All Things Far: Maybe You Should Talk to Someone

Maybe You Should Talk to Someone - Lori Gottlieb (Notes)

Change and loss travel together...We can’t have change without loss

We learn how to accept feedback, tolerate discomfort, become aware of blind spots, and discover the impact of our histories and behaviors on ourselves and others.

Sometimes we are the cause of our difficulties. And if we can step out of our own way, something astonishing happens.

presenting problem; inflection points

If you go through life picking and choosing, if you don’t recognize that “the perfect is the enemy of the good,” you may deprive yourself of joy.

Most big transformations come about from the hundreds of tiny, almost imperceptible, steps we take along the way.

A lot can happen in the space of a step.

The things we protest against the most are often the very things we need to look at.

Therapists talk a lot about how the past informs the present—how our histories affect the ways we think, feel, and behave and how at some point in our lives, we have to let go of the fantasy of creating a better past. If we don’t accept the notion that there’s no redo, much as we try to get our parents or siblings or partners to fix what happened years ago, our pasts will keep us stuck. Changing our relationship to the past is a staple of therapy. But we talk far less about how our relationship to the future informs the present too. Our notion of the future can be just as powerful a roadblock to change as our notion of the past.

And having the future taken away is the mother of all plot twists. But if we spend the present trying to fix the past or control the future, we remain stuck in place, in perpetual regret.

everyone who comes to therapy worries that what they think or feel might not be “normal” or “good,” and yet it’s our honesty with ourselves that helps us make sense of our lives with all of their nuances and complexity. Repress those thoughts, and you’ll likely behave “badly.” Acknowledge them, and you’ll grow.

people are often at their most interesting when they’ve got a proverbial gun to their head.

Julie and Matt decided that they had to live their lives, even in the face of such uncertainty. If they had learned anything, it was that life is the very definition of uncertainty.

the person behind the diagnosis

The answer to an unasked question is always no

Therapists will be supportive, but our support is for your growth, not for your low opinion of your partner. (Our role is to understand your perspective but not necessarily to endorse it.) In therapy, you’ll be asked to be both accountable and vulnerable. Rather than steering people straight to the heart of the problem, we nudge them to arrive there on their own, because the most powerful truths—the ones people take the most seriously—are those they come to, little by little, on their own. Implicit in the therapeutic contract is the patient’s willingness to tolerate discomfort, because some discomfort is unavoidable for the process to be effective.

Most things worth doing are difficult

“It’s like that Mary Oliver poem,” I say to Wendell. “‘What is it you plan to do with your one wild and precious life?’

In other words, therapy is about understanding the self that you are. But part of getting to know yourself is to unknow yourself—to let go of the limiting stories you’ve told yourself about who you are so that you aren’t trapped by them, so you can live your life and not the story you’ve been telling yourself about your life.

“I’m reminded,” he begins, “of a famous cartoon. It’s of a prisoner, shaking the bars, desperately trying to get out—but to his right and left, it’s open, no bars.” He pauses, allowing the image to sink in. “All the prisoner has to do is walk around. But still, he frantically shakes the bars. That’s most of us. We feel completely stuck, trapped in our emotional cells, but there’s a way out—as long as we’re willing to see it.”

You are your own jailer.

Most of us come to therapy feeling trapped—imprisoned by our thoughts, behaviors, marriages, jobs, fears, or past. Sometimes we imprison ourselves with a narrative of self-punishment. If we have a choice between believing one of two things, both of which we have evidence for—I’m unlovable, I’m lovable—often we choose the one that makes us feel bad. Why do we keep our radios tuned to the same static-ridden stations (the everyone’s-life-is-better-than-mine station, the I-can’t-trust-people station, the nothing-works-out-for-me station) instead of moving the dial up or down? Change the station. Walk around the bars. Who’s stopping us but ourselves?

There is a way out—as long as we’re willing to see it. A cartoon, of all things, has taught me the secret of life.

I open my eyes and smile, and Wendell smiles back. It’s a conspiratorial smile, one that says, Don’t be fooled. It may seem as though you’ve had an earth-shattering breakthrough, but this is just the beginning. I know full well what challenges lie ahead, and Wendell knows that I know, because we both know something else: freedom involves responsibility, and there’s a part of most of us that finds responsibility frightening.

“Insight is the booby prize of therapy” is my favorite maxim of the trade, meaning that you can have all the insight in the world, but if you don’t change when you’re out in the world, the insight—and the therapy—is worthless. Insight allows you to ask yourself, Is this something that’s being done to me or am I doing it to myself? The answer gives you choices, but it’s up to you to make them.

Therapists are always weighing the balance between forming a trusting alliance and getting to the real work so the patient doesn’t have to continue suffering.

Our work is an intricate dance between support and confrontation.

resistance is a clue to where the crux of the work lies; it signals what a therapist needs to pay attention to. During training, whenever we interns felt frustrated by resistant patients, our supervisors would counsel, “Resistance is a therapist’s friend. Don’t fight it—follow it.” In other words, try to figure out why it’s there in the first place.

It’s important to disrupt the depressive state with action, to create social connections and find a daily purpose, a compelling reason to get out of bed in the morning.

Sometimes “drama,” no matter how unpleasant, can be a form of self-medication, a way to calm ourselves down by avoiding the crises brewing inside.

One of the things that surprised me as a therapist was how often people wanted to be told what to do, as if I had the right answer or as if right and wrong answers existed for the bulk of choices people make in their daily lives. Taped up next to my files is the word ultracrepidarianism, which means “the habit of giving opinions and advice on matters outside of one’s knowledge or competence.” It’s a reminder to myself that as a therapist, I can come to understand people and help them sort out what they want to do, but I can’t make their life choices for them.

I realized that people resent being told what to do. Yes, they may have asked to be told—repeatedly, relentlessly—but after you comply, their initial relief is replaced by resentment. This happens even if things go swimmingly, because ultimately humans want to have agency over their lives, which is why children spend their childhoods begging to make their own decisions. (Then they grow up and plead with me to take that freedom away.)

Sometimes patients assume that therapists have the answers and we simply aren’t telling them—that we’re being withholding. But we aren’t out to torture people. We hesitate to give answers not only because patients don’t really want to hear them, but also because they often misconstrue what they hear (leaving us thinking, for instance, I never suggested you say that to your mother! ). Most important, we want to support their independence.

the information the patient presents to you is distorted through a particular lens; that the presentation of the information will change over time as it becomes less distorted; that the dilemma may even be about something entirely different that has yet to be uncovered; that the patient is sometimes gunning for you to support a particular choice and this will become more clear as your relationship develops; and that the patient wants others to make decisions so that she doesn’t have to take responsibility if things don’t work out.

Once he said, “I only know what I would do. I don’t know what you should do,” and instead of absorbing his meaning, I replied, “Okay, then, just tell me—what would you do?”

Everyone wages this internal battle to some degree: Child or adult? Safety or freedom? But no matter where people fall on those continuums, every decision they make is based on two things: fear and love. Therapy strives to teach you how to tell the two apart.

emotional blindness: alexithymia. She doesn’t know what she’s feeling or doesn’t have the words to express it.

