My A+ in mental health: am I doing wellness now?

My chronic panic attacks resolved upon Jake's terminal diagnosis, only to be recently replaced by intense attacks of anticipatory grief. Screaming goats help, the injectable hormones probably less so.

To break up the monotony of yet another internal meltdown about my husband’s impending death from recurrent metastatic squamous cell carcinoma of the tongue, I call my friend Kate to say: “I’m panicking, because I’m catastrophizing.”

Kate’s a psychiatrist—and also a very good person who seems to like me a lot, based largely on our mutual weirdness, so when I feel my mental health slipping like a dog with long nails on a waxed marble floor, I call her for confirmation that I still seem like someone who could get an A+ in mental health. Meeting Kate a few years ago was like winning the midlife new friend jackpot. Someone who’ll tell you you’re not crazy for calling every day to ask if you’re crazy is the sign of a true friend—or, alternately, another crazy person, though I’m not sure that friendship is much more than compatible insanity. Even though Kate went to a fancy exclusionary school in Boston and I went to Arizona State* (well known for its academic rigor and features in Girls Gone Wild: Cancun parts 1-4), we’re both doctors, which means that no matter how long it’s been since we graduated, or where we went to school, our self-esteem is still way too wrapped up in how we’d be graded on any particular topic.

“I can’t seem to logic my way out of it,” I say, “Aren’t you supposed to look at things rationally when you catastrophize? To see that you’re overreacting?”

“Oh, no, no don’t do that,” she says. “That’s not gonna work on this one.”

I don’t think she’s teasing me. There’s nothing quite like being told, by a professional, that thinking clearly and logically about a situation will only prove that it is, in fact, much worse than you previously believed. But then, what about Jake having his tongue cut out, developing eight tumors in his neck and chest, and starting an experimental clinical trial drug after failing chemo and immunotherapy, all while I’m injecting myself full of hormones in preparation for an egg retrieval so that we can make embryos for IVF, did I think wouldn’t inspire panic?

I force a cough, trying to cover the distress sounds I make as I start hyperventilating. Should I bother trying to cover it? If I’m not overreacting, I could probably get away with freaking out even more. Really lean into it. Switch to FaceTime and throw myself to the ground for added dramatic effect.

“Rage a little! Shriek into the void,” Kate says. “This is the time for compartmentalization and denial.”

“It is?” I say.

“It is.”

My psychiatrist just told me to delude myself. She’s not my psychiatrist? Well, she’s close enough. I’ll Venmo a quick co-pay to make it official. There.

Now I can delude myself.

…Now.

Okay…NOW…

                    NOW!

Crap.

How does a person delude herself on command? You know, as a little treat? Like a macaron?

I just can’t seem to do it.

Instead, I suffer from what I call “acute objective realism.” I blame medical school: years of learning to see the objective facts a body presents, uninfluenced by sentimentality, is one of the most clinically useful, yet emotionally useless, skills I’ve brought to Jake’s illness. It’s a key to being a good, or a good-enough, doc. Like when Jake first developed symptoms of his tumor: he noticed a painful, funny looking spot that he attributed to biting his tongue repeatedly. It wasn’t wholly unreasonable in that Jake is a vigorous yet absentminded masticator.

When he showed me his tongue, I recognized leukoplakia, a precancerous condition, so I pestered him to see the sadist ENT who proceeded to take a biopsy of the area without adequate lidocaine. Jake came back from the ENT’s office and didn’t use the word “torture,” but the concept was in the air, and I was angry. Why had the ENT done that, or not done that? I checked with large physician communities on Facebook, and it turns out that sadism in the form of insufficient numbing is sort of ENT’s “thing,” and everyone but us knew it. Their standard of care seems to be “bring the pain.” If you’re an ENT reading this, please use appropriate lidocaine or nerve blocks on your patients.

Although I’ve been encouraged to let other people doctor and to stick with playing “wife,” letting the line blur between personal and professional has been critical to Jake’s care—plus, my personal and professional life already overlap too frequently, like when strangers at parties learn I’m a physician and then want to show me their rash.  

While my powers of observation might have helped keep Jake alive, and also revealed to my friend’s co-worker at her office Christmas party that his rash might be secondary syphilis, Jake and I are in the kind of situation where too much knowledge isn’t just power: it’s fuel for perseveration. I’ve heard other doctors say the reason you’re not supposed to play doctor for your own family is because it’s hard to be objective when it comes to monitoring the person you love most. I suspect they mean that it’s easy to miss things when you’re too close. Instead, I’m experiencing the exact opposite: I don’t miss a thing, and usually and distressingly, when I’ve brought up a problem with his actual doctors, I’m right. This isn’t a brag. I want to be wrong. I want to notice a new symptom and learn it’s indicative of a little eczema, a bug bite, strep throat, bad vibes, sudden onset milk allergy, or increased obstreperousness (how can Jake possibly get more obstreperous?!).

