Excerpts from Must Read Books & Articles on Mental Health Topics
Articles- Part IX

Documents
Charles D'Ambrosio, New Yorker- 6/24/2002

Poem by Father (1972). One Sunday morning when I was a boy, my father came out of his office and handed me a poem. It was about a honeybee counselling a flea to flee a doggy and see the sea. The barbiturates my father took to regulate his emotions made him insomniac, and I understood that he'd been awake most of the night, laboring over these lines, listing all the words he could think of ending in a long "e." This meant using many adverbs and the elevated "thee" as a form of address. My father was a professor of finance who wrote fairly dry textbooks, where the prose marched in soldierly fashion across the page, broken by intricate formulas calculating risk and return, and this poem was a somewhat frilly production for him. The poem was an allegory about his desire to leave our family. Like a lot of people, my father felt that a poem was a bunch of words with a tricky meaning deeply buried away, like treasure, below a surface of rhyming sounds. I was twelve years old, and I understood the sense of the poem instantly, but the strange mixture of childish diction and obvious content silenced me. I was ashamed. That Sunday morning, I was sitting on the living-room floor, on a tundra of white carpet that my father considered elegant. The drapes were closed, because he worried that sun would fade the fabric on the fiirniture, but a bright bar of light cut through a gap in the curtains, and that's where I sat, since it was warm there, in a house where we were otherwise forbidden to adjust the thermostat above sixtytwo degrees.
    Letter from younger brother (1997). Not long ago, I was in Seattle, sitting in a cafe downtown. It was raining. I'd been there for sometime before I realized that someone was staring at me through the window I turned around and saw worn tennis shoes and dirty gray sweats. The man outside the window was my brother Mike. My father had three sons. I'm the eldest; Danny, the youngest, killed himself sixteen years ago.
    In addition to the tennis shoes and sweats, Mike was wearing a white T shirt that hung to his knees and a black leather jacket he'd bought with V A. money at a thrift store. His thinning hair was soaked, and his face had the pallor of warm cheese. In a plastic sack he carried a carton of cigarettes he'd bought at the Navy PX. He's schizophrenic, and on some level I'm always aware that he's a stranger. I went outside, and we talked and, in talking, we were brothers again. He did not look good; he was shivering. He was several miles from his halfway house, but when I offered to give him a ride he said, quite happily, that he preferred to walk. He started up the hill, limping a little from a pelvic injury he received, years ago, when he tried to kill himself by jumping off the Aurora Bridge, in Seattle. Very soon he was gone.
    Only a few years ago, Mike was doing much better, and he wrote letters regularly, often two or three a month. Here is one:

Dear Char,
Mike here, who is there? I am fine as a blade of grass. How about you? As I was leaving church the other day there was an opportunity to be part of a poor person's Kriss Kringle. I decided to buy an AIDS patient some high-quality gloves. The situation reminded me of Danny-I don't know why. The gift will be given to him although I believe I will never actually see the recipient. I will give him a card that says, "To a friend I don't know" I don't think of Danny a lot. I don't feel pain about his death a lot either. Jesus has stepped into his boots and has replaced him. It caused me to heal and be born again. It is really quite beautiful. My heart is still with that kid like you cannot believe-or I suppose you could. Love can play a trick on you. It can cause you pain like you were suffering in hell, but it is still love and still beautiful like heaven and the heaven and the hell of it are woven into one fabric, which is love. It's a mindblower to think like that but that is what Danny has done to me. Call or write please. I don't own a cat or dog--but I do the same by looking at squirrels and crows. I plan to buy some peanuts to feed the squirrels and bread for the birds. It is so much cheaper and I enjoy it the same as having my own animal. When I pray I can see my life flash before my eyes. It is very beautiful. My life flashes before my eyes about twenty times a year. Other stuff like that happens to me also. I've been through so much since becoming mentally ill-most of it, believe it or not, was good. Because of that I became sort of an indestructible man.