Sometimes people can’t identify their feelings because they were talked out of them as children. The child says, “I’m angry,” and the parent says, “Really? Over such a tiny thing? You’re so sensitive!” Or the kid says, “I’m sad,” and the parent says, “Don’t be sad. Hey, look, a balloon!” Or the child says, “I’m scared,” and the parent says, “There’s nothing to be worried about. Don’t be such a baby.” But nobody can keep profound feelings sealed up forever. Inevitably, when we least expect it—seeing a commercial, for instance—they escape.

Children, however, don’t like having to be hyper-competent.

Charlotte and I have talked about anticipating the outcome of her decisions, but I know this is more than an intellectual process. Repetition compulsion is a formidable beast. For Charlotte, stability and its attendant joy isn’t to be trusted; it makes her feel queasy, anxious. When you’re a child and your father is loving and playful, then disappears for a while, and later comes back and acts as if nothing happened—and does this repeatedly—you learn that joy is fickle. When your mother emerges from her depression and suddenly seems interested in your days and acts the way you see other kids’ moms acting, you don’t dare feel joy because you know from experience that it will all go away. And it does. Every single time.

Like John, she’s prone to what we call “doorknob disclosures.”

It’s not uncommon for patients to go through an entire session talking about this or that, only to spill something important in the last ten seconds (“I think I’m bisexual,” “My biological mother found me on Facebook”). People do this for a variety of reasons—they’re embarrassed, they don’t want you to have a chance to comment, they want to leave you feeling as unsettled as they do.

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

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?

the thirties are a decade of building the foundation of the future.

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?

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.

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.

Very Angry People aren’t Very Approachable

common defense mechanism called compartmentalization

Will you see the human in my being?

Therapy elicits odd reactions because, in a way, it’s like pornography. Both involve a kind of nudity

Robert Frost poem: “The only way out is through.” The only way to get to the other side of the tunnel is to go through it, not around it.

Johann Wolfgang von Goethe succinctly summarized this sentiment: “Too many parents make life hard for their children by trying, too zealously, to make it easy for them.”

Worried All the Time, put it this way: “The cardinal rules of good parenting—moderation, empathy, and temperamental accommodation with one’s child—are simple and are not likely to be improved upon by the latest scientific findings.”

Happiness equals reality minus expectations

often different parts of ourselves want different things, and if we silence the parts we find unacceptable, they’ll find other ways to be heard

So many of our destructive behaviors take root in an emotional void, an emptiness that calls out for something to fill it

It’s not just the words people say or even the visual cues that therapists notice in person—the foot that shakes, the subtle facial twitch, the quivering lower lip, the eyes narrowing in anger. Beyond hearing and seeing, there’s something less tangible but equally important—the energy in the room, the being together. You lose that ineffable dimension when you aren’t sharing the same physical space

Whenever one person in a family system starts to make changes, even if the changes are healthy and positive, it’s not unusual for other members in this system to do everything they can to maintain the status quo and bring things back to homeostasis

We’ve talked before about how there’s a difference between a criticism and a complaint, how the former contains judgment while the latter contains a request. But a complaint can also be an unvoiced compliment

deeper feelings long enough to understand them and listen to what they’re telling you, you’ll not only manage your anger in more productive ways, you also won’t be so angry all the time

anger serves another function—it pushes people away and keeps them from getting close enough to see you.

It’s like that Mary Oliver poem,” I say to Wendell. “‘What is it you plan to do with your one wild and precious life?

therapy is about understanding the self that you are. But part of getting to know yourself is to unknow yourself—to let go of the limiting stories you’ve told yourself about who you are so that you aren’t trapped by them, so you can live your life and not the story you’ve been telling yourself about your life

We feel completely stuck, trapped in our emotional cells, but there’s a way out—as long as we’re willing to see it.”

You are your own jailer

knows that I know, because we both know something else: freedom involves responsibility, and there’s a part of most of us that finds responsibility frightening

feelings lead to behaviors. Once we know what we’re feeling, we can make choices about where we want to go with them. But if we push them away the second they appear, often we end up veering off in the wrong direction, getting lost yet again in the land of chaos

While women feel cultural pressure to keep up their physical appearance, men feel that pressure to keep up their emotional appearance

It’s impossible to grow without first becoming vulnerable

love can often look like so many things that don’t seem like love

Anger is the go-to feeling for most people because it’s outward-directed—angrily blaming others can feel deliciously sanctimonious. But often it’s only the tip of the iceberg, and if you look beneath the surface, you’ll glimpse submerged feelings you either weren’t aware of or didn’t want to show: fear, helplessness, envy, loneliness, insecurity. And if you can tolerate these

Insight is the booby prize of therapy” is my favorite maxim of the trade, meaning that you can have all the insight in the world, but if you don’t change when you’re out in the world, the insight—and the therapy—is worthless. Insight allows you to ask yourself, Is this something that’s being done to me or am I doing it to myself? The answer gives you choices, but it’s up to you to make them

Therapists are always weighing the balance between forming a trusting alliance and getting to the real work so the patient doesn’t have to continue suffering

Our work is an intricate dance between support and confrontation.

But she still wanted to experience that sense of purpose and community, of being a small part of lots of different people’s lives—even if just for the time it took to ring up their groceries

Therapists tell their patients: Follow your envy—it shows you what you want.

Often people talk about suicide not because they want to be dead but because they want to end their pain. If they can just find a way to do that, they very much want to be alive

person can’t yet hold, and I wasn’t seeing much hope here. Typically I see possibility because the people who are depressed have something to keep them going—it might be a job that gets them out of bed (even if they don’t love that particular job), a network of friends (just one or two people they can talk to), or contact with some family members (problematic but present). Having children in the house or a beloved pet or religious faith can also protect against suicide. But most notably, the depressed people I saw were younger. More malleable. Their lives might seem bleak now, but they had time to turn things around and create something new

With aging comes the potential to accrue many losses: health, family, friends, work, and purpose

like the way she sauntered to the sofa in slow motion, a sign of depression known as psychomotor retardation. (This slowing down of coordinated efforts between the brain and the body might also explain why I kept missing the tissue box in Wendell’s office.)

Often at the beginning of therapy, I’ll ask patients to recount the past twenty-four hours in as much detail as possible. In this way I get a good sense of the current situation—their level of connectedness and sense of belonging, how their lives are peopled, what their responsibilities and stressors are, how peaceful or volatile their relationships might be, and how they choose to spend their time. It turns out that most of us aren’t aware of how we actually spend our time or what we really do all day until we break it down hour by hour and say it out loud

As Andrew Solomon wrote in The Noonday Demon: “The opposite of depression isn’t happiness, but vitality.”

Even if she hadn’t given herself a one-year deadline, there was another deadline that neither of us could change: mortality.

What should be accepted and what should be changed in my own life?

I thought about how regret can go one of two ways: it can either shackle you to the past or serve as an engine for change.

We marry our unfinished business

But it’s a deep human need. It’s well documented that touch is important for well-being throughout our lifetimes. Touch can lower blood pressure and stress levels, boost moods and immune systems. Babies can die from lack of touch, and so can adults (adults who are touched regularly live longer). There’s even a term for this condition: skin hunger.

rapprochement

How all of them must feel so ripped off and full of resentment that none of them can see what’s actually there and what kind of lives they might still be able to create

I remembered the old medical-school quip: “Psychiatrists don’t make people happy—prescriptions do!”

