came home from the gym yesterday," Julie says, "and he said that he had a fantastic workout, and I said, ‘That's great,' but I felt so sad, because we used to go to the gym together. He'd always tell people that I was the one with the stronger body, the marathon runner. ‘She's the superstar, I'm the wimp!' he'd say, and the people we became friends with at the gym started calling us that.

"Anyway, we used to have sex a lot after the gym. So yesterday when he gets back, he comes over and kisses me, and I start kissing him back, and we have sex, but I'm out of breath in a way I've never been before. I don't let on, though, so Matt gets up to shower, and as he's walking into the bathroom, I look at his muscles and think, I used to be the one with the stronger body. And then I realize that it's not just Matt who's watching me die. It's me, too. I'm watching myself die. And I'm so angry at everyone who gets to live. My parents will outlive me! My grandparents might too! My sister's having a second baby. But me?"

She reaches for her water bottle. After Julie recovered from her initial cancer treatment, her doctors told her that drinking water flushes out toxins, so Julie began carrying a sixty-four-ounce bottle everywhere she went. Now it's no longer useful but it's become a habit. Or a prayer.

"It's hard to see what's still there," I say, "and to let it in when you're grieving for your own life."

We sit in silence for a while. Finally, she wipes her eyes and the slip of a smile forms on her lips. "I have an idea."

I look at her expectantly.

"You'll tell me if it's too wacky?"

I nod.

"I was just thinking," she begins, "that instead of spending my time being jealous of everyone else, maybe part of my purpose for the time I have left could be helping the people I love to move forward."

She shifts on the couch, getting excited. "Take Matt and me. We won't grow old together. We won't even grow middle-aged together. I've been wondering if, for Matt, my death will feel more like a breakup than the end of a marriage. Most of the women in the cancer group who talk about leaving their husbands behind are in their sixties and seventies, and the one in her forties has been married for fifteen years, and she and her husband have two kids. I want to be remembered as a wife and not an ex-girlfriend. I want to behave like a wife and not an ex-girlfriend. So I'm thinking, What would a wife do? Do you know what these wives say about leaving their husbands behind?"

I shake my head.

"They talk about making sure their husbands are going to be okay," she says. "Even if I'm jealous of his future, I want Matt to be okay." Julie looks at me like she just said something I'm supposed to understand, but I don't.

"What would make you feel that he'll be okay?" I ask.

She shoots me a grin. "As much as this makes me want to vomit, I want to help him find a new wife."

"You want to let him know it's okay to love again," I say. "That doesn't sound wacky at all." Often a dying spouse wants to give the surviving one this blessing—to say that it's okay to hold one person in your heart and fall in love with another, that our capacity for love is big enough for both.

"No," Julie says, shaking her head. "I don't want to just give him my blessing. I want to actually find him a wife. I want that gift to be part of my legacy."

As when Julie first suggested the Trader Joe's idea, I feel myself recoil. This seems masochistic, a form of torture in an already torturous situation. I think about how Julie would not want to see this, could not bear this. Matt's future new wife will have his babies. She'll go on long hikes and climb mountains with him. She'll cuddle up with him and laugh with him and have passionate sex with him the way Julie once did. There's altruism and love, sure, but Julie's also human. And so is Matt.

"What makes you think he'll want this gift?" I ask.

"It's crazy, I know," Julie says. "But there's a woman in my cancer group whose friend did that. She was dying, and her best friend's husband was dying, and she didn't want her husband or her best friend to be alone, and she knew how well they got along—they'd been good friends for decades. So her dying wish was that they would go on a date after the funeral. One date. So they did. And now they're engaged." Julie's crying again. "Sorry," she says. Almost every woman I see apologizes for her feelings, especially her tears. I remember apologizing in Wendell's office too. Perhaps men apologize preemptively, by holding their tears back.

"I mean, not sorry, just sad," Julie says, echoing a phrase I shared with her earlier.

"You're going to miss Matt a lot," I say.