Love, Mike

Letter from youngest brother (November 26, 1986). My brother Danny wrote his suicide note in my bedroom, and then, after a caesura that I know exists because he had to put down the pen in order to pick up the gun, he shot himself: For some reason, I've always been concerned about the length of the lapse, whether he reread what he'd written or stared dumbly at his signature, his name the final piece in a puzzling life he was about to end, before he pressed the gun to his head and pulled the trigger. Most suicides go about the last phase of their business in silence and don't leave notes. Death itself is the summary statement, and they step into its embrace hours or days before the barrel is finally raised to the roof of the mouth or the fingertips last feel the rough metal of the bridge rail. They are dead and then they die. But Danny wrote a note, or not so much a note as an essay, a long document full of self-hatred and sorrow, love and despair, and now I'm glad that I have it, because, this way, we're still engaged in a dialogue. His words are there and so is his hand, a hand I'd held, but, more important, one that left words that, like an artifact, are as real and physical to me as the boy who, at twenty-one, in a November long ago, wrote them.
    I read the pages he wrote two or three times a month, often enough so that the words ring like the lines of poems I know well. All the struggle is still there in the headlong sentences that tumble toward his signature, in the misspelled words and syntactical errors, in the self-conscious language of a boy starved for love and trying, instead, to live a moment more off pride. The note has the back-and-forth of a debate, of words equally weighed and in balance, of a slightly agonized civility. He says, "I stopped making dreams." He says, "I don't know why I am doing this. I don't want to. I have dreams." He says that there is no God and that God is looking over his shoulder as he writes, making editorial remarks. He says, "I am glorifying myself now I am afraid to stop writing though. I want to keep talking." He says, "I don't know what to say except I am sorry and I love. I love the whole family quite a bit and the terrible=' He clearly wants to find a way back, but he can't. He asks that we keep "the way" he died a secret and, as though he were done, signs his name. But on the next page, the last, he again asks that we keep "the way" he died secret, and again he signs his name. Much of the note is printed, and those letters stand upright, but in the end Danny slips permanently into a sloping cursive as despair and self-hatred accelerate beyond return, as if he were being pulled down by the dark undercurrent of his life, his last words looping quickly across the page, continuous as breath.
    Letters from eldest brother (2001). Two years ago, I moved to Philipsburg, Montana. In the fall, I went for walks and brought home bones. The best bones weren't on trails-deer and moose don't die conveniently-and soon I was wandering so far into the woods that I needed a map and compass to find my way home. When winter came and snow blew into the mountains, burying the bones, I continued to spend my days and often my nights in the woods. I vaguely understood that I was doing this because I could no longer think; I found relief in walking up hills. When the night temperatures dropped below zero, I felt visited by necessity, a baseline purpose, and I walked for miles, my only objective to remain upright, keep moving, preserve warmth. When I was lost, I told myself stories, recounting my survival, implying that I would live and be able to look back at it all. At some point, I realized that I was telling my father these stories.
    I decided that I would try corresponding with him. I had built a lean-to at seven thousand feet, and I routinely slept there. In the morning, I warmed myself by a fire and then walked home and began writing. I worked for days, even weeks, on the letters. The last time I'd seen him he made a point of showing me the stains in his bed, on the sheets. He pulled away the blankets, revealing bright-yellow splotches of mustard, red patches of spaghetti sauce, something urinous that had spilled from a carton of take-out Chinese. I'm not sure what he meant to show me, and I'm not sure what saddened me more, this man eating alone in bed, who could not clean up after himself, or this man who needed to share with his son a grotesque failure.
    My father and I had survived the same wounds. His lost sons were my brothers. I believed we might have something to talk about. I was drawn to the antique idea of a correspondence because it seemed restrained and formal, even ritualized. In Philipsburg, there is no home delivery, and people go to town to pick up mail. I always walked to the post office with my dog, and even that little effort, that mile of dirt road, blowing with dust or running with mud or silent under new snow, made the mail that much more meaningful.
    I delayed sending my first letter for several months. My father replied with a long, bulleted outline. I read it bullet by bullet, feeling disoriented, despite the orderly indents and the nesting of what, in outlines, are called "children." After four or five readings, I was able to breathe normally. I reread his outline until I lost its meaning, then got out my colored pens and began highlighting. The bullets and dashes and indentations were like the sleeves and straps and buckles of a straitjacket. I've often thought that the unit of measure that best suits prose is the human breath, but there was no air in my father's sentences; he seemed to be suffocating inside them.