It wasn’t that she didn’t respect psychiatrists; it was that psychiatry today tends to be more about the nuances of medication and neurotransmitters than the subtleties of people’s life stories—all of which she knew I knew.

“Being a therapist is going to require a blend of the cognitive and the creative

Often when patients see our humanity, they leave us.

In movies, therapist silences have become a cliché, but it’s only in silence that people can truly hear themselves. Talking can keep people in their heads and safely away from their emotions. Being silent is like emptying the trash. When you stop tossing junk into the void—words, words, and more words—something important rises to the surface. And when the silence is a shared experience, it can be a gold mine for thoughts and feelings that the patient didn’t even know existed.

If something isn’t working, do something different,

She was approaching “emotional sobriety”—the ability to regulate one’s feelings without self-medicating, whether that medication comes in the form of substances, defenses, affairs, or the internet

You sound like my ten-year-old. What makes you think life is supposed to be fair?”

The internet can be both a salve and an addiction, a way to block out pain (the salve) while simultaneously creating it (the addiction

What most people mean by type is a sense of attraction—a type of physical appearance or a type of personality turns them on. But what underlies a person’s type, in fact, is a sense of familiarity

Why would people do this to themselves? Because the pull toward that feeling of “home” makes what they want as adults hard to disentangle from what they experienced as children. They have an uncanny attraction to people who share the characteristics of a parent who in some way hurt them. In the beginning of a relationship, these characteristics will be barely perceptible, but the unconscious has a finely tuned radar system inaccessible to the conscious mind. It’s not that people want to get hurt again. It’s that they want to master a situation in which they felt helpless as children. Freud called this “repetition compulsion.” Maybe this time, the unconscious imagines, I can go back and heal that wound from long ago by engaging with somebody familiar—but new. The only problem is, by choosing familiar partners, people guarantee the opposite result: they reopen the wounds and feel even more inadequate and unlovable.

The therapist Terry Real described our well-worn behaviors as “our internalized family of origin. It’s our repertoire of relational themes.” People don’t have to tell you their stories with words because they always act them out for you. Often they project negative expectations onto the therapist, but if the therapist doesn’t meet those negative expectations, this “corrective emotional experience” with a reliable and benevolent person changes the patients; the world, they learn, turns out not to be their family of origin

She has the gift of time, if she uses it wisely.

Medical school was also a trial by fire; in medicine, students learned procedures by the “see one, do one, teach one” method. In other words, you watched a physician, say, palpate an abdomen, you palpated the next abdomen yourself, and then you taught another student how to palpate an abdomen. Presto! You’re deemed competent to palpate abdomens.

I should be asking how long she’s felt this way (“history of present condition”), how severe it’s been, whether something happened that brought this on (a “precipitating event”).

would take practice before I’d come to feel the rhythm of every session by instinct, to know that there was an arc to every hour, with the most intense parts in the middle third, and that you needed about three or five or ten minutes to put the patient back together, depending on the person’s fragility, the subject matter, the context. It would take years to learn what should or shouldn’t be brought up when and how to work with the time available to get the most out of it

Don’t bullshit your patients.” She lets that sink in, then goes on to explain that if I don’t know something, I should simply say, “I don’t know

It takes a while to hear a person’s story and for that person to tell it, and like most stories—including mine—it bounces all over the place before you know what the plot really is.

People with conversion disorder aren’t faking it—that’s called factitious disorder. People with factitious disorder have a need to be thought of as sick and intentionally go to great lengths to appear ill. In conversion disorder, though, the patient is actually experiencing these symptoms; it’s just that there’s no identifiable medical explanation for them. They seem to be caused by emotional distress that the patient is completely unconscious of.

Maybe they’d be happier if they didn’t try to change things. Just be

There was certainly some truth here. Sometimes people needed to accept themselves and others the way they were. But sometimes in order to feel better, you need a mirror held up to you, and not the mirror that makes you look pretty, like the one I was looking in now.

al desco

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.”

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

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

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

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.

MIT researcher Sherry Turkle

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?

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

writer Philip K. Dick put it, “Strange how paranoia can link up with reality now and then

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.

Avoidance is a simple way of coping by not having to cope.”

How would you make sense of her certainty in the face of 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.

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.

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.)

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

this midlife crisis may be more about opening up than shutting down, an expansion rather than a constriction, a rebirth rather than a death

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

Losing somebody you love is such a profoundly lonely experience, something only you endure in your own particular way

what therapists call flooded, meaning that his nervous system is in overdrive, and when people feel flooded, it’s best to wait a beat

It’s the not knowing that torments John. I think about how it’s the not knowing that torments all of us.

At a certain point, we all have to come to terms with the unknown and the unknowable. Sometimes we’ll never know why.

You’re so focused on being a good dad,” I say to John, “but maybe part of being a good dad is allowing yourself the full range of human emotions, of really living, even if living fully can sometimes be harder than not. You can feel your feelings privately, or with Margo, or here with me—you can let them out in the adult sphere—and doing that might allow you to be more alive with your kids. It might be a different way of keeping your shit together for them. It might even be confusing for them if Gabe is never mentioned. And allowing yourself to rage or cry or sit with the despair at times might be more manageable if Gabe were given some air in your household and not tucked away in a box in the proverbial attic.”

At some point, you have to make a decision to move on.

there are many ways to defend oneself from the unspeakable. Here’s one: you split off unwanted parts of yourself, hide behind a false self, and develop narcissistic traits

Freud, Jung, Erikson, Piaget, and Maslow

If therapy is about guiding people from where they are now to where they’d like to be, we must always consider: How do humans actually change?

James Prochaska developed the transtheoretical model of behavior change (TTM)

sequential stages that look like this: Stage 1: Pre-contemplation Stage 2: Contemplation Stage 3: Preparation Stage 4: Action Stage 5: Maintenance

you’re in the first stage, pre-contemplation, which is to say, you’re not even thinking about changing

Contemplation is rife with ambivalence. If pre-contemplation is denial, contemplation might be likened to resistance. Here, the person recognizes the problem, is willing to talk about it, and isn’t opposed (in theory) to taking action but just can’t seem to get herself to do it.

People often start therapy during the contemplation stage.

Here people procrastinate or self-sabotage as a way to stave off change—even positive change—because they’re reluctant to give something up without knowing what they’ll get in its place. The hiccup at this stage is that change involves the loss of the old and the anxiety of the new

What we can do is try to help them understand themselves better and show them how to ask themselves the right questions until something happens—either internally or externally—that leads them to do their own persuading.

Sometimes the changes you want in another person aren’t on that person’s agenda—even if he tells you they are

Whereas Freud believed that people are driven to seek pleasure and avoid pain (his famous pleasure principle), Frankl maintained that people’s primary drive isn’t toward pleasure but toward finding meaning in their lives

Everything can be taken from a man but one thing: the last of the human freedoms—to choose one’s attitude in any given set of circumstances.”

Reacting vs. responding = reflexive vs. chosen. We can choose our response, Frankl was saying, even under the specter of death.

Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.”

therapy takes place face-to-face

As your eyes are opening, his are beginning to close,”

romantic transference, a common reaction patients have to their therapists

Sharing difficult truths might come with a cost—the need to face them—but there’s also a reward: freedom. The truth releases us from shame

In the mid-1900s, Erikson came up with eight stages of psychosocial development that still guide therapists in their thinking today. Unlike Freud’s stages of psychosexual development, which end at puberty and focus on the id, Erikson’s psychosocial stages focus on personality development in a social context (such as how infants develop a sense of trust in others). Most important, Erikson’s stages continue throughout the entire lifespan, and each interrelated stage involves a crisis that we need to get through to move on to the next. They look like this: Infant (hope)—trust versus mistrust Toddler (will)—autonomy versus shame Preschooler (purpose)—initiative versus guilt School-age child (competence)—industry versus inferiority Adolescent (fidelity)—identity versus role confusion Young adult (love)—intimacy versus isolation Middle-aged adult (care)—generativity versus stagnation Older adult (wisdom)—integrity versus despair

Erikson maintained that, in later years, we experience a sense of integrity if we believe we have lived meaningful lives. This sense of integrity gives us a feeling of completeness so that we can better accept our approaching deaths. But if we have unresolved regrets about the past—if we think that we made poor choices or failed to accomplish important goals—we feel depressed and hopeless, which leads us to despair

She was used to viewing the world from a place of deficit, and as a result, joy felt foreign to her. If you’re used to feeling abandoned, if you already know what it’s like for people to disappoint or reject you—well, it may not feel good, but at least there are no surprises; you know the customs in your own homeland. Once you step into foreign territory, though—if you spend time with reliable people who find you appealing and interesting—you might feel anxious and disoriented. All of a sudden, nothing’s familiar. You have no landmarks, nothing to go by, and all of the predictability of the world you’re used to is gone. The place you came from may not be great—it might, in fact, be pretty awful—but you knew exactly what you’d get there (disappointment, chaos, isolation, criticism).

A gift wrapped in a criticism

Why do parents do this? Often, they envy their children’s childhoods—the opportunities they have; the financial or emotional stability that the parents provide; the fact that their children have their whole lives ahead of them, a stretch of time that’s now in the parents’ pasts. They strive to give their children all the things they themselves didn’t have, but they sometimes end up, without even realizing it, resenting the kids for their good fortune

She envied their young, energetic parents. And it was, in part, her unconscious envy—her fury at the unfairness of it all—that kept her from allowing them to have the happy childhood she didn’t, that kept her from saving them in the way she so badly wanted to be saved when she was young.

Forgiveness is a tricky thing, in the way that apologies can be. Are you apologizing because it makes you feel better or because it will make the other person feel better? Are you sorry for what you’ve done or are you simply trying to placate the other person who believes you should be sorry for the thing you feel completely justified in having done? Who is the apology for?

There’s a term we use in therapy: forced forgiveness. Sometimes people feel that in order to get past a trauma, they need to forgive whoever caused the damage—the parent who sexually assaulted them, the burglar who robbed their house, the gang member who killed their son. They’re told by well-meaning people that until they can forgive, they’ll hold on to the anger. Granted, for some, forgiveness can serve as a powerful release—you forgive the person who wronged you, without condoning his actions, and it allows you to move on. But too often people feel pressured to forgive and then end up believing that something’s wrong with them if they can’t quite get there—that they aren’t enlightened enough or strong enough or compassionate enough.

You can have compassion without forgiving. There are many ways to move on, and pretending to feel a certain way isn’t one of them

Dave was livid—did his father expect absolution now, at the eleventh hour? The time to make repairs, he felt, was long before you left this earth, not on the eve of your departure; you don’t automatically get the gift of closure or forgiveness from a deathbed confession

We may want others’ forgiveness, but that comes from a place of self-gratification; we are asking forgiveness of others to avoid the harder work of forgiving ourselves

Many of us torture ourselves over our mistakes for decades, even after we’ve genuinely attempted to make amends. How reasonable is that sentence?

Your misery doesn’t change their situation. You can’t lessen their misery by carrying it for them inside you. It doesn’t work that way. There are ways for you to be a better mother to them at this point in all of your lives. Sentencing yourself to life in prison isn’t one of them.

pain can be protective; staying in a depressed place can be a form of avoidance. Safe inside her shell of pain, she doesn’t have to face anything, nor does she have to emerge into the world, where she might get hurt again. Her inner critic serves her: I don’t have to take any action because I’m worthless. And there’s another benefit to her misery: she may feel that she stays alive in her kids’ minds if they relish her suffering. At least somebody has her in mind, even in a negative way—and in this sense, she’s not completely forgotten.

Feeling deep in your cells that you matter is part of the alchemy that takes place in good therapy.

The humanistic psychologist Carl Rogers practiced what he called client-centered therapy, a central tenet of which was unconditional positive regard. His switch from using the term patient to client was representative of his attitude toward the people he worked with. Rogers believed that a positive therapist-client relationship was an essential part of the cure, not just a means to an end—

But unconditional positive regard doesn’t mean the therapist necessarily likes the client. It means that the therapist is warm and nonjudgmental and, most of all, genuinely believes in the client’s ability to grow if nurtured in an encouraging and accepting environment. It’s a framework for valuing and respecting the person’s “right to determination” even if her choices are at odds with yours. Unconditional positive regard is an attitude, not a feeling

liking my neshama, which is the Hebrew word for “spirit” or “soul.” The concept registers instantly

sometimes patients seem one way on the outside, but that’s often because they’re confusing me with others from their past who may not have seen them the way I do. Even so, I told this young woman, I feel genuine affection for my patients all the time—their tender places, their bravery, their souls. For, as Wendell is saying, their neshamot.

You can still have another child. At least he lived a long life. She’s in a better place now. When you’re ready, you can always get another dog. It’s been a year; maybe it’s time to move on. To be sure, these comments are meant to comfort, but they’re also a way of protecting the speakers from the uncomfortable feelings that somebody else’s bad situation stirs up. Platitudes like these make a terrible circumstance more palatable for the person saying the words but leave the person experiencing the adversity feeling angry and alone

Not speaking about something doesn’t make it less real. It makes it scarier. For Julie, the worst thing is the silence, people who avoid her so that they don’t have to get into a conversation and say those awkward things in the first place. She’d choose awkward over ignored.

One thing that has surprised Julie about going through the process of watching herself die is how vivid her world has become. Everything that she used to take for granted produces a sense of revelation, as if she were a child again

All of this, no matter how mundane, delights her to no end. She’s become hyper-present. When people delude themselves into believing they have all the time in the world, she’s noticed, they get lazy.

She hadn’t expected to experience this pleasure in her grief, to find it invigorating, in a way. But even as she’s dying, she’s realized, life goes on

Even as she’d discovered hidden parts of herself since the cancer diagnosis—more spontaneity, more flexibility—she was still, at heart, a planner, and if she was going to have to contend with her early death sentence, she would do as much of it as she could the way she wanted

When we give our minds space to wander, they take us to the most unexpected and interesting places

Dragons’ “On Top of the World

A flight to health is a phenomenon in which patients convince themselves that they’re suddenly over their issues because, unbeknownst to them, they can’t tolerate the anxiety that working through these issues is bringing up

not? It’s easy to conflate the intimate experience of romance or sex with the intimate experience of having somebody pay undivided attention to the details of your life, accept you fully, support you without competing agendas, and know you so deeply. Some patients even flirt overtly, often unaware of ulterior motives (throwing the therapist off balance; deflecting from difficult topics; regaining power if feeling powerless; repaying the therapist in the only way the patient knows how to given his or her history). Other patients don’t flirt but vehemently deny any attraction, like John telling me that I wasn’t the kind of person he’d choose as his mistress. (“No offense.”)

that the movement of dance allows our bodies to express our emotions in a way that words sometimes can’t. When we dance, we express our buried feelings, talking through our bodies instead of our minds—and that can help us get out of our heads and to a new level of awareness. That’s partly what dance therapy is about. It’s another technique some therapists use.

we all interact with people in different ways based on any number of things we notice about them. Political correctness aside, we aren’t emotionally blind to qualities like appearance, wardrobe, gender, race, ethnicity, or age. That’s the way transference works.