Once I’ve made the observation, I can’t stop thinking about all the ways things can go wrong, knowing that one of them will be the way things eventually go catastrophically wrong. I look at the visible tumors on Jake’s neck and imagine them suddenly eroding into his carotid or his jugular and in my imagination Jake staggers, yells out “Rosebud!” and collapses, yet all the medical training in the world is helpless to stop it. I notice variations in Jake’s heart rate and imagine a sudden arrhythmia, even though he claims his recent tachycardia is “love fever” while making a groping motion. I watch for side effects from petosemtamab, the experimental EGFR inhibitor he’s receiving every two weeks, which has already caused him to break out in a rash so reminiscent of smallpox that, were we on an eighteenth century whaling vessel, they’d have chucked him overboard in an attempt to stall contagion. But what else might occur? Low blood pressure? High blood pressure? Demonic possession? A 360-degree rotation of his head with associated projectile vomiting? We’re not Catholic. Where would I even find a priest?

I’d love to tell myself that these things won’t happen, but I’ve seen them happen (okay, maybe not the demonic possession or real-life Exorcist) to my own patients, and I can’t delude myself into thinking I haven’t, or that Jake is somehow magically exempt. Emergency medicine teaches its practitioners about worst-case scenarios. I’ve given out more surprise cancer diagnoses than I care to recall, and now my husband has gotten one of those red cards in the soccer game of life. I still try to imagine Jake will be the exception to certain death from recurrent / metastatic squamous cell carcinoma of the tongue—he could be a super responder to the clinical trial drug, it’s not impossible—but, so far, whenever he’s been the exception, it’s because things are worse for him than average. Already, the tumor on the right side of his neck looks larger than it did just a few days ago, which is the observation triggering today’s nervous breakdown. An infected, necrotic lymph node in the same area just erupted with goo, causing more problems. Jake has read too many stories about antibiotic resistance and worries that the infection will get him before the cancer.

“That’s too much being a doctor for right now,” says Kate, to whom I have just rapid-fired shared all these ideas with. “Compartmentalization and denial” Kate reiterates, when I reassert that the tumors look larger. “Don’t skimp on the denial.”

I’ve never been gifted this kind of quick, anti-self-actualizing advice by a therapist before. Usually “Ignore them and see if they go away!” is the wrong answer to the question “How do we face challenges?” Instead, therapists might recommend journaling, or sitting with discomfort, or prescription drugs, or gradual positive change through daily habits like meditation or getting regular sleep on a schedule, which I literally make a living not doing as an ER doctor. But sometimes, as Jake has said: “Things suck, and they just suck, and there’s nothing you can do to make them suck less.” And thinking about how much they suck in great detail, clearly, is one of those things that just doesn’t help. Still, the little hamster running on a wheel made of my amygdyla won’t stop.

How do I face challenges? Stoically, as unlikely as that sounds. Seneca used to recommend something called “premeditation malorum,” Latin for “premeditation.” Premeditation malorum is basically meditating on the litany of things that could go wrong as a means of preparing for them. Which, in a way is exactly what I’m doing. Although Seneca probably wouldn’t appreciate the level of emotional lability that I employ.  Seneca said:

What is quite unlooked for is more crushing in its effect, and unexpectedness adds to the weight of a disaster. This is a reason for ensuring that nothing ever takes us by surprise. We should project our thoughts ahead of us at every turn and have in mind every possible eventuality instead of only the usual course of events. Rehearse them in your mind.

Maybe these moments I feel I’m melting down are really meditations and this shows I’m good at meditating! My anticipatory grief is a means of readying myself for the real thing, so I’m not taken by surprise. Insofar that anyone can be ready, which, I suspect you can’t.    

“I feel like I’m going nuts,” I say to Kate.

“You’re not nuts,” Kate says.

“Well, then, I’m unhinged,” I say.

I start crying again; the kind of ugly cry that turns all my speech to one long wailing mess. I’ve been experiencing intense, sustained crying jags about once a week for the last month, since Jake started getting the clinical trial drug—they come and go for a day, maybe two—before receding back to a baseline level of cry. When they begin, they’re accompanied by a sensation that there is no such thing as the ground. You know that feeling you get when you’re about to fall asleep, but your body decides that you’re actually falling off a cliff instead of snuggled under your duvet and above your mattress? It’s that feeling, except the myoclonic jerk that should snatch me out of it and awake never comes and I’m just clawing at the air getting more and more distressed, the only things I’m grabbing onto are the insubstantial filaments of my despair and there’s so many of them, but they won’t slow the fall. It’s that feeling.

