Maybe You Should Talk to Someone

by Lori Gottlieb

  I’d enjoyed watching her stretch from the risk-averse stance she’d embraced all her life. She had always thought that achieving tenure would give her freedom, but now she was tasting a completely unexpected kind of freedom.

  “Is this too off-the-wall?” she’d sometimes say before presenting a new idea to me. She was eager to veer from her mapped-out course, but not so far that she’d get lost. Yet nothing she proposed surprised me.

  Then, finally, Julie had an idea that caught me off guard. She told me that at one point during those weeks when she believed she was about to die, she was waiting in line at Trader Joe’s and found herself mesmerized by the cashiers. They seemed so themselves in the ways they interacted with their customers and one another, making conversation about the small daily things that are really the big things in people’s lives—food, traffic, the weather. How different she imagined this job from her own, which she loved but which also came with a constant pressure to produce and publish, to position herself for advancement. With a shortened future, she imagined doing work where she could see tangible results in the moment—you pack groceries, you cheer up customers, you stock items. At the end of the day, you’ve done something concrete and useful.

  Julie decided that if she had only, say, a year to live, she’d apply to be a weekend cashier at Trader Joe’s. She knew she was idealizing the job. 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.

  “Maybe Trader Joe’s can be part of my Holland,” she mused.

  I could feel myself push against the idea, and I sat for a minute, trying to understand why. It might have had something to do with a dilemma I’d been facing in treating Julie. If Julie hadn’t had cancer, I’d try to help her look at the part of her that had felt inhibited for so long. She seemed to be opening the lid on aspects of herself that hadn’t had space to breathe.

  But with someone who’s dying, did it make sense to do therapy or simply offer support? Should I treat Julie like a healthy patient in terms of more ambitious goals, or should I just offer comfort and not upset the apple cart? I wondered if Julie would ever have asked herself the questions about risk and safety and identity that had been hiding beneath her awareness had she not faced the terror of imminent death. And now that she had, how far should we delve into them?

  These are questions we all deal with in a quieter way: How much do we want to know? How much is too much? And how much is too much when you’re dying?

  The Trader Joe’s fantasy seemed to represent an escape of some sort—like a child saying, “I’m running away to Disneyland!”—and I wondered how this fantasy related to Julie’s pre-cancer self. But mostly, I wondered if she could handle the job physically. The experimental treatment had added to her fatigue. She needed rest.

  Her husband, she told me, thought she was insane.

  “You have a limited time to live, and your dream is to work at Trader Joe’s?” he’d asked.

  “Why, what would you do if you only had a year or so to live?” Julie countered.

  “I’d work less,” he said, “not more.”

  As Julie told me about Matt’s reaction, it occurred to me that he and I both seemed unsupportive, even though we wanted Julie to experience joy. Sure, there were some practical concerns, but could our hesitation also be that we were both, in a strange way, envious of Julie and her conviction to follow her dream, no matter how odd it sounded? Therapists tell their patients: Follow your envy—it shows you what you want. Did watching Julie’s blossoming highlight the fact that we were too afraid to act on our own equivalents of working at Trader Joe’s—and that we wanted Julie to remain like us, dreaming without doing, constrained by nothing more than the open bars on our prison cells?

  Or maybe that was just me.

  “Besides,” Matt had said in his conversation with Julie, “don’t you want to spend that time together?”

  Julie said that of course she did. But she also wanted to work at Trader Joe’s, and it became a kind of obsession. So she applied for a job there, and on the day that she learned she was tumor-free, she was offered a Saturday-morning shift.

  In my office, Julie got out her cell phone and played both phone messages for me: one from her oncologist, one from a manager at Trader Joe’s. She was grinning as if she’d won not just any lottery, but the Powerball of all Powerballs.

  “I told them yes,” she said after the Trader Joe’s message ended. She explained that nobody knew if the tumors would come back, and she didn’t want to just add things to her bucket list; she wanted to cross things off too.

  “You have to pare it down,” she said, “or else it’s just a useless exercise in what could have been.”

  So here I am, standing in the market, and I’m not sure which checkout line to choose. I knew, of course, that Julie had started working at Trader Joe’s, but I had no idea it was this Trader Joe’s.

  She hasn’t seen me yet, and I can’t help but watch her from afar. She rings the bell for a bagger, gets a child some stickers, laughs with a customer over something I can’t hear. She’s like the Queen of Cashiers, the party everyone wants to be at. People seem to know her and, not surprisingly, she’s incredibly efficient, moving the line along quickly. I feel my eyes get wet and the next thing I know my son calls out, “Mom, over here!” and I see that he has negotiated his way into Julie’s line.