I’d been mistaking feeling less for feeling better. The feelings are still there, though. They come out in unconscious behaviors, in an inability to sit still, in a mind that hungers for the next distraction, in a lack of appetite or a struggle to control one’s appetite, in a short-temperedness, or—in Boyfriend’s case—in a foot that twitched under the covers as we sat in that heavy silence under which lay the feeling that he’d kept to himself for months: whatever he wanted, it wasn’t me.

there was a difference between examining and dwelling, and if we’re cut off from our feelings, just skating on the surface, we don’t get peace or joy—we get deadness.

Though we travel the world over to find the beautiful, we must carry it with us, or we find it not. —Ralph Waldo Emerson

This may seem surprising, but when therapists are late, many patients are shaken. Though we try to avoid this, every therapist I know has let a patient down this way. And when we do, it can bring up old experiences of distrust or abandonment, leaving patients feeling anything from discombobulated to enraged.

People imagine they come to therapy to uncover something from the past and talk it through, but so much of what therapists do is work in the present, where we bring awareness to what’s going on in people’s heads and hearts in the day-to-day. Are they easily injured? Do they often feel blamed? Do they avoid eye contact? Do they fixate on seemingly insignificant anxieties? We take these insights and encourage patients to practice making use of them in the real world. Wendell once put it this way: “What people do in therapy is like shooting baskets against a backboard. It’s necessary. But what they need to do then is go and play in an actual game.”

The inability to say no is largely about approval-seeking—people imagine that if they say no, they won’t be loved by others. The inability to say yes, however—to intimacy, a job opportunity, an alcohol program—is more about lack of trust in oneself. Will I mess this up? Will this turn out badly? Isn’t it safer to stay where I am? But there’s a twist. Sometimes what seems like setting a boundary—saying no—is actually a cop-out, an inverted way of avoiding saying yes

“You know,” I tell Charlotte as I watch some of the bees begin to disperse, “I agree that things are better in your life, and that you’ve worked hard to make that happen. I also have the sense that you’re still struggling with getting close to people and that the parts of your life that might be related to this—your dad, the conversation about the guy that you don’t want to have—feel too painful to talk about. By not talking about them, part of you might believe that you can still hold out hope that things might be different—and you wouldn’t be alone in that way of thinking. Some people hope that therapy will help them find a way to be heard by whoever they feel wronged them, at which point those lovers or relatives will see the light and become the people they’d wished for all along. But it rarely happens like that. At some point, being a fulfilled adult means taking responsibility for the course of your own life and accepting the fact that now you’re in charge of your choices. You have to move to the front seat and be the mommy dog driving the car.”

If you stay in therapy,” I say softly, “you might have to let go of the hope for a better childhood—but that’s only so that you can create a better adulthood.”

but the stages of change are such that you don’t drop all of your defenses at the same time. Instead, you release them in layers, moving closer and closer to the tender core: your sadness, your shame.

And so it begins, at last. Charlotte doesn’t leave this time. Instead, she stays in therapy until she learns to drive her own car, navigating her way through the world more safely, looking both ways, making many wrong turns but finding her way back, always, to where she truly wants

There’s no hierarchy of pain. Suffering shouldn’t be ranked, because pain is not a contest. Spouses often forget this, upping the ante on their suffering—I had the kids all day. My job is more demanding than yours. I’m lonelier than you are. Whose pain wins—or loses?

But Wendell told me that by diminishing my problems, I was judging myself and everyone else whose problems I had placed lower down on the hierarchy of pain. You can’t get through your pain by diminishing it, he reminded me. You get through your pain by accepting it and figuring out what to do with it. You can’t change what you’re denying or minimizing. And, of course, often what seem like trivial worries are manifestations of deeper ones.

All parents forget these details about their kids as they grow, and they mourn that loss too. The difference is that as the past recedes in their memories, the present is right in front of them. For John, the loss of his memories brings him closer to the loss of Gabe. And so at night, John tells me, while Margo seethes, assuming that he’s working or watching porn, he’s hiding out with his laptop watching videos of Gabe, thinking about how these are the only videos he’ll ever have of his son, just as the memories John has of Gabe are the only memories he’ll ever have. There will be no more memories made. And while the memories might get blurry, the videos won’t. John says that he’s watched these videos hundreds of times and can no longer tell the difference between his actual memories and the videos. He watches obsessively, though, “to keep Gabe alive in my mind.” “Keeping him alive in your mind is your way of not abandoning him,” I say.

Keep moving, don’t stop. But the next year, when I woke up I’d want to die. I kept my game face on but I was bleeding internally, you know? I wanted to be strong for Margo and Gracie, and I had to keep a roof over our heads, so I couldn’t let anyone see the bleeding

“What if it’s both?” I say. “What if your sadness—your grief—is what allowed you to love Ruby with so much joy when you first saw her?”

It wasn’t their judgment she was hearing—it was her own. What if her happiness was an insult to her husband’s memory? It took her a while to see that her happiness didn’t diminish her love for her husband—it honored it

I’ve always thought that “closure” was an illusion of sorts. Many people don’t know that Elisabeth Kübler-Ross’s familiar stages of grieving—denial, anger, bargaining, depression, acceptance—were conceived in the context of terminally ill patients learning to accept their own deaths. It wasn’t until decades later that the model came to be used for the grieving process more generally. It’s one thing to “accept” the end of your own life, as Julie is struggling to do. But for those who keep on living, the idea that they should be getting to acceptance might make them feel worse (“I should be past this by now”; “I don’t know why I still cry at random times all these years later”). Besides, how can there be an endpoint to love and loss? Do we even want there to be? The price of loving so deeply is feeling so deeply—but it’s also a gift, the gift of being alive. If we no longer feel, we should be grieving our own deaths.

The grief psychologist William Worden takes into account these questions by replacing stages with tasks of mourning. In his fourth task, the goal is to integrate the loss into your life and create an ongoing connection with the person who died while also finding a way to continue living. But many people come to therapy seeking closure. Help me not to feel. What they eventually discover is that you can’t mute one emotion without muting the others. You want to mute the pain? You’ll also mute the joy.

psychological immune system. Just as your physiological immune system helps your body recover from physical attack, your brain helps you recover from psychological attack. A series of studies by the researcher Daniel Gilbert at Harvard found that in responding to challenging life events from the devastating (becoming handicapped, losing a loved one) to the difficult (a divorce, an illness), people do better than they anticipate.

impermanence. Sometimes in their pain, people believe that the agony will last forever. But feelings are actually more like weather systems—they blow in and they blow out. Just because you feel sad this minute or this hour or this day doesn’t mean you’ll feel that way in ten minutes or this afternoon or next week. Everything you feel—anxiety, elation, anguish—blows in and out again.