    I had made an effort to discuss the events of our past, but he regarded this as a trespass. "When did God empower you," he asked me, "with such omniscient abilities?" His position was truth; mine was not. My letter, he wrote, "is incorrect throughout, is a fictional (Having no foundation in fact, OED) version of reality (Reality: The quality of being real or having an actual existence, OED)." He was defensive, which I should have anticipated: "After nine years of sixtyhour weeks of intensive research, not reading and study, but research, I know I was a terrific dad and terrific husband."
    I wrote more letters. His replies were long--seven, eight, nine pages. There were words he couldn't get past. He be came obsessed with "boundaries." Boundaries were bad. "Those who set them up," he wrote, "protect the dysfunctionality they see in themselves and seek to foist that malady on others through their boundaries." Boundaries, he wrote, "are the antithesis of meaningful honest relations." Boundaries have no place between a father and his children. Instead, he insisted that the proper word was "relation': "Relation is a mathematical notion which means one-to-one correspondence."
    Another time, it was the word "gag." He had used the word, saying that I was prevented from speaking honestly; I objected; he objected to my objection. "Emphasis on the word, gag, denies the act!!! The gag is the aggressive act. The word gag fits, is proportional to, the act. The gag is the loaded act; the word gag fits the denigrative power of the act. The act, not the word, is aggressive and odious. Place the focus where it belongs, properly, on the aggressive and repugnant act, and not on the word."
    Some nights, I dug into the lee of a snowdrift and hollowed a shelter for myself: Snow contains air and insulates, holding the body's warmth so that, at a certain point, the temperature remains constant, blood and ice in equilibrium. In deep snow, I dragged supplies with a pulka I'd made from a child's sled and plastic conduit. I was afraid of avalanches and checked a slope meter before traversing open, treeless hillsides. What I feared was suffocation, particularly the inability to make my chest expand. I really knew nothing about winter, nothing about surviving the season beyond the blunt lesson in fatality I'd learned from picking up bones. Sometimes I slept in the open mouths of mine shafts, their crumbled headframes like broken teeth, where twice I found clusters of bats, hanging by their feet, their wings folded in, like the strange fruits of darkness itself.
    I wrote, asking him about our home movies. For years I'd kept alive the fantasy that he burned the movies, only because I was haunted by the image of them orphaned in a Salvation Army thrift shop, reels and reels of birthdays, Christmases, and Easters, all reduced to an ironic treasure for strangers. In the past, I had wanted to believe my father was a liar rather than a man who could destroy something so valuable to his children. The movies were old Super 8s, poorly lit and without sound, but the only place left where I could see my brother's face.
    I wrote, "You intentionally destroyed something inside your children, a place of warmth and fondness, a cherished dream, a continuity that connects us in time to our history and across space to one another." His response was icy: "Of what sense of warmth and fondness are you speaking? It is an interesting sentiment, laced with some romanticism, but devoid of reality." And he wanted to know, "What did I destroy in you that was not already destroyed?"
    In my father's last letter, the grammar carries the summary tone of a narrative closing down. It is framed by the forms of family affection. He opens with "Dear Char" and parts with "Love," followed by his signature. In between, the language suggests closure, termination. My previous letter, he says, continued an "unacceptable tenor and deadend focus." It smacked of "recidivism;" it followed a "desolate and vacuous path." None of my letters "added a repayment," he says. "So be it."
    I sometimes wonder if by "repairment" he meant "repayment," and I always pause at the caesura created by the simple sentence "So be it," which Catholic kids were once taught is the meaning of "Amen." Was this the phrase that ran through my brother's mind as he paused between his two signatures? So be it: with these, my father's last words, I know I will never hear from him again. But I save his letters, as I save Danny's, as I save Mike's, neatly bound and held between the Army-surplus boots that my brother died in, and which I keep, filled with rocks, on my desk.

Sick With Worry
Jerome Groopman, The New Yorker- 8/11/2003

Amanda was sure that she had contracted leukemia, developed a brain tumor, and had a stroke--all around the same time. She made this self-diagnosis while experiencing intermittent discomfort in her abdomen and feeling a persistent wooziness in her head. She often felt off balance, as if she were walking on a warped floor. "I was also really worried about my spleen," she told me in a recent conversation. (Amanda is not her real name.) For almost a year, she had sought explanations for her various complaints, discussing her symptoms with twenty physicians in her H.M.O. All of them told her that they could find nothing wrong. These doctors spent little time with her, and none offered a follow-up appointment, although they readily referred her to other physicians.