  I hesitate. After all, Julie might feel awkward ringing up her therapist. And, truth be told, I might feel awkward too. She knows so little about me that even displaying the contents of my shopping cart feels somehow too revealing. But mostly, I’m thinking about how Julie talks about the sadness she experiences whenever she sees her friends’ kids while she and her husband are trying to find a way to become parents themselves. What will it be like for her to see me with my son?

  “Over here!” I reply, gesturing for Zach to move to a different line.

  “But this one’s shorter!” he yells back, and of course it is, because Julie’s so goddamned efficient, and that’s when Julie looks over at my son and then follows his gaze to me.

  Busted.

  I smile. She smiles. I start to head to the other line, but Julie says, “Hey, lady, listen to the boy. This line’s shorter!” I join Zach in Julie’s line.

  I try not to stare as we wait our turn, but I can’t help it. I’m watching the real-life version of the vision she described in her therapy session—her dream literally come true. When Zach and I get to the register, Julie banters with us as she does with her other customers.

  “Joe’s O’s,” she says to my son. “A good breakfast.”

  “They’re for my mom,” he answers. “No offense, but I like Cheerios better.”

  Julie looks around to make sure nobody’s in earshot, gives him a sly wink, and whispers, “Don’t tell anyone, but me too.”

  They spend the rest of the time discussing the merits of the various chocolate bars my son selected. When we’re all bagged up and rolling our cart away, Zach examines the stickers from Julie.

  “I like that lady,” he says.

  “I do too,” I say.

  It isn’t until half an hour later, as I’m unpacking the bags in my kitchen, that I see something scrawled on my credit card receipt.

  I’m pregnant! it says.

  24

  Hello, Family

  Chart note, Rita:

  Patient is a divorced woman who presents with depression. Expresses regret over what she believes to be “bad choices” and a life poorly lived. Reports that if her life doesn’t improve in one year, she plans to “end it.”

  “I have something to show you,” Rita says.

  In the hallway between the waiting room and my office, she hands me her cell phone. Rita has never handed me her phone before, much less begun speaking to me before we’re settled in my office with the door closed, so I’m surprised by the gesture. She indicates that
I should take a look.

  On her screen is a profile from the dating app called Bumble. Rita recently started using Bumble because, unlike more hookup-oriented apps like Tinder (“Revolting!” she said), Bumble allows only women to contact men. Coincidentally, my friend Jen had just seen an article about it and forwarded it to me with the message For whenever you’re ready to date again. I’d texted back, Whenever isn’t here yet.

  I glance from the phone to Rita.

  “Well?” she says expectantly as we enter my office.

  “Well what?” I ask, handing her back the phone. I’m not sure what she’s getting at.

  “Well what?” she replies incredulously. “He’s eighty-two! I’m no spring chicken, but please! I know what eighty looks like naked, and that gave me nightmares for a week. I’m sorry, but seventy-five is as far as I’ll go. And don’t try to talk me out of it!”

  Rita, I should mention, is sixty-nine.

  A few weeks ago, after months of encouragement, Rita had decided to try a dating app. After all, in her daily life, she wasn’t encountering any single older men, much less those who met her requirements: intelligent, kind, financially stable (“I don’t want anyone looking for a nurse and a purse”), and physically fit (“Somebody who can still get an erection in a timely manner”). Hair was optional, but teeth, she insisted, were not.

  Before the eighty-year-old, there had been a same-age gentleman who was not so gentle. They had gone out to dinner, and the night before what was supposed to be their second date, Rita had texted him the recipe and photo of a dish he said he wanted to try. Mmmm, he texted back. Sounds delicious. Rita was about to respond, but then another Mmmm popped up, followed by You’re killing me here . . . , followed by If you don’t stop, I won’t be able to stand up, followed a minute later by Sorry, I was texting my daughter about my bad back.

  “Bad back, my eye, the pervert!” Rita exclaimed. “He was doing who knows what with who knows who, and he certainly wasn’t talking about my salmon dish!” There was no second date, and no dates at all until she met the eighty-year-old.

  Rita had come to me at the beginning of spring. At our very first session, she was so depressed that when she gave me an account of her situation, it seemed as if she were reading an obituary. The final line had been written, and her life, she believed, was a tragedy. Thrice-divorced and the mother of four troubled adults (due to her own bad mothering, she explained), grandchildless and living alone, retired from a job she disliked, Rita saw no reason to get up in the morning.

  Her list of mistakes was long: choosing the wrong husbands, failing to put her children’s needs above her own (including not protecting them from their alcoholic father), not using her skills in a professionally fulfilling way, not making an effort when she was younger to form a community. She had numbed herself with denial for as long as that worked. Recently, it had lost its efficacy. Even painting—the one activity she enjoyed and excelled at—barely held her interest.

  Now her seventieth birthday was coming up and she had struck a deal with herself to make her life better by then or stop living it.

  “I think I’m beyond help,” she concluded. “But I want to give it one last try, just to be certain.”

  No pressure, I thought. While suicidal thoughts—known as suicidal ideation—are commonplace with depression, most people respond to treatment and never act on those hopeless impulses. In fact, it’s as patients begin to get better that the risk for suicide increases. During this short window, they’re no longer so depressed that eating or dressing seem like monumental efforts but they’re still in enough pain to want to end it all—a dangerous mix of residual distress and newfound energy. But once the depression lifts and suicidal thoughts subside, a new window opens. That’s when the person can make changes that improve life significantly over the long term.

  Whenever suicide comes up—either because the patient or the therapist broaches the topic (bringing it up does not, as some worry, “plant” the idea in a person’s head), the therapist has to assess the situation. Does the patient have a concrete plan? Is there a means to carry out the plan (a gun in the house, a spouse out of town)? Have there been previous attempts? Are there particular risk factors (lack of social support or being male; men commit suicide three times more often than women)? 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. We make the best assessment we can, and as long as there’s no imminent danger, we monitor the situation closely and work with the depression. If the person is set on suicide, though, there are a series of steps to take right away.

  Rita was telling me that she would kill herself, but she was very clear that she would wait out the year and not do anything before her seventieth birthday. She wanted change, not death—as it was, she was already dead inside. For now, suicide wasn’t my concern.

  What was concerning to me, though, was Rita’s age.

  I’m ashamed to admit this, but at first I worried that I might secretly agree with Rita’s grim perspective. Maybe she really was beyond help—or at least beyond the kind of help she wanted. A therapist is supposed to be a container for the hope that a depressed 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.

  Rita, however, seemed like a cautionary tale: a senior citizen, utterly alone, lacking in purpose and full of regret. By her account, she had never truly been loved by anybody. The only child of older and distant parents, she had messed up her own children so badly that none of them spoke to her, and she had no friends or relatives or social life. Her father had been dead for decades, and her mother had died at ninety after suffering for years with Alzheimer’s.

  She looked me in the eye and presented me with a challenge. Realistically, she asked, what could change at this late date?

  About a year earlier, I’d gotten a call from a well-respected psychiatrist in his late seventies. He asked if I would see his patient, a woman in her thirties who was considering freezing her eggs while she continued to look for a partner. He thought that this woman might benefit from consultation with me because, he said, he didn’t know enough about the dating and baby-making landscape for today’s thirty-somethings. Now I knew how he felt. I wasn’t sure that I fully understood the aging landscape for today’s senior citizens.

  I’d learned in my training about the unique challenges faced by older adults, and yet this age group gets short shrift when it comes to mental-health services. For some, therapy is a foreign concept, like TiVo, and besides, their generation grew up largely believing that they could “get through it” (whatever “it” was) on their own. Others, living on retirement savings and seeking help at low-cost clinics, don’t feel comfortable seeing the twenty-something therapy interns who predominantly staff them. Before long, these patients drop out. Still other older people assume that what they’re feeling is a normal part of aging and don’t realize that treatment might help. The result is that many therapists see relatively few seniors in their practices.

  At the same time, old age is a proportionately larger percentage of the average person’s life than it used to be. Unlike the sixty-year-olds of a few generations ago, the sixty-year-olds of today are often at the top of their games in terms of skill, knowledge, and experience, but they’re still pushed out professionally for younger employees. The average life expectancy in the United States now hovers around eighty, and it�
��s becoming common to live into one’s nineties, so what happens to these sixty-year-olds’ identities during the decades they still have left? With aging comes the potential to accrue many losses: health, family, friends, work, and purpose.

  But Rita, I realized, wasn’t experiencing loss primarily as a result of aging. Instead, as she aged, she was becoming aware of the losses she had been living with her entire life. Here she was, wanting a second chance, a chance she was giving herself only a year to realize. As she saw it, she had lost so much that she had nothing left to lose.

  That part I agreed with too—mostly. She could still lose her health and beauty. Tall and slim, with large green eyes and high cheekbones, her thick naturally red hair flecked with just a few strands of gray, Rita was genetically blessed with the complexion of a forty-year-old. (Terrified of living as long as her mother had and running out of retirement funds, she refused to pay for what she called “modern beauty expenses,” her euphemism for Botox.) She also attended an exercise class at the Y every morning, “just to have a reason to get out of bed.” Her physician, who had sent her to me, said that she was “one of the healthiest people her age I’ve seen.”

  But in every other way, Rita seemed dead, lifeless. Even her movements were listless, 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.