Do I want advice (counseling) or self-understanding (therapy)?

Catch-22 (because the best way to defuse an emotional land mine is to expose it).

Sometimes a therapist will deliberately “prescribe the problem” or symptom that the patient wants to resolve.

This strategy, in which the therapist instructs patients not to do what they’re already not doing, is called a paradoxical intervention. Given the ethical considerations involved, a therapist has to be well trained on how and when to use paradoxical directives, but the idea behind them is that if patients believe that a behavior or symptom is beyond their control, then making it voluntary, something they can choose whether or not to do, calls that belief into question. Once patients realize that they’re choosing a behavior, they can examine the secondary gains—the unconscious benefits it offers (avoidance, rebellion, a cry for help).

using the “good” time I had in a meaningful way.

living on borrowed time”: our lives are literally on loan to us. Despite what we think in our youth, none of us have all that much time. Like Julie, I told Wendell, I was starting to strip my life down to its essentials

In couples therapy, therapists talk about the difference between privacy (spaces in people’s psyches that everyone needs in healthy relationships) and secrecy (which stems from shame and tends to be corrosive). Carl Jung called secrets “psychic poison,

therapy is a profession you learn by doing—not just the work of being a therapist, but also the work of being a patient. It’s a dual apprenticeship, which is why there’s a saying that therapists can take their patients only as far as they’ve gone in their own inner lives.

the most important skill I’ve learned from Wendell is how to remain strategic while also bringing my personality into the room.

In internships, therapists learn how to do therapy by the book, mastering the fundamentals the way you have to master scales when learning to play piano. For both, once you know the basics, you can skillfully improvise. Wendell’s rule isn’t as simple as “There are no rules.” There are rules, and we’re trained to adhere to them for a reason. But he has shown me that when rules are bent with thoughtful intention, it broadens the definition of what effective treatment can be.

There’s a word we use for the end of therapy: termination. I’ve always found it to be oddly harsh-sounding for what’s ideally a warm, bittersweet, and moving experience, much like a graduation. Generally, when the therapy is coming to an end, the work moves toward its final stage, which is saying goodbye. In those sessions, the patient and I consolidate the changes made by talking about “process and progress.” What was helpful in getting to where the person is today? What wasn’t? What has she learned about herself—her strengths, her challenges, her internal scripts and narratives—and what coping strategies and healthier ways of being can she take with her when she leaves? Underlying all this, of course, is how do we say goodbye?

In our daily lives, many of us don’t have the experience of meaningful goodbyes, and sometimes we don’t get goodbyes at all. The termination process allows someone who has spent a great deal of time working through a significant life issue to do more than simply leave with some version of “Well, thanks again—see ya!” Research shows that people tend to remember experiences based on how they end, and termination is a powerful phase in therapy because it gives them the experience of a positive conclusion in what might have been a lifetime of negative, unresolved, or empty endings.

The future is hope,” Julie said. “But where’s the hope if you already know what happens? What are you living for then? What are you striving for?”

You want to have touched people and for them to be affected by your death,” I said. “And for those people to remember you, to keep you in mind.”

I thought about how I did this with Wendell—how I’d internalized his lines of questioning, his way of reframing situations, his voice. This is such a universal experience that one litmus test of whether a patient is ready for termination is whether she carries around the therapist’s voice in her head, applying it to situations and essentially eliminating the need for the therapy.

In training, we’re taught to be careful with our words to avoid misinterpretations. There are many ways to convey to patients how deeply we’ve come to care about them without getting into dicey territory

I have the fantasy that all adults should be given the opportunity to hear parents—not their own—rip themselves open, become completely vulnerable, and give their versions of events, because in seeing this, you can’t help but come to a newfound understanding of your own parents’ lives, whatever the situation.

Displacement’s a bitch, isn’t it? We all use defense mechanisms to deal with anxiety, frustration, or unacceptable impulses, but what’s fascinating about them is that we aren’t aware of them in the moment.

denial—a smoker might cling to the belief that his shortness of breath is due to the hot weather and not his cigarettes. Another person might use rationalization (justifying something shameful)—saying after he’s rejected for a job that he never really wanted the job in the first place. In reaction formation, unacceptable feelings or impulses are expressed as their opposite, as when a person who dislikes her neighbor goes out of her way to befriend her or when an evangelical Christian man who’s attracted to men makes homophobic slurs. Some defense mechanisms are considered primitive and others mature. In the latter group is sublimation, when a person turns a potentially harmful impulse into something less harmful (a man with aggressive impulses takes up boxing) or even constructive (a person with the urge to cut people becomes a surgeon who saves lives).

Displacement (shifting a feeling toward one person onto a safer alternative) is considered a neurotic defense, neither primitive nor mature.

parental relationships evolve in midlife as people shift from blaming their parents to taking full responsibility for their lives. It’s what Wendell calls “the changing of the guard.”

Whereas in their younger years, people often come to therapy to understand why their parents won’t act in ways they wish, later on, people come to figure out how to manage what is. And so my question about my mother has gone from “Why can’t she change?” to “Why can’t I?” How is it, I ask Wendell, that even in my forties, I can be affected so deeply by a phone call from my mother?

people regress; that you might astonish yourself with how far you’ve come, only to slip back into your old roles.

when we feel fragile, we’re like raw eggs—we crack open and splatter if dropped. But when we develop more resilience, we’re like hard-boiled eggs—we might get dinged up if dropped, but we won’t crack completely and spill all over the place. Over the years, I’ve gone from being a raw egg to a hard-boiled egg with my mother, but sometimes the raw egg in me emerges.

Years ago I might have deconstructed our pas de deux, trying to garner sympathy for my predicament: Can’t you see? Isn’t she difficult? But now I find his more clear-eyed approach comforting.

the healthy work of what’s called “separation and individuation.”

Wendell once said: “The nature of life is change and the nature of people is to resist change.” It was a paraphrase of something he’d read that had resonated with him both personally and as a therapist, he told me, because it was a theme that informed nearly every person’s struggles.

But maybe an emotional presbyopia happens around this age too, where people pull back to see the bigger picture: how scared they are to lose what they have, even if they still complain about it.

We don’t have all the answers,” this doctor said, and while the prospect of still not knowing scared me, another doctor’s comment frightened me even more: “Whatever it is will present itself eventually.

I’d told Wendell again that my greatest fear is leaving Zach without a mother, and Wendell said that I had two choices: I could give Zach a mother who’s constantly worried about leaving him motherless, or I could give him a mother whose uncertain health makes her more acutely aware of the preciousness of their time together. “Which scares you less?” he’d asked rhetorically.

It wasn’t just my inexperience that gave me pause, I realized later—it was that Julie would force me to face my own mortality, something I wasn’t ready to do. Even after agreeing to her request, I’d been keeping myself safe in that relationship by never comparing my mortality to hers. After all, nobody has put a time limit on my lifespan in the same way. But Julie had learned to live with who she was and what she had—which was, in essence, what I’d helped her to do and what we all need to do. There’s so much about our lives that remains unknown. I would have to cope with not knowing what my future held, manage my worry, and focus on living now. This couldn’t be just a piece of advice I’d given Julie. It was time for me to take my own medicine. “The more you welcome your vulnerability,” Wendell had said, “the less afraid you’ll feel.”