"I am," she squeaks out. "Everything about him. The way he gets so excited about little things, like a latte or a line in a book. The way he kisses me, and the way his eyes take ten minutes to open if he wakes up too early. How he warms my feet in bed and looks at me when we're talking, like his eyes are soaking up everything I'm saying as much as his ears are." Julie pauses to catch her breath. "And you know what I'm going to miss most of all? His face. I'm going to miss looking at his beautiful face. It's my favorite face in the entire world."

Julie is crying so hard that no sound comes out. I wish that Matt could have been here for this.

"Have you told him?" I ask.

"All the time," Julie says. "Every time he holds my hand, I say, ‘I'm going to miss your hands.' Or when he's whistling around the house—he's an amazing whistler—I'll tell him how much I'm going to miss that sound. And he always used to say, ‘Jules, you're still here. You can hold my hands and hear me whistle.' But now—" Julie's voice cracks. "Now he says, ‘I'm going to miss you just as much.' I think he's starting to accept the fact that I'm really dying this time."

Julie wipes her upper lip.

"You want to hear something?" she continues. "I'm also going to miss myself. All those insecurities I'd spent my life wanting to change? I was just getting to a place where I really like myself. I like me. I'm going to miss Matt, and my family, and my friends, but I'm also going to miss me."

She goes on to name all the things she wishes she'd appreciated more before she got sick: Her breasts, which she used to think weren't perky enough until she had to give them up; her strong legs, which she often thought were too thick, even though they served her well in marathons; her quiet way of listening, which she feared some might find boring. She's going to miss her distinctive laugh that a boy in fifth grade called "a squawk," a comment that somehow stuck like a burr inside her for years until that laugh made Matt glance her way in a crowded room and then make a beeline for her to introduce himself.

"I'm going to miss my freaking colon!" she says, laughing now. "I didn't appreciate it enough before. I'm going to miss sitting on a toilet and shitting. Who thinks they'll miss shitting?" Then come the tears—angry ones.

Every day is another loss of something she took for granted until it was gone, like what happens to the couples I see who take each other for granted and then miss each other when the marriage seems to be dying. Many women, too, have told me that they loathed getting their menstrual periods but grieved the loss of them when they reached menopause. They missed bleeding the way Julie will miss shitting.

Then, in almost a whisper, Julie adds, "I'm going to miss life.

"Fuck, fuck, fuck, fuck, fuck!" she says, starting soft and getting louder, surprising herself with her volume. She looks at me, embarrassed. "Sorry, I didn't mean—"

"It's okay," I say. "I agree. It fucking sucks."

Julie laughs. "And now I got my therapist to say fuck! I never used to swear like this. I don't want my obituary to read, ‘She swore like a sailor.'"

I wonder what she does want her obituary to say, but time is almost up and I make a mental note to come back to this next time.

"Oh, who cares, that felt good. Let's do it again," Julie says. "Will you do it with me? We've got a minute left, right?"

At first I don't know what she's talking about—do what? But she has that mischievous look again, and then it clicks.

"You want us to—"

Julie nods. The rule-follower is asking me to yell obscenities with her. Recently in my consultation group, Andrea had said that while we need to hold hope for our patients, we have to hope for the right thing. If I can no longer hold hope for Julie's longevity, Andrea said, I have to hold hope for something else. "I can't help her in the way that she wants," I'd said. But sitting here now, I see that maybe I can, at least for today.

"Okay," I say. "Ready?"

We both yell, "FUCK, FUCK, FUCK, FUCK, FUCK, FUCK, FUCK!" When we're done, we catch our breath, exhilarated.

Then I walk her to the door, where, as usual, she hugs me goodbye.

In the hallway, other patients are leaving their sessions, doors opening at ten to the hour like clockwork. My colleagues look at me questioningly as Julie leaves. Our voices must have carried into the corridor. I shrug, close my door, and start laughing. That was a first, I think.

Then I feel the tears well up. Laughter to tears—grief. I'm going to miss Julie and I'm having a hard time with this myself.

Sometimes the only thing to do is yell, "Fuck!"