    With growing frustration, Amanda visited more specialists, undergoing physical examinations, blood tests, and sonograms. Nothing abnormal was found, but with each test she became more convinced that she was seriously ill. She kept looking for a doctor who would tell her, unequivocally, that her symptoms could not possibly indicate a fatal sickness. When doctors couldn't give her absolute assurance, she concluded that something terrible must be wrong with her. I asked Amanda, a petite woman with a lightly freckled face, why she thought doctors kept referring her to others. She was perplexed by the question. "We live in a litigious society," she said. "Maybe they were afraid of lawsuits, if they missed something." She paused. "Maybe they were confused by what was wrong with me."
    Amanda, who is thirty-three years old and teaches theatre arts at a West Coast college, has suffered from medical anxieties many times before. Several years ago, she was in a travelling theatrical group for children, and played a role that required her to wear an elephant costume for more than a hundred days in a row. After a long day spent in rehearsal and onstage, she often felt exhausted and queasy. Most people would attribute these feelings to stress, but she was convinced that her symptoms indicated a dire disease; one day, during a prolonged episode of abdominal pain, she thought she might be dying and, in a panic, asked a colleague to take her to a local hospital. The doctors there failed to detect anything out of order. The next night, she went again, and once more the E.R. physicians sent her home.
    Amanda's fears about illness began when she was nine, after she heard that a schoolmate had almost died from a severe case of chicken pox. As a teenager, she was terrified each time she had to visit a doctor. "I remember when I was fourteen years old, and I was sitting in biology class and had a doctor's appointment later that day," she said. "I was so scared, I couldn't think." She entered college at the peak of the AIDS epidemic. Though she told me that she "wasn't strongly at risk for H.I.V. "--she had few sexual partners and regularly used protection--she became consumed by the idea that she was infected. "I really thought I had the virus," she said. Shortly after graduation, Amanda moved to New York City, where she got a job in a bookstore. "Each day, I checked reference books in the store, and called people about AIDS," she said. "It got so bad that my co-workers tried to keep me away from the health section."
    She finally decided to be tested for H.I.V. and, one day, stood for more than an hour in a long line at a New York public-health facility. Part of the free testing procedure involved undergoing a pelvic exam. "I was up in the stirrups," she recalled. "And this horrible doctor I didn't know said to me, `Oh, my God! There is something definitely wrong with your cervix.' " Her heart started to race, and she asked the physician whether her condition could be related to cancer. He replied that her cervix was inflamed, and that some women with H.I.V. had a similar condition. "I began to cry hysterically," Amanda said. "The doctor looked at me and said I should learn to relax--listen to music or something." Amanda ended up getting two tests for H.I.V. , in case one yielded a false result. Both were negative, and the inflammation was benign, but she was so traumatized that she didn't have another gynecological exam for three years.
    People like Amanda populate every doctor's waiting room. Studies show that at least a quarter of all patients report symptoms that appear to have no physical basis, and that one in ten continues to believe that he has a terminal disease even after the doctor has found him to be healthy. Experts say that between three and six per cent of patients seen by primary-care physicians suffer from hypochondria, the irrational fear of illness. The number is likely growing, thanks to increased medical reporting in the media, which devotes particular attention to scary new diseases like SARS, and to the Internet, which provides a wealth of clinical information (and misinformation) that can help turn a concerned patient into a neurotic one. Nevertheless, hypochondria is rarely discussed in the doctor's office. The "worried well," as sufferers are sometimes called, typically feel insulted by any suggestion that their symptoms have a psychological basis. Most patients are given a formal diagnosis of hypochondria only after ten or so years of seeing physicians, if they get such a diagnosis at all.
    Doctors often dislike their hypochondriac patients; they consume inordinate amounts of time, and strain hospital resources with their interminable complaints. In the United States, it is estimated, twenty billion dollars a year is spent on patients whose psychological distress requires repeated tests and procedures. Many doctors and nurses make fun of hypochondriacs, calling them "crocks" and "turkeys." The favored epithet among interns and residents is GOMER, which stands for Get Out of My Emergency Room. Many doctors are relieved when a hypochondriac leaves them for another physician.