“Feeling unhinged and being unhinged are different things,” Kate assures me.  

“…And I’m…?”

“Feeling unhinged.”

“That mean I qualify for the heavy-duty drugs?”

“No, sorry.”

If this is just a feeling, what’s actually being unhinged? Turns out you can ask that kind of rhetorical question to a psychiatrist and they often answer. Kind of like asking an ER doc if a little thing on your body could really be anything dangerous, and the ER doc starts to point out all sorts of early life-threatening illnesses that normal people have never heard of but normal people most definitely might have, even though us ER docs typically route skin complaints to derm so derm can deal with the problem by wetting the dry stuff and drying the wet stuff, but before I get the derm consult, let me ask: is your skin actually peeling off of your body right now, perhaps? That might be dangerous. To return to the first sentence of this paragraph, before I let my not-actually-unhinged mind take over, apparently “unhinged” looks like any of the twelve patients in the thrall of a psychotic break on Kate’s unit, currently. I’m not doing well, but I’m not that unwell, either.  

To be fair, I ought to know better because I’ve seen and treated unhinged: A woman once came to the ER with a rolling cart filled with trash bags each containing her own vomit, which she wanted tested for tracking devices and drugs. In the ER, we do not generally test conserved vomit. A man once was so convinced that his left arm was trying to kill him, that he’d tried to kill it first. I’ll spare you the details, though they involved a failed attempt with handsaw. I assume “unhinged” is a spectrum. There’s medically unhinged and situationally unhinged and I’m well on my way to situationally unhinged, but I’m too high functioning to warrant a diagnosis. I’m existentially falling apart even while I’m managing appointments, and clinical trial minutia, and monitoring test results (and Jake). I’m a good student, as always—I’m A+ unhinged!

Kate says that I’m doing better than most people would when their beloved spouse is dying, but I’m not entirely sure what that means, or how.  I’ve heard versions of “you’re doing so well” from a number of different, apparently unconnected people. Doing so well compared to what? I speculate that there’s a difference between the idea that I’m “doing” well— meaning I’m still doing a good job at things like getting out of bed in the morning and keeping track of life admin. despite the horrors—and doing “well”, meaning I’m performing actions in line with an internal state of wellness. But a lot of people subsume their existential terror into a project and can “do” well even if the world around them is crumbling. I think I’m one of those people.  But being well? Feeling well? My internal state is currently Alaska, but it’s during bear season and I’m a salmon.  Alternately, I’m baked Alaska, and about to be set on (or currently on) fire.

As an exercise to help convince me that I’m killing it at dealing with Jake’s illness—perhaps I should phrase this differently? oh well—I make a list of things that are potential proof I’m “doing better than most.” The bar seems low, but all the following are things I haven’t done and would never do:

• Run off and leave Jake to fend for himself. Who’d do that? A lot of people, it turns out! Especially men. A woman is six times more likely to be separated or divorced soon after receiving a cancer diagnosis than a male patient. When people say to me that Jake is lucky I’ve stuck by him, I’m so horrified by the notion that the bare minimum of love should require a pat on a back, that I dislike hearing this. I start to wonder—are people surprised? Do they think I should have left? Did they think I would leave? Would they have left? Which is, of course, my first thought when they say that. Jake’s the most important person in the world to me, as I am to him. He’d do the same if the roles were reversed. Despite all the horrible things I’ve seen at my job, I think I don’t like to see dark truths about the human race foregrounded in such a personal way.

• Take Jake out to the desert and left him there with a peyote button, a bottle of water and instructions to go on a vision quest in an attempt to find a cure. I would never let him do that alone, I’d definitely join him.

• Asked Jake to eschew a clinical trial and instead go to a sketchy clinic in Tijuana where he would receive coffee enemas three times a day and eat nothing but alkaline water and the glandular extract of some pygmy goat. Though I admittedly tried to get him to see an energy healer in New Jersey. I’m not sure which he thinks was worse: that I wanted him to see an energy healer, or that the energy healer was in New Jersey. I’m not sure why people, including me, feel compelled to make fun of New Jersey; it’s a fine state. Lots of good food. Needs more subways.

• Ask Jake what the cancer is there to teach him, and why he won’t just let go of his illness. I don’t think this needs further explanation, but we all know that person who talks like this. If you feel this way, or ever have the urge to offer this kind of “assistance,” please don’t. Jake has observed that cancer has taught him nothing, apart from that cancer sucks, which he believed beforehand anyway.

• Forced Jake to self-heal through interpretive dance before driving him to appointments. I’d still like to see this. I’ve requested it happen, but I get points for not forcing him.

