“Are you asking for counseling or therapy?” Wendell says at today’s session after I tell him that I have a professional question. He knows I’ll understand the distinction because he’s offered professional guidance twice before. Do I want advice (counseling) or self-understanding (therapy)?
The first time I asked Wendell such a question, I’d been talking about my frustration with people choosing the quick fix over the deeper work of psychotherapy. As a relatively new therapist, I was curious how someone more seasoned—specifically Wendell—dealt with this. It was one thing to hear what older colleagues had to say, but from time to time, I couldn’t help but wonder how Wendell handled the frustrations of the profession.
I doubted he would answer my question directly—he would more likely express empathy for my predicament. In fact, I knew I was putting him in the classic Catch-22 position in which therapists often find themselves: I want empathy, but if you give it to me, I’ll feel angry and hopeless, because empathy alone won’t solve my very real problem, so what good are you anyway? I was thinking that he might even say something about this Catch-22 (because the best way to defuse an emotional land mine is to expose it).
Instead, he looked at me and asked, “Would you like a practical suggestion?”
I wasn’t sure I’d heard him correctly. A practical suggestion? Are you kidding me? My therapist was going to give me a concrete piece of advice?
I moved closer.
“My father was a businessman,” Wendell began quietly. At that time, I hadn’t yet fessed up to my Google-binge, so I nodded, pretending this information was new. He told me that when he was starting out, his father suggested that he make an offer to prospective patients: They could try a session, and if they chose not to continue to work with Wendell after that, the session would be free. Since many people were nervous about starting therapy, this risk-free session would give them the opportunity to see what therapy was about and how Wendell might help them.
I tried to picture Wendell having this conversation with his father. I imagined the pleasure his father might have gotten from finally giving professional advice to his gentler son. His suggestion wasn’t groundbreaking in the world of business, but therapists don’t often think of what we do as a business. And yet we do run small businesses, and Wendell’s father must have realized that his son, despite leaving the family’s company, had actually become a businessman after all. Maybe he took great joy in having that connection with his son. And maybe it meant a lot to Wendell, which is why he was willing to pass this wisdom along to other therapists like me.
In any event, his father was smart. As soon as I implemented this offer, my practice filled up.
But his second piece of counseling—which I not only asked for, but pushed for—flopped. While I was grappling with my happiness-book dilemma, I kept agitating for Wendell to tell me what to do. I pushed so hard and so often that finally, Wendell (who, of course, had no knowledge of the publishing business) gave in near the end of one session. “Well, I don’t know what else there is to say about this,” he replied to my eighty-seventh query on that topic. “It sounds like you’ll just have to find a way to write this so that you can write what you want next time.” Then he patted his legs twice and stood, signaling our time was up.
Sometimes a therapist will deliberately “prescribe the problem” or symptom that the patient wants to resolve. A young man who keeps putting off finding a job might be told in therapy that he can’t look for a job; a woman who won’t initiate sex with her partner might be told not to initiate it for a month. 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).
But Wendell hadn’t been doing that. He was just reacting to my endless complaints. If I came in upset because my agent once more insisted that nothing could be done and that I had to write this book or I’d never get another book contract, Wendell would question why I couldn’t get a second opinion—or another agent—and I would explain that I couldn’t approach other agents because I had nothing to offer them other than the mess I was currently in. Wendell and I had some version of this conversation often, and finally I convinced both of us that there was just one way out: to keep writing. So I trudged on, now blaming not just myself but also him for my predicament. Of course, I didn’t realize I was blaming Wendell, but my resentment surfaced the week after I emailed my editor and told her I wouldn’t be finishing the book. I’d been edgy all session, unable to share this milestone with him.
“Are you angry with me?” Wendell asked, picking up on my vibe, and suddenly it hit me: Yes! I was furious with him, I replied. And, I added, guess what—I had canceled my book contract, finances and consequences be damned! I was walking around those prison bars! Especially given my mysterious medical condition and its debilitating fatigue, I wanted to be sure that I was using the “good” time I had in a meaningful way. Julie had once said that she finally understood the meaning of the phrase “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 rather than sleepwalking my way through it, so who was he to tell me to hunker down and write this book? All therapists make mistakes, but when it happened with Wendell, I felt irrationally betrayed.
When I finished talking, he looked at me thoughtfully. He didn’t get defensive, though he could have. He simply apologized. He’d failed, he said, to see something important that was going on between us. In trying to convince him how trapped I was, I left him feeling trapped as well, imprisoned by my perceived imprisonment. And in his frustration, like me in mine, he’d taken the easiest way out: Fine, you’re screwed—write the damn book.
“The counseling I want today is about a patient,” I say now.
I tell Wendell that I have a patient whose wife sees him, Wendell, and that every time I come here, I think about whether she’s the woman I’ve seen leaving his office. I tell him that I know he can’t say anything about a patient to me, but still I wonder if she’s mentioned the name of her husband’s therapist—me—to him. And how should we handle this coincidence? As a patient, I can say whatever I want about any aspect of my life, but I don’t want to cloud his patient’s therapy with my private knowledge of her husband.