    Perhaps unsurprisingly, research on the subject is sketchy. The most recent edition of the "Cecil Textbook of Medicine," a volume of more than two thousand pages that is one of the bibles of internal medicine, includes only two sentences on hypochondria: "Chronic preoccupation with the idea of having a serious disease. The preoccupation is usually poorly amenable to reassurance." The National Institutes of Health currently funds no studies on the topic.
    Among the few psychiatrists and primary-care physicians who are interested in the problem, there is little agreement about the reasons for the disorder and what to do about it. Only in recent decades has a working definition of hypochondria been formulated by the American Psychiatric Association: "The fear or belief of serious illness that persists six months or more despite physician reassurance." Conventional medical wisdom holds that hypochondria is a hopeless condition and should be treated by ignoring it, because a hypochondriac's recognition of his problem does not result in a change in his symptoms or in his behavior. Indeed, doctors like to joke that a hypochondriac's symptoms will disappear only when the patient lands on a desert island--and nobody is around to listen to his whining.
    The term "hypochondrium" can be found in the writings of Hippocrates. The word originally had an anatomical emphasis--indicating the area under (hypo) the cartilage of the ribs (chondros)--and referred to digestive disorders of the liver, spleen, and gallbladder. Starting in the seventeenth century, "hypochondria" was used to describe a melancholic disorder that was also marked by indigestion and vague pains. Leeches were the preferred mode of treatment. The diagnosis developed a certain cultural chic, particularly in eighteenth-century England, where it was called "hyp," and an anxious, gloomy temperament was considered a sign of high intelligence. Samuel Johnson and his biographer, James Boswell, both suffered from the malady. (In his "Life of Johnson," Boswell wrote of his friend, "All his labours, and all his enjoyments, were but temporary interruptions of its baleful influence.") Men were thought to be affected by hyp more than women, whose nervous behavior was typically interpreted as hysteria.
    It wasn't until the nineteenth century that hypochondria came to be narrowly defined as an excessive fear of illness. Not coincidentally, the disorder flowered at the same time that modern medicine began identifying one rare disease after another. In his novel "In Search of Lost Time," Proust wrote, "For each illness that doctors cure with medicine, they provoke ten in healthy people by inoculating them with the virus that is a thousand times more powerful than any microbe: the idea that one is ill."
    Modern psychologists have devoted surprisingly little attention to the disorder. Freud simply asserted that it was the result of libidinal energies being directed at one's own body, and declared that the disorder was not susceptible to "purely psychological inquiry." In later years, psychoanalysts offered a variety of explanations for hypochondria. Some saw the behavior as a general cry for help from the subconscious; others defined it as a targeted, if covert, expression of anger toward physicians.
    Hypochondria is so hazily understood that most doctors have no dear idea how to manage patients who suffer from it. The disorder is particularly tricky for the primary-care physician, who often sees patients with nebulous complaints and must judge how deeply to explore these ambiguous symptoms. The doctor knows that a fair number of people in his waiting room each day will prove to have no physical disorder--yet he must remain open to the possibility that each patient might truly be sick. Hypochondriacs, in effect, risk deafening a physician with their relentless background noise.
    I am a medical specialist who cares for patients with blood diseases, cancer, and AIDS. Several years ago, I was a consulting oncologist for a woman who had developed breast cancer. The tumor had been found early and was removed by surgery. I saw her only once or twice a year, but her internist had told me that she was a severe hypochondriac. At each visit, she unloaded a series of complaints, but almost always mentioned having a queasy feeling in her stomach. Her husband sometimes accompanied her to my office; once, when I asked her how long she had suffered from the stomach symptom, he interrupted and said, "Since I married her." The couple had been together for thirty years. I looked at him from the corner of my eye and we exchanged a dismissive look. Some weeks later, I was called by the patient's primary-care doctor, who told me that she had almost died from sepsis owing to an infected gallbladder. I was distraught that I had treated her complaints with such a cavalier attitude. Sometimes, even a hypochondriac's complaints are valid.