Then there’s a list of things I could do because they seem like they’d be very satisfying, or at least entertaining, and maybe I’d like to do them, but haven’t done because they’d be proof of true unhingement:

• Walk into the San Diego ocean with very dramatic music playing behind me until the last of my head is consumed by the dark, steely waves, firm in the expectation that a pod of dolphins will rescue and whisk me off to a small island somewhere with a steady supply of coconuts. Before you call a wellness check on me, know that I’d have a snorkel; San Diego beaches also feature seals and sea lions, which are less majestic than dolphins.

• Flinging myself at the wall in order to feel the same external resistance I feel internally, then bouncing off, then doing it again, and again, and again like a Roomba whose guidance system can’t get it out of a corner. Eventually someone would probably take pity on me and turn me around.

• Consult a VooDoo Priestess and see what kind of zombie-options might be on the table, as long as I don’t have to sacrifice any small, furry animals. I’d just cry. It wouldn’t work. It baffles Jake that I’m not a vegetarian. I am a hypocrite in that if I had to kill the animals myself, I’d be a vegetarian, and probably one with a menagerie of cows and pigs as pets instead of meals. Living in an apartment would be hard.

I’ve tried guided meditation apps, relaxation teas, weighted blankets, and breathing exercises, all of which are more sustainable but less appealing than the few tablets of prescribed Valium. I’ve also tried an amulet in the form of a small goat statue given to me by a friend. When you press down on the goat, it makes a very human screaming sound. It’s completely absurd. It’s wonderful in its absurdity. Every time I’m about to throw it out, I make it scream one last time and slip it back on my bookshelf.

If reality is too much, and denial isn’t my style, what’s left? Taking things moment by moment, maybe. Being fully present with all the things that are, no matter how awful, and no matter what they mean for a future that hasn’t happened yet. Here’s Seneca again: “A man who suffers before it is necessary, suffers more than is necessary.”

Jake is still alive, and here, and breathing. Jake and I are together, doing the best we can with what we have. The list of things he can still lose is long, which is both comforting and terrifying, as he’s already lost so, so much. After the horribly savage May 25 salvage surgery, Jake justifiably considered auto-termination, but he’s also promised to tell me if he’s thinking seriously about it or if he wants to go through it. Like everyone, Jake has his faults and flaws, but he’s not cruel and won’t leave me without any warning. If he’s riding his electric bike to the store he tells me, so I’d want to know and he’d tell me about a decision infinitely more consequential. The view down that slope to the permanent end is vertiginous, and I may meditate on the view from the bottom, but we’re thankfully not at the point where corporeal existence is too much for Jake to bear. He’s said that he’ll likely be ready to leave before the moment he’s physically forced to. But he’s also said he’s going to stay with me as long as he feasibly can, and I’m comforted by that.

I can’t logic my way out of the catastrophe that’s coming, but logic can tell me it’s not yet here. I can save my meltdown for when Jake is not beside me, holding my hand, and then suffering will seem as necessary as air, for a time.

I take a deep breath and focus on the moment. I breathe in and think about how well I’m doing, which, according to my lists, is pretty well. I breathe out and think about how not unhinged I am. I think about how reasonable my behavior is, according to my personal psychiatrist, and how I’m just trying to cope the best I can, the best any of us can, though I can’t quite remember how I got here: half naked and covered in flour, weeping and ranting in the baked goods aisle of this grocery store, wondering why everyone is pointing while Jake gets a phone call to come pick me up, sure that people are starting to circle around me and stare because they’re all just jealous of my A+ in mental health***

Am I doing wellness, now?

If you’ve gotten this far, consider the Go Fund Me that’s funding Jake’s ongoing care. You can also read Jake’s perspective (and I highly recommend that you do!) at JakeSeliger.com

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* A sampling of the jokes at ASU’s expense:

To be fair to ASU and myself, at ASU, like many if not most schools, you get out what you put in; chemistry majors took the same standardized American Chemistry Society exams that many other schools used, for example. Although Manzanita hall, where I lived and worked as a tutor, did happen to have the highest STD rate of any dorm in the country, so sometimes the things people were putting in weren’t adequately wrapped up.

** I’m teasing you, oncologists, because I love and respect you so. But seriously, stop sending patients with worsening symptoms to the ER without warning them first that it might be a sign of disease progression, leaving me to give them the bad news and do your dirty work.

*** For the record, this is a joke. This did not actually happen. I only cry in the grocery store fully clothed. I also usually cry in the dairy aisle for some reason. It’s also not a metaphor for a psyche ward, a witches’ coven, or graduate school. It might be a metaphor for medical school.

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