“This is the counseling you want?” Wendell asks.
I nod. Given the earlier fiasco, I imagine he’s being extra-careful in how he responds.
“What can I tell you that will be useful to you?” he asks.
I think about this. He can’t answer my question about whether Margo has the appointment before mine or even say if he’s aware that we’re talking about Margo. He can’t tell me if the fact that I see his patient’s husband is new information or if he’s known all along. He can’t tell me what Margo may or may not have said about me. And I know if I were ever to say anything about John, Wendell would handle it professionally and we’d talk about it in the moment. Maybe I want his advice on whether I did the right thing by telling him about the situation.
“Do you ever wonder if I’m a good therapist?” I ask instead. “I mean, given all you’ve seen in here?” I remember my earlier “Do you like me?,” but this time I’m asking something different. Then I was saying, Do you love me as a child, love my neshama? Now I’m saying, Can you picture me as an adult, as a competent grownup? Of course, Wendell has never seen me do therapy, has never supervised my work. How can he have any opinion at all on the matter? I start to say this but Wendell stops me.
“I know you are,” he says.
At first I don’t understand. He knows I’m a good therapist? Based on wha—oh! So Margo thinks things are getting better with John.
Wendell smiles. I smile. We both know what he can’t tell me.
“I have one more question,” I say. “Given the situation, how do we lessen the awkwardness?”
“Maybe you just did,” he says.
And he’s right. 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,” and after all of the secrets I’ve kept from Wendell, it feels good to have this final secret out in the open.
I don’t ask for counseling again because the truth is that Wendell has been counseling me from day one, in the sense that 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. (There’s much debate about this idea—like my colleagues, I’ve seen patients reach heights I can only aspire to. But still, it’s no surprise that as I heal inside, I’m also becoming more adept at healing others.)
On a practical level, too, I’ve taken Wendell’s lessons straight to my office.
“I’m reminded of a cartoon of a prisoner, shaking the bars . . .” I said to John early on, in a Hail Mary attempt to help him see that the “idiot” he was talking about that day wasn’t his jailer after all.
When I got to the punch line—the bars are open on each side—John smiled for a second in what seemed like recognition but then batted it back at me. “Oh, give me a break,” he said, rolling his eyes. “Do other patients actually fall for this?” But he was the outlier. The intervention has worked beautifully with everyone else.
Still, the most important skill I’ve learned from Wendell is how to remain strategic while also bringing my personality into the room. Would I kick a patient to make a point? Probably not. Would I sing? I’m not sure. But I might not have yelled “Fuck!” with Julie had I not seen Wendell be so utterly himself with me. 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.
Wendell and I don’t talk about John or Margo again, but a few weeks later, as I settle into my chair in the waiting room, Wendell’s door opens and I hear a male voice. “So this time next Wednesday?”
“Yes, see you then,” replies Wendell, then his door clicks shut.
Past the screen, a guy in a suit slips out the door to the hall. Interesting, I think. Maybe the woman before me ended her therapy, or maybe she was Margo, and Wendell engineered the switch to protect my privacy in case Margo eventually figured it out. I don’t ask, though, because it doesn’t matter anymore.
Wendell was right: The awkwardness had disappeared. The secret was out, the psychic poison diluted.
I’d gotten all the counseling—or was it therapy?—I needed.
It’s ten minutes before Julie’s session, and I’m mainlining pretzels in our suite’s kitchen. I don’t know when our last session will be. If she’s late, I think the worst. Should I check on her between sessions or let her call if she needs me (knowing she has trouble asking for help)? Should therapists’ boundaries be different—looser—with terminally ill patients?
The first time I saw Julie at Trader Joe’s, I’d been reluctant to get in her line, but every time after that, if I happened to be there when she was, Julie would wave me over and I’d happily go. If my son was with me, he’d get an extra sheet of stickers and a high five. And when Julie wasn’t there anymore, he noticed.
“Where’s Julie?” he asked, scanning the counters for her as we approached the checkout. It wasn’t that I wouldn’t talk about death with him—a close childhood friend of mine had died of cancer a few years before, and I had told Zach the truth about her illness. But because of confidentiality, I couldn’t reveal more about Julie. One question would lead to another, to lines I couldn’t cross.
“Maybe she changed days,” I said, as if I knew her only as the clerk at Trader Joe’s. “Or maybe she got another job.”
“She wouldn’t get another job,” Zach said. “She loved her job!” I was struck by his response: even a young child could tell.
Without Julie there anymore, we’ve been going in Emma’s line—the woman who offered to carry Julie’s baby. Emma also gives him extra stickers.
But back at my office, waiting for Julie to arrive, I ask the same question Zach did: “Where’s Julie?”
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.
Julie and I have been preparing for another kind of termination, though. We both know that her therapy won’t end until she dies; I made her that promise. And our process lately has consisted of more and more silence, not because we’re avoiding saying something, but because this is how we’re facing each other most honestly. Our silences are rich, our emotions swirling in the air. But the silences are also about her declining state. She has less energy, and talking can take a toll. Jarringly, Julie looks healthy, if thin, on the outside, which is why so many people have trouble believing that she’s dying. Sometimes I do too. And in a way, our silences serve another purpose: They give us the illusion of stopping time. For fifty blissful minutes, we’re both granted a respite from the outside world. She feels safe here, she told me, not having to worry about people worrying about her, having their own feelings.