    Another reason that doctors are uncomfortable with hypochondriacs is that physicians routinely become afflicted with the disorder themselves. After all, doctors are trained to be exquisite observers of subtle symptoms. As one colleague put it, "When we learned about Hodgkin's disease in medical school, everyone was feeling his lymph nodes, and for several weeks was terrified that he was on the brink of being diagnosed."
    This winter, I injured my right hand, and it was not clear whether one of the small bones in my wrist was fractured. An orthopedic surgeon suggested a bone scan. The night after the scan, he called me at home. "It doesn't look like a fracture," he said. "Before we deal with the wrist, however, we need to evaluate the suspicious areas in your left upper ribs." One radiologist thought that the scan, which had surveyed my entire body, showed changes in the ribs which were consistent with metastatic cancer.
    As I hung up the phone, my hand trembling, I noticed that my left upper ribs ached. They hadn't hurt before the call. My wife, who is also a doctor, was out of town. I reached her on the phone, and she tried to reassure me that bone scans are notoriously inaccurate and are often misread. I was unable to sleep that night, and the pain in my left ribs became more intense. At eight o'clock the next morning, I was the first in line at the radiology department to have further X-rays done. My ribs were normal. But the discomfort didn't subside for a week, and it was nearly two weeks before I could fully dismiss the fear that I was going to die from bone cancer.
    Tom Delbanco is a professor of medicine at Harvard, and the founder of a primary-care and teaching practice at the Beth Israel Deaconess Medical Center, in Boston. This spring, he talked to me about how he handles hypochondria. "The primary-care doctor has to be the principal therapist in these circumstances, and he has to be proactive, not reactive," he said. "We doctors are very bad at explaining most things that bother people. And the worst illness in the world is uncertainty. Medicine is imperfect. Yet hypochondriacs want their doctors to be one hundred per cent certain that nothing is wrong, and, of course, they can't be."
    The interaction between the hypochondriac and the physician, Delbanco told me, subverts everything that a doctor is taught about how to communicate with patients. Expressing concern only reinforces the hypochondriac's sense that something is awry. Marshalling the considerable technological resources of modern medicine, by ordering sophisticated blood tests and high-resolution M.R.I. scans, still falls short of providing reassurance.
    The physician, therefore, is frequently forced into an uncomfortable corner: he must either continue to send the patient for needless evaluations or refuse the patient's urgent requests for another blood analysis. Too often, a fear of lawsuits encourages the doctor to proceed with unnecessary tests, which can in turn heighten a hypochondriac's anxiety.
    Delbanco believes that other recent changes in the doctor-patient relationship have further amplified the problem of hypochondria. Self-help books encourage patients to distrust conventional medicine and to be "in touch" with their bodies--to rely on their feelings as much as on a CAT scan or a blood test. "Patients are supposed to be empowered in today's society, and are entitled to demand answers from their doctors," Delbanco said. Moreover, today's physicians are trained to respect a patient's intuition and become more of a partner with the patient. A doctor's egalitarian posture can inadvertently validate the irrational feelings of a hypochondriac.
    Instead of just listening quietly, Delbanco also speaks assertively to his hypochondriac patients, readily invoking his authority as a physician. When I met with Delbanco, he talked about how he had dealt with one challenging patient, an intense, flamboyant Russian musician. The patient was terrified that the sensation of pressure in his chest meant that he could suddenly die of a heart attack. Delbanco dismissed these concerns, saying that the symptoms were caused by a particularly difficult piece by Brahms that the musician was performing. (Delbanco is a gifted violinist.) Moreover, he refused to send the musician for an expensive evaluation, declining requests for X-rays and a referral to a specialist. "You're an artist," he told him. "That is why you are suffering. I know you think you are dying, but you have to trust me that you are not. We're not doing any tests. The sun is out. Now get out! See me in two weeks if you have to."
    Delbanco almost never accommodates hypochondriacal patients between scheduled visits. "They can send me an e-mail if their fears are boiling over," he said. "But I establish with each patient how many visits he is allowed to my practice." Delbanco and the clinic's other doctors work alongside nurse practitioners and psychiatric social workers. "The most hypochondriacal patients are shared among us, so no single health-care provider has to shoulder the burden all the time," he said. Regular communication within the team prevents these patients from pitting one member against another, or evading one doctor's limits on additional testing.