Our younger selves think in terms of a beginning, middle, and some kind of resolution. But somewhere along the way—perhaps in that middle—we realize that everyone lives with things that may not get worked out. That the middle has to be the resolution, and how we make meaning of it becomes our task. Although time feels like it’s slipping away and I just can’t hold on to it, something else is true too: My illness has sharpened my focus. It’s why I couldn’t write the wrong book. It’s why I’m dating again. It’s why I’m soaking in my mother and looking at her with a generosity I have for so long been unable to access. And it’s why Wendell is helping me examine the mothering I’ll leave Zach with someday. Now I keep in mind that none of us can love and be loved without the possibility of loss but that there’s a difference between knowledge and terror.

She starts talking about her favorite TV therapists: Jennifer Melfi from The Sopranos, Tobias Fünke from Arrested Development, Niles Crane from Frasier, even the goofy Marvin Monroe on The Simpsons. “Did you ever watch In Treatment?” I ask. “The Gabriel Byrne character?”

There are two main categories of people who are so depressed that they contemplate suicide. One type thinks, I had a nice life, and if I can just emerge from this terrible crisis—the death of a loved one; extended unemployment—I’ll have something to look forward to. But what if I can’t? The other type thinks, My life is barren, and there’s nothing to look forward to.

the story a patient comes into therapy with may not be the story she leaves with. What was included in the telling at first might now be written out, and what was left out might become a central plot point. Some major characters might become minor ones, and some minor characters might go on to receive star billing. The patient’s own role might change too—from bit player to protagonist, from victim to hero.

After all, what if Rita had chosen not to kill herself on her seventieth birthday but was still severely depressed? What we’re celebrating today isn’t her continued physical presence so much as her still-in-progress emotional revival—the risks she’s taken to begin to move from a position of ossification to one of openness, from self-flagellation to something closer to self-acceptance.

I tell everyone who’s afraid of getting hurt in relationships—which is to say, everyone with a heartbeat. I explained to her that even in the best possible relationship, you’re going to get hurt sometimes, and no matter how much you love somebody, you will at times hurt that person, not because you want to, but because you’re human. You will inevitably hurt your partner, your parents, your children, your closest friend—and they will hurt you—because if you sign up for intimacy, getting hurt is part of the deal.

what was so great about a loving intimacy was that there was room for repair. Therapists call this process rupture and repair, and if you had parents who acknowledged their mistakes and took responsibility for them and taught you as a child to acknowledge your mistakes and learn from them too, then ruptures won’t feel so cataclysmic in your adult relationships. If, however, your childhood ruptures didn’t come with loving repairs, it will take some practice for you to tolerate the ruptures, to stop believing that every rupture signals the end, and to trust that even if a relationship doesn’t work out, you will survive that rupture too. You will heal and self-repair and sign up for another relationship full of its own ruptures and repairs. It’s not ideal, opening yourself up like this, putting your shield down, but if you want the rewards of an intimate relationship, there’s no way around it.

“My friend, all you do is talk about this woman. At our age, who doesn’t come with enough baggage to bring down an airplane? You think you’ve got nothing? You’ve got a dead wife you talk to every day and an aunt in the loony bin that nobody mentions. You’re a good catch, but c’mon. Who do you think you are, Prince Charming?”

His voice inside said, Take a risk. Maybe our pasts don’t define us but inform us. Maybe all she’s been through is exactly what makes her so interesting—and so caring now.

Sitting with Rita, I was reminded that the heart is just as fragile at seventy as it is at seventeen. The vulnerability, the longing, the passion—they’re all there in full force. Falling in love never gets old. No matter how jaded you are, how much suffering love has caused you, a new love can’t help but make you feel hopeful and alive, like that very first time. Maybe this time it’s more grounded—you have more experience, you’re wiser, you know you have less time—but your heart still leaps when you hear your lover’s voice or see that number pop up on your phone. Late-in-life love has the benefit of being especially forgiving, generous, sensitive—and urgent.

Irvin Yalom, the psychiatrist, wrote that it was “far better that [a patient make progress but] forget what we talked about than the opposite possibility (a more popular choice for patients)—to remember precisely what was talked about but to remain unchanged.”

Underneath these details were the same essential questions Julie had been forced to face: How do I feel safe in a world of uncertainty? How do I connect? Seeing Julie called forth in me an even greater sense of responsibility to my other patients. Every hour counts for all of us, and I want to be fully present in the therapy hour I spend with each one.

Not every therapist would make the same choice. Some worry that this might be crossing a line—being overly invested, as it were. And while in some instances that might be true, it seems odd that in a profession dedicated to the human condition, therapists are expected to compartmentalize their humanity when it comes to their patients’ deaths.

Most of the time, therapists grieve their patients’ deaths in private. Who could I talk to about Julie’s death other than my colleagues in my consultation group or Wendell? And even then, none of them knew her the way I did or the way her family and friends (who get to grieve together) did. The therapist is left to grieve alone.

What do you want to leave with them? What do you want them to leave you with?

transformative deathbed conversations—those are mostly fantasies. People may seek peace and clarity, understanding and healing, but deathbeds themselves are often a stew of drugs, fear, confusion, weakness. That’s why it’s especially important to be the people we want to be now, to become more open and expansive while we’re able. A lot will be left dangling if we wait too long. I remember a patient who, after years of indecisiveness, finally reached out to his biological father who had been seeking a relationship, only to be devastated to learn that he was lying unconscious, in a coma, and would die within a week.

We also place undue pressure on those last moments, allowing them to supersede whatever came before.

Near the end, Julie fell asleep more often during our sessions, and if before it seemed like time stopped whenever she came to see me, now it felt like a dress rehearsal for her death; she was “trying on” what it would feel like in the stillness without the terror she had of being alone. “Almost is always the hardest, isn’t it?” she said one afternoon. “Almost getting something. Almost having a baby. Almost getting a clean scan. Almost not having cancer anymore.” I thought about how many people avoid trying for things they really want in life because it’s more painful to get close to the goal but not achieve it than not to have taken the chance in the first place.

We didn’t have a profound “grand finale,” as Julie had been calling our final session. Her last words to me were about steak. “God, what I would give for a steak!” she said, her voice weak and barely audible. “They better have steak wherever I’m going.” And then she fell asleep. It was an ending not unlike our sessions, where even though “our time is up,” the conversation lingers. In the best goodbyes, there’s always the feeling that there’s something more to say.

When it’s Matt’s turn, everyone goes silent, and sitting in the back row, I look down at my iced tea and the napkin in my hand. IT’S MY PARTY AND YOU’LL CRY IF YOU WANT TO! it says. Earlier I’d noticed a big banner that read I STILL CHOOSE NEITHER. Matt takes some time to settle himself before he speaks. When he does, he shares an anecdote about how Julie had written a book for him to have after she was gone, and she titled it, The Shortest Longest Romance: An Epic Love and Loss Story. He loses it here, then slowly composes himself and keeps going.