Chapter 36 The Speed of Want

After completing my traineeship year, I began my internship at a nonprofit clinic located in the basement of a sleek office building. Upstairs, the light-filled suites had views of Los Angeles's mountains to one side and beaches to the other, but downstairs was another story. In cramped, cave-like, windowless consultation rooms furnished with decades-old chairs, broken lamps, and torn sofas, we interns thrived on patient volume. When a new case came in, we all vied for it, because the more people we saw, the more we learned and the closer we came to finishing our hours. Between back-to-back sessions, clinical supervision, and mounds of paperwork, we didn't pay much attention to the fact that we were living underground.

Sitting in the break room (aroma: microwaved popcorn and ant spray), we would scarf down some food (lunch was always eaten "al desco") and commiserate about our lack of time. But despite our gripes, our initiation as therapists felt exhilarating—partly because of the steep learning curve and our wise supervisors (who gave us advice like "If you're talking that much, you can't be listening" and its variant "You have two ears and one mouth; there's a reason for that ratio"), and partly because we knew this phase was blessedly temporary.

The light at the end of the years-long tunnel was licensure, when we imagined we could improve people's lives by doing the work we loved but with reasonable hours and a less frenetic pace. As we hunkered down in that basement, doing our charts by hand and searching for reception on our phones, we didn't realize that upstairs, a revolution was under way, one of speed, ease, and immediate gratification. And that what we were being trained to offer—gradual but lasting results that required some hard work—was becoming increasingly obsolete.

I'd seen hints of these developments in my patients at the clinic but, focused on my own harried existence, I failed to see the bigger picture. I thought: Of course these people have trouble slowing down or paying attention or being present. That's why they're in therapy.

My life wasn't much different, of course, at least during this phase. The faster I finished my work, the sooner I'd get to spend time with my son, and then the quicker we could do the bedtime routine, the quicker I could get to bed so that I could wake up the next day and hurry all over again. And the quicker I moved, the less I saw, because everything became a blur.

But this would end soon, I reminded myself. Once I finished my internship, my real life would begin.

One day I was in the break room with some fellow interns, and we once again started counting our required number of hours and calculating how old we'd be when we finally got licensed. The higher the number, the worse we felt. A supervisor in her sixties walked by and overheard the conversation.

"You'll turn thirty or forty or fifty anyway, whether your hours are finished or not," she said. "What does it matter what age you are when that happens? Either way, you won't get today back."

We all went quiet. You won't get today back.

What a chilling idea. We knew that our supervisor was trying to tell us something important. But we didn't have time to think about it.

Speed is about time, but it's also closely related to endurance and effort. The faster the speed, the thinking goes, the less endurance or effort required. Patience, on the other hand, requires endurance and effort. It's defined as "the bearing of provocation, annoyance, misfortune, or pain without complaint, loss of temper, irritation, or the like." Of course, much of life is made up of provocation, annoyance, misfortune, and pain; in psychology, patience might be thought of as the bearing of these difficulties for long enough to work through them. Feeling your sadness or anxiety can also give you essential information about yourself and your world.

But while I was down in that basement rushing toward licensure, the American Psychological Association published a paper called "Where Has All the Psychotherapy Gone?" It noted that 30 percent fewer patients received psychological interventions in 2008 than they had ten years earlier and that since the 1990s, the managed-care industry—the same system that my medical-school professors had warned us about—had been increasingly limiting visits and reimbursements for talk therapy but not for drug treatment. It went on to say that in 2005 alone, pharmaceutical companies spent $4.2 billion on direct-to-consumer advertising and $7.2 billion on promotion to physicians—nearly twice what they spent on research and development.

Of course, it's a lot easier—and quicker—to swallow a pill than to do the heavy lifting of looking inside yourself. And I had nothing against patients using medication to feel better. Just the opposite; I was, in fact, a strong believer in the tremendous good it often did in the right situations. But did 26 percent of the general population in this country really need to be on psychiatric medications? After all, it wasn't that psychotherapy didn't work. It was that it didn't work fast enough for today's patients, who were now, tellingly, called "consumers."

There was an unspoken irony to all of this. People wanted a speedy solution to their problems, but what if their moods had been driven down in the first place by the hurried pace of their lives? They imagined that they were rushing now in order to savor their lives later, but so often, later never came. The psychoanalyst Erich Fromm had made this point more than fifty years earlier: "Modern man thinks he loses something—time—when he does not do things quickly; yet he does not know what to do with the time he gains except kill it." Fromm was right; people didn't use extra time earned to relax or connect with friends or family. Instead, they tried to cram more in.

One day, as we interns begged to be given more new cases despite our full caseloads, our supervisor shook her head.

"The speed of light is outdated," she said dryly. "Today, everybody moves at the speed of want."

Indeed, I sped through. Before long, I completed my internship, passed my board exams, and moved upstairs into an airy office with a view of the world around me. After two false starts—Hollywood, medical school—I was ready to begin a career I felt passionate about, and my being older also gave it a sense of urgency. I had taken a circuitous route, arriving late to the game, and though now I could finally slow down and appreciate the hard-won fruits of my labor, I still felt as rushed as I had in my internship—this time, I felt rushed to enjoy it. I sent out an email announcement introducing my practice and did some networking. After six months, I had a smattering of patients, but then the number seemed to plateau. Everyone I spoke to was having a similar experience.

I joined a consultation group for new therapists, and one night, after we'd discussed our cases, the conversation turned to the state of our practices—were we imagining things, or was our generation of therapists doomed? Somebody said she had heard about branding specialists specifically for therapists, professionals who could help to bridge the gap between the culture's need for speed and ease and what we were trained to do.

We all laughed—branding consultants for therapists? How ludicrous. The influential therapists of the past that we admired would be turning in their graves! But secretly, she got my attention.

A week later, I found myself on the phone with a branding consultant for therapists.

"Nobody wants to buy therapy anymore," the consultant said matter-of-factly. "They want to buy a solution to a problem." She made some suggestions about positioning myself for this new marketplace—even proposing that I should offer "text therapy"—but the whole thing made me uncomfortable.

Still, she was right. The week before Christmas, I got a call from a man in his early thirties about coming in for therapy. He explained that he wanted to figure out whether to marry his girlfriend, and he hoped we could "resolve this" quickly because Valentine's Day was coming up and he knew he had to produce a ring or she'd bail. I explained that I could help him with clarity but couldn't guarantee his timeline. It was a big life question, and I didn't know anything about him yet.

We set up an appointment, but the day before he was to come in, he called and told me he'd found someone else to help sort things out. She'd given him a guarantee that they'd resolve the issue in four sessions, which would meet his Valentine's Day deadline.

Another patient who genuinely wanted to find a life partner told me that she was going through people on the dating apps so fast that several times she had contacted a guy only to have him reply that they'd already met. She'd actually spent an hour having coffee with this person, but she was cycling through her options so quickly that she couldn't keep track.

Both of these patients were examples of, as my supervisor had put it, "the speed of want"—want in the sense of a desire. But I also began to think of the term slightly differently, as referring to the other sort of want—a lack or deficit.

If you'd asked me when I started as a therapist what most people came in for, I would have replied that they hoped to feel less anxious or depressed, to have less problematic relationships. But no matter the circumstances, there seemed to be this common element of loneliness, a craving for but a lack of a strong sense of human connection. A want. They rarely expressed it that way, but the more I learned about their lives, the more I could sense it, and I felt it in many ways myself.

One day at my new practice, in the long lull between patients, I found a video online of MIT researcher Sherry Turkle talking about this loneliness. In the late 1990s, she said, she had gone to a nursing home and watched a robot comfort an elderly woman who had lost a child. The robot looked like a baby seal, with fur and large eyelashes, and it processed language well enough to respond appropriately. The woman was pouring her heart out to this robot, and it seemed to follow her eyes, to be listening to her.

Turkle went on to say that while her colleagues considered this seal robot to be great progress, a way to make people's lives easier, she felt profoundly depressed.

I gasped in recognition. Just the day before, I'd joked to a colleague, "Why not have a therapist in your iPhone?" I didn't know then that soon there would be therapists in smartphones—apps through which you could connect with a therapist "anytime, anywhere . . . within seconds" to "feel better now." I felt about these options the way Turkle felt about the woman with the robotic seal.

"Why are we essentially outsourcing the thing that defines us as people?" Turkle asked in the video. Her question made me wonder: Was it that people couldn't tolerate being alone or that they couldn't tolerate being with other people? Across the country—at coffee with friends, in meetings at work, during lunch at school, in front of the cashier at Target, and at the family dinner table—people were texting and Tweeting and shopping, sometimes pretending to make eye contact and sometimes not even bothering.

Even in my therapy office, people who were paying to be there would glance at their phones when they buzzed just to see who it was. (These were often the same people who later admitted that they also glanced at pinging phones during sex or while sitting on the toilet. Upon learning this, I placed a bottle of Purell in my office.) To avoid distraction, I'd suggest turning off their phones during sessions, which worked well, but I noticed that before patients even reached the door at the end of the session, they'd grab their phones and start scrolling through their messages. Wouldn't their time have been better spent allowing themselves just one more minute to reflect on what we had just talked about or to mentally reset and transition back to the world outside?

The second people felt alone, I noticed, usually in the space between things—leaving a therapy session, at a red light, standing in a checkout line, riding the elevator—they picked up devices and ran away from that feeling. In a state of perpetual distraction, they seemed to be losing the ability to be with others and losing their ability to be with themselves.

The therapy room seemed to be one of the only places left where two people sit in a room together for an uninterrupted fifty minutes. Despite its veil of professionalism, this weekly I-thou ritual is often one of the most human encounters that people experience. I was determined to establish a flourishing practice, but I wasn't willing to compromise this ritual in order to make that happen. It may have seemed quaint, if not downright inconvenient, but for those patients I did have, I knew there was a tremendous payoff. If we create the space and put in the time, we stumble upon stories that are worth waiting for, the ones that define our lives.

And my own story? Well, I wasn't really allowing the time and the space for that—gradually, I became too busy listening to the stories of others. But beneath the hectic bustle of therapy sessions and school drop-offs, of doctor appointments and romance, a long-repressed truth was percolating beneath the surface and just beginning to make itself felt when I arrived in Wendell's office. Half my life is over, I would say, seemingly out of nowhere, in our very first session—and Wendell would jump right on this. He was picking up where my internship supervisor had left off years earlier.

You won't get today back. 

And the days were flying by.

Chapter 37 Ultimate Concerns

I'm soaked when I get to Wendell's office this morning. During my short walk across the street from the parking lot to his building, the winter's first downpour began unannounced. Having no umbrella or coat, I threw my cotton blazer over my head and ran.

Now my blazer is dripping, my hair is frizzing, my makeup is running, and my wet clothes are sticking to my body like leeches in the most unfortunate places. Too damp to sit, I'm standing by the waiting-room chairs, wondering how I'm going to make myself presentable for work, when the door to Wendell's inner office opens and out comes the pretty woman I've seen before. Again, she's wiping her tears. She lowers her head and rushes past the paper screen, and I hear the click-clack of her boots echoing down the building's corridor.

Margo?

No—it's coincidence enough that she's also seeing Wendell, but to have our weekly appointments back to back? I'm being paranoid. Then again, as the writer Philip K. Dick put it, "Strange how paranoia can link up with reality now and then."

I stand there shivering like a wet puppy until Wendell's door opens again, this time to let me in.

I drag myself to the sofa and settle into position B, arranging the familiar mismatched pillows behind my back in the way I've become accustomed. Wendell quietly closes the office door, walks across the room, lowers his tall body into his spot, and crosses his legs when he lands. We begin our opening ritual: our wordless hello.

But today I'm getting his sofa wet.

"Would you like a towel?" he asks.

"You have towels?"

Wendell smiles, walks over to his armoire, and tosses me a couple of hand towels. I dry my hair with one and sit down on the other.

"Thanks," I say.

"You're welcome," he says.

"Why do you have towels here?"

"People get wet," Wendell replies with a shrug, as if towels are an office staple. How strange, I think—and yet I feel so taken care of, like when he tossed me the tissues. I make a mental note to store towels in my office.

We look at each other in silent greeting again.

I don't know where to start. Lately I've been anxious about pretty much everything. Even little things like making small commitments have left me paralyzed. I've become cautious, afraid of taking risks and making mistakes because I've made so many already and I fear I won't have time to clean up the mistakes anymore.

The night before, as I tried to relax in bed with a novel, I came across a character who described his constant worry as "a relentless need to escape a moment that never ends." Exactly, I thought. For the past few weeks, every second has been linked to the next by worry. I know the anxiety is front and center because of what Wendell said at the end of our last session. I'd had to cancel my next appointment to go to an event at my son's school, then Wendell was away the following week, so I've been sitting with Wendell's words for three weeks now. Me: What fight? Him: Your fight with death.

The skies opening up on me on my way in today felt appropriate. I take a deep breath and tell Wendell about my wandering uterus.

Until today, I've never told this story from beginning to end. If before I'd been embarrassed by it, now, as I say it aloud, I realize how truly terrified I've been. Layered on top of the grief Wendell had mentioned early on—that half my life is over—has been the fear that I, like Julie, might be dying much sooner than expected. There's nothing scarier to a single mom than contemplating leaving her young child on this earth without her. What if the doctors are missing something that could be treated if found promptly? What if they find the cause but it can't be treated?

Or what if this is all in my head? What if the person who can cure my physical symptoms is none other than the person I am sitting with right now, Wendell?

"That's quite a story," Wendell says when I'm done, shaking his head and blowing out some air.

"You think it's a story?" Et tu, Brute?

"I do," Wendell says. "It's a story about something frightening that's been happening to you over the past couple of years. But it's also a story about something else."

I anticipate what Wendell will say: It's a story about avoidance. Everything I've told him since coming to therapy has been about avoidance, and we both know that avoidance is almost always about fear. Avoidance of seeing the clues that Boyfriend and I had irreconcilable differences. Avoidance of writing the happiness book. Avoidance of talking about not writing the happiness book. Avoidance of thinking about my parents getting older. Avoidance of the fact that my son is growing up. Avoidance of my mysterious illness. I remember something I learned during my internship: "Avoidance is a simple way of coping by not having to cope."

"It's a story about avoidance, isn't it?" I say.

"Well, in some ways, yes," Wendell replies. "Though I was going to say uncertainty. It's also a story about uncertainty."

Of course, I think. Uncertainty.

I've always thought about uncertainty in terms of my patients. Will John and Margo stay together? Will Charlotte stop drinking? But now so much seems uncertain in my own life. Will I be healthy again? Will I find the right partner? Will my writing career go up in flames? What will the next half of my life—if I even have that long—look like? I'd once told Wendell that it was hard to walk around those prison bars when I didn't know where I was headed. I might be free, but which way should I go?

I remember a patient who had pulled into her garage at the end of an ordinary workday and was greeted by an intruder with a gun. The intruder's accomplice, she would soon learn, was in the house with her children and their babysitter. After a horrific ordeal, they were saved when a neighbor called the police. My patient told me that the worst thing about this incident was that it had shattered her smug sense of safety, however illusory it might have been.

And yet, whether she realized it or not, she still held on to that illusion.

"Do you worry about pulling into your new garage?" I asked when the family, too traumatized to live at the scene of the crime, had moved into a new home.

"Of course not," she said, as if it were an absurd question. "Like this would happen twice? What are the chances of that?"

I tell Wendell this story and he nods. "How do you make sense of her response?" he asks.

Wendell and I rarely talk about my work as a therapist, and now I feel self-conscious. Sometimes I wonder how Wendell would be with my patients, what he would say to Rita or John. Therapy is a completely different experience with a different therapist; no two are exactly the same. And because Wendell has been doing this much longer than I have, I feel like the student to his teacher, Luke Skywalker to his Yoda.

"I think we want the world to be rational, and it was her way of having control over how uncertain life is," I say. "Once you know a truth, you can't unknow it, but at the same time, to protect herself from that knowledge, she convinces herself she could never be assaulted again." I pause. "Did I pass the test?"

Wendell starts to open his mouth but I know what he's about to say: This isn't a test.

"Well," I say, "was that what you were thinking? How would you make sense of her certainty in the face of uncertainty?"

"The way you did with her," he says. "The same way I'd make sense of it with you."

Wendell goes through the concerns I've brought to him: my breakup, my book, my health, my father's health, my son's rapid ascent through childhood. The seemingly offhand observations I'd pepper our conversations with, like "I heard on the radio that about half of today's Americans weren't alive in the 1970s!" Everything I talk about is shaded with uncertainty. How much longer will I live, and what will happen in that time before I die? How much control will I have over any of it? But, Wendell says, like my patient, I've come up with my own way to cope. If I screw up my life, I can engineer my own death rather than have it happen to me. It may not be what I want, but at least I'll choose it. Like cutting off my nose to spite my face, this is a way to say, Take that, uncertainty.

I try to wrap my mind around this paradox: self-sabotage as a form of control. If I screw up my life, I can engineer my own death rather than have it happen to me. If I stay in a doomed relationship, if I mess up my career, if I hide in fear instead of facing what's wrong with my body, I can create a living death—but one where I call the shots.

Irvin Yalom, the scholar and psychiatrist, often talked about therapy as an existential experience of self-understanding, which is why therapists tailor the treatment to the individual rather than to the problem. Two patients might have the same problem—say, they have trouble being vulnerable in relationships—but the approach I take with them will vary. The process is highly idiosyncratic because there's no cookie-cutter way to help people through what are at the deepest level existential fears—or what Yalom called "ultimate concerns."

The four ultimate concerns are death, isolation, freedom, and meaninglessness. Death, of course, is an instinctive fear that we often repress but that tends to increase as we get older. What we fear isn't just dying in the literal sense but in the sense of being extinguished, the loss of our very identities, of our younger and more vibrant selves. How do we defend against this fear? Sometimes we refuse to grow up. Sometimes we self-sabotage. And sometimes we flat-out deny our impending deaths. But as Yalom wrote in Existential Psychotherapy, our awareness of death helps us live more fully—and with less, not more, anxiety.

Julie, with the "wacky" risks she's been taking, is a perfect example of this. I never paid attention to my own death until I embarked on the Medical Mystery Tour—and even then, Boyfriend allowed me to distract myself from my fears of extinction, both professional and actual. But he also offered me an antidote to my fear of isolation, another ultimate concern. There's a reason that solitary confinement makes prisoners literally go crazy; they experience hallucinations, panic attacks, obsessional behavior, paranoia, despair, difficulty with focus, and suicidal ideation. When released, these people often struggle with social atrophy, which renders them unable to interact with others. (Perhaps this is simply a more intense version of what happens with our increasing want, our loneliness, created by our speedy lifestyles.)

And then there's the third ultimate concern: freedom, and all the existential difficulties that freedom poses for us. On the surface, it's almost laughable how much freedom I have—if, as Wendell pointed out, I'm willing to walk around those bars. But there's also the reality that as people get older, they face more limitations. It becomes harder to change careers or move to a different city or marry a different person. Their lives are more defined, and sometimes they crave the freedom of youth. But children, bound by parental rules, are really free only in one respect—emotionally. For a while, at least, they can cry or laugh or have tantrums unselfconsciously; they can have big dreams and unedited desires. Like many people my age, I don't feel free because I've lost touch with that emotional freedom. And that's what I'm doing here in therapy—trying to free myself emotionally again.

In a way, this midlife crisis may be more about opening up than shutting down, an expansion rather than a constriction, a rebirth rather than a death. I remember when Wendell said that I wanted to be saved. But Wendell isn't here to save me or solve my problems as much as to guide me through my life as it is so that I can manage the certainty of uncertainty without sabotaging myself along the way.

Uncertainty, I'm starting to realize, doesn't mean the loss of hope—it means there's possibility. I don't know what will happen next—how potentially exciting! I'm going to have to figure out how to make the most of the life I have, illness or not, partner or not, the march of time notwithstanding.

Which is to say, I'm going to have to look more closely at the fourth ultimate concern: meaninglessness.