    I asked Delbanco how his patients fared in this constraining structure. "Most adjust to it," he said. "And the hypochondriacal behavior often improves, but rarely disappears." Some patients, of course, find his strictures intolerable. "A young man whose sister had died of cancer initially insisted on seeing me every two weeks," he said. "He was filled with fears that he had a malignancy. I cared for him on and off over some five years, and refused to do repeated tests for his symptoms. Recently, he left in disgust for another doctor."
    Delbanco said that he didn't necessarily regard losing a patient as a defeat. "In any illness where you're really tough with patients, some will leave you," he said. "When you tell an alcoholic, `You're drinking too much and you've got to cut it out, 'there's a good chance that he'll get another doctor. But he'll never be the same again. He'll wake up the next morning and say, `Maybe I drank too much. 'The alcoholism field knows that. It's the same with the hypochondriac."
    Most of Delbanco's cases end without rancor. He told me of a middle-aged woman who began visiting him ten years ago. The patient was the wife of a busy entrepreneur; she stayed at home, and seemed frustrated and bored. She had fleeting pains in her joints and deep muscle aches in her back, arms, and legs, and was seen by a rheumatologist, who ordered numerous blood tests but did not arrive at a diagnosis. In addition to the joint and muscle pains, the patient felt a tightness across her chest. She had undergone pulmonary-function tests, multiple X-rays, ventilation-perfusion scans, and, ultimately, a lung biopsy, all of which failed to explain her symptoms. She came to Delbanco, certain that she was deathly ill. At first, Delbanco explored a variety of arcane diagnoses, but when all the tests came back negative he grew convinced that the woman was healthy. The patient was so zealous in her desire for treatment, however, that Delbanco became concerned that she would end up undergoing unnecessary exploratory surgery on her chest and abdomen. "I told her we had to stop," he recalled. "I said I had no clue what was wrong, but it was my job to keep her away from harm." Surprisingly, the patient accepted Delbanco's forceful advice, and her symptoms have largely subsided; now she visits him only once or twice a year.
    Brian Fallon, a neuropsychiatrist at Columbia University's Department of Psychiatry and at the New York State Psychiatric Institute, has devoted considerable time to the study of hypochondria. He became interested in the subject about fifteen years ago, when he was a resident-in-training and treated a year-old stockbroker who was convinced that he had a brain tumor. He had seen ten doctors and undergone four brain scans. Even after receiving four negative test results, the broker spent much of his day consumed with thoughts about the subtle ways that a brain tumor can signal its presence through a headache.
    Fallon thought that the patient's symptoms might be rooted in an obsessional problem, and prescribed Prozac, at twenty milligrams a day. But then, as is common for residents-in-training, Fallon was assigned to other duties. Months later, he had a chance encounter with the stockbroker. "It was a eureka experience," he said. The stockbroker told him that the Prozac had not had any impact until the initial dose of twenty milligrams was tripled, to sixty milligrams a day and then his constant worrying about headaches disappeared.
    "I was a young university-based psychiatrist looking to begin an academic career," Fallon said. One way to do that was to lay claim to an effective therapy for a difficult disorder. Fallon postulated that hypochondria was a form of obsessive-compulsive disorder. He speculated that the same neural pathways involved in O.C.D. were connected to hypochondria; high doses of serotonin-absorption inhibitors like Prozac had been reported to alleviate some types of O.C.D.
    In 1993, Fallon sent more than five hundred letters to physicians affiliated with Columbia, asking them to refer patients who might be hypochondriacs to his clinic. "I got a single referral. Just one," Fallon told me. Hypochondria was apparently such an embarrassing diagnosis that no physician would dare suggest to a patient that he suffered from it. Undeterred, Fallon took out advertisements in the Daily News and the Post. Instead of using the loaded word "hypochondria in his ad, Fallon said that he was seeking people with "heightened illness concerns" to participate in a clinical trial. He was deluged with responses.
    Fallon's study, which enrolled subjects for nine months, showed a statistically significant difference in the amelioration of hypochondriacal symptoms between a group taking Prozac and one taking a placebo. Fallon remains cautious about his findings--only fifty-seven patients were involved in the study--but he does think that the anti-obsessional agent holds