He explains that in the book, he was surprised to find that near the end of the story—their story—Julie had included a chapter on how she hoped Matt would always have love in his life. She encouraged him to be honest and kind to what she called his “grief girlfriends”—the rebound girlfriends, the women he’ll date as he heals. Don’t mislead them, she wrote. Maybe you can get something from each other. She followed this with a charming and hilarious dating profile that Matt could use to find his grief girlfriends, and then she got more serious. She wrote the most achingly beautiful love letter in the form of another dating profile that Matt could use to find the person he’d end up with for good. She talked about his quirks, his devotion, their steamy sex life, the incredible family she inherited (and that, presumably, this new woman would inherit), and what an amazing father he’d be. She knew this, she wrote, because they got to be parents together—though in utero and for only a matter of months. The people in the crowd are simultaneously crying and laughing by the time Matt finishes reading. Everyone should have at least one epic love story in their lives, Julie concluded. Ours was that for me. If we’re lucky, we might get two. I wish you another epic love story. We all think it ends there, but then Matt says that he feels it’s only fair that Julie have love wherever she is too. So in that spirit, he says, he’s written her a dating profile for heaven. There are a few chuckles, although they’re hesitant at first. Is this too morbid? But no, it’s exactly what Julie would have wanted, I think. It’s out-there and uncomfortable and funny and sad, and soon everyone is laugh-sobbing with abandon. She hates mushrooms, Matt has written to her heavenly beau, don’t serve her anything with mushrooms. And If there’s a Trader Joe’s, and she says that she wants to work there, be supportive. You’ll also get great discounts. He goes on to talk about how Julie rebelled against death in many ways, but primarily by what Matt liked to call “doing kindnesses” for others, leaving the world a better place than she found it. He doesn’t enumerate them, but I know what they are—and the recipients of her kindnesses all speak about them anyway.

I’m glad I came, glad that I got to fulfill my promise to Julie and also see a side of her that I can never know about any of my patients—what their lives look like outside of the therapy office. One on one, therapists get depth but not breadth, words without illustrations. Despite being the ultimate insider in terms of Julie’s thoughts and feelings, I’m an outsider here among all these people I don’t know but who knew Julie. We’re told, as therapists, that if we do attend a patient’s funeral, we should stay off to the side, avoid interacting. I do this, but just as I’m about to leave, a friendly couple starts talking to me. They say that Julie is responsible for their marriage—she set them up on a blind date five years ago. I smile at their story, then try to excuse myself, but before I can, the woman in the couple asks, “And how did you know Julie?”

Later, though, when it became clear that Julie would die, that question took on another meaning: Will a part of me remain alive in you?

A mentor once remarked that often in therapy, change happens “gradually, then suddenly,

about the beauty of the word sometimes, how sometimes evens us out, keeps us in the comfortable middle rather than dangling on one end of the spectrum or the other, hanging on for dear life. It helps us escape from the tyranny of black-or-white thinking.

Maybe happiness is sometimes,

Those who can’t do, teach.”

It’s clear that his success was driven as much by revenge as passion.

Gain and loss. Loss and gain. Which comes first?

For many people, going into the depths of their thoughts and feelings is like going into a dark alley—they don’t want to go there alone. People come to therapy to have somebody to go there with, and people watch John’s show for a similar reason: it makes them feel less alone, allows them to see a version of themselves muddling through life on the screen. Maybe in this way, he is a psychiatrist to many—and maybe his bravery in writing about his own loss had inspired me to write about mine.

All week, I wrote about my breakup, my therapist, my mortality, our fear of taking responsibility for our lives and the need to do so in order to heal. I wrote about outdated stories and false narratives and how the past and the future can creep into the present, sometimes eclipsing it entirely. I wrote about holding on and letting go and how hard it is to walk around those prison bars even when freedom isn’t just right in front of us but literally inside of us, in our minds. I wrote about how no matter our external circumstances, we have choices about how to live our lives and that, regardless of what has happened, what we’ve lost, or how old we are, as Rita put it, it ain’t over till it’s over. I wrote about how sometimes we have the key to a better life but need somebody to show us where we left the damn thing. I wrote about how for me, that person has been Wendell, and how for others, that person is sometimes me.

I was searching for meaning—from which fulfillment and, yes, occasionally happiness ensue

But I got a second chance too. Wendell once pointed out that we talk to ourselves more than we’ll talk to any other person over the course of our lives but that our words aren’t always kind or true or helpful—or even respectful. Most of what we say to ourselves we’d never say to people we love or care about, like our friends or children. In therapy, we learn to pay close attention to those voices in our heads so that we can learn a better way to communicate with ourselves. So today, when Wendell says, “It has meaning,” I know that by “it,” he’s also referring to us, our time together. People often think they go to therapy for an explanation—say, why Boyfriend left, or why they’ve become depressed—but what they’re really there for is an experience, something unique that’s created between two people over time for about an hour each week. It was the meaning of this experience that allowed me to find meaning in other ways.

Therapists take risks all the time on behalf of their patients, making split-second decisions on the presumption that these risks will do far more good than harm. Therapy isn’t a paint-by-numbers business, and sometimes the only way to move patients beyond their stuckness is by taking a risk in the room, by going out of the therapist’s own comfort zone to teach by example.

First you will do, then you will understand.” Sometimes you have to take a leap of faith and experience something before its meaning becomes apparent. It’s one thing to talk about leaving behind a restrictive mindset. It’s another to stop being so restrictive. The transfer of words into action, the freedom of it, made me want to carry that action outside the therapy room and into my life.

The strangest thing about therapy is that it’s structured around an ending. It begins with the knowledge that our time together is finite, and the successful outcome is that patients reach their goals and leave. The goals are different for each person, and therapists talk to their patients about what those goals are. Experiencing less anxiety? Relationships going more smoothly? Being kinder to yourself? The endpoint depends on the patient.

therapy is also about forming deep attachments to people and then saying goodbye.

As an intern, I was taught that when patients thank us, it helps to remind them that they did the hard work.

It’s all you, we tend to say. I was just here to guide you. And in a sense, that’s true. The fact that they picked up the phone and decided to come to therapy and then work through things every week is something no one else could do for them. But we’re also taught something else that we can’t really understand until we’ve done thousands of hours of sessions: We grow in connection with others. Everyone needs to hear that other person’s voice saying, I believe in you. I can see possibilities that you might not see quite yet. I imagine that something different can happen, in some form or another. In therapy we say, Let’s edit your story.

Wendell didn’t want to do therapy the way I wanted him to.

both loved and hated Wendell for saying that. It’s like when somebody finally has the guts to tell you that you have a problem and you feel both defensive and relieved that this person is telling it like it is. That’s the delicate work that therapists do. Wendell and I worked on my grief but also my self-imprisonment. And we did it together—it wasn’t all me. Therapy can only work if it’s a joint endeavor.Nobody is going to save you, Wendell had said. Wendell didn’t save me, but he did help me to save myself.So when I express my gratitude to Wendell, he doesn’t push away the compliment with a trite line of humility.

Relationships in life don’t really end, even if you never see the person again. Every person you’ve been close to lives on somewhere inside you. Your past lovers, your parents, your friends, people both alive and dead (symbolically or literally)—all of them evoke memories, conscious or not. Often they inform how you relate to yourself and others. Sometimes you have conversations with them in your head; sometimes they speak to you in your sleep.

we grow in connection with others.

All Things Far

Sunday, November 13, 2022

Maybe You Should Talk to Someone - Lori Gottlieb (Notes)

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