“But I have feelings about you too,” I said the day that Julie brought this up.
She thought about this for a second and then said simply, “I know.”
“Would you like to know what they are?” I asked.
Julie smiled. “I know that too.” And then we went back to silence.
Of course, between the silences, Julie and I have also been talking. Recently, she said she was thinking about time travel. She’d heard a radio show about it and shared a quote she loved, a description of the past as “a vast encyclopedia of calamities you can still fix.” She’d memorized it, she said, because it made her laugh. And then it made her cry. Because she’ll never live long enough to have this list of calamities that other people acquire by the time they reach old age—relationships they’d want to mend, career paths they’d want to take, mistakes that they’d go back and “get right” this time.
Instead, Julie has been time-traveling to the past to relive parts of her life that she’s enjoyed: birthday parties as a child, vacations with her grandparents, her first crush, her first publication, her first conversation with Matt, one that lasted until dawn and still hasn’t ended. But even if she were healthy, she said, she’d never want to travel to the future. She wouldn’t want to know the plot of the movie, to hear the spoilers.
“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?”
I immediately thought of a difference between Julie and Rita, between young and old, but flip-flopped. Julie, who was young, had no future but was happy with her past. Rita, who was old, had a future but was plagued by her past.
It was that day that Julie fell asleep in session for the first time. She dozed off for a few minutes, and when she woke up and realized what had happened, she made a joke, out of embarrassment, about how I must have been time-traveling while she was sleeping, wishing I were someplace else.
I told her I wasn’t. I was remembering hearing what must have been the same show she’d heard on the radio, and I was thinking about an observation made at the end of that segment—that we’re all time-traveling into the future and at exactly the same rate: sixty minutes per hour.
“Then I guess we’re fellow time travelers in here,” Julie said.
“We are,” I said. “Even when you’re resting.”
Another time Julie broke our silence to tell me that Matt thought she was being a Deathzilla—going crazy with the death-party planning, the way some brides become over-the-top Bridezillas with their weddings. She’d even hired a party planner to help carry out her funeral-party vision (“It’s my day, after all!”), and despite his initial discomfort, Matt was now fully onboard.
“We planned a wedding together and now we’re planning a funeral together,” Julie said, and it has been, she told me, one of the most intimate experiences of their lives, full of deep love and deep pain and gallows humor. When I asked what she wanted that day to be like, first she said, “Well, I’d rather not be dead that day,” but failing that, she didn’t want it to be all “sugarcoated” and “cheery.” She liked the idea of a “celebration of life,” which the party planner told her was all the rage nowadays, but she didn’t like the message that came with it.
“It’s a funeral, for God’s sake,” she said. “All these people in my cancer group say, ‘I want people to celebrate! I don’t want people to be sad at my funeral.’ And I’m like, ‘Why the fuck not? You died!’”
“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.”
Julie told me that she wanted people to keep her in mind the way she keeps me in mind between sessions.
“I’ll be driving, and I’ll panic about something, but then I’ll hear your voice,” she explained. “I’ll remember something you said.”
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. “I started to get depressed,” a patient might report near the end of treatment, “but then I thought of what you said last month.” I’ve had entire conversations in my head with Wendell, and Julie has done the same with me.
“This might sound crazy,” Julie said, “but I know that I’ll hear your voice after I die—that I’ll hear you wherever I am.”
Julie had told me that she’d begun thinking about the afterlife, a concept she insisted that she didn’t completely believe in but nonetheless contemplated, “just in case.” Would she be alone? Afraid? Everyone she loved was still alive—her husband, her parents, her grandparents, her sister, her nephew and niece. Who would keep her company there? And then she realized two things: first, that her babies from her miscarriages might be there, wherever “there” was, and second, that she was coming to believe that she would hear, in some unknowable spiritual way, the voices of those she loved.
“I would never say this if I weren’t dying,” she said shyly, “but I include you in those I love. I know you’re my therapist, so I hope you don’t think it’s creepy, but when I tell people that I love my therapist, I really mean I love my therapist.”
Though I’d come to love many patients over the years, I’d never used those words with any of them. 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. Saying “I love you” isn’t one of those ways. But Julie had said she loved me, and I wasn’t going to stand on professional ceremony and reply with a watered-down response.
“I love you too, Julie,” I said to her that day. She smiled, then closed her eyes and dozed off again.
Now, as I stand in the kitchen waiting for Julie, I think about that conversation and about the ways I know that I’ll hear her voice too, long after she’s gone, especially at certain times, like while shopping at Trader Joe’s or folding laundry and seeing that pajama top with NAMAST’AY IN BED in the pile. I’m saving that top not to remember Boyfriend anymore, but to remember Julie.
I’m still munching on pretzels when my green light goes on. I pop one more into my mouth, rinse my hands, and breathe a sigh of relief.
Julie’s early today. She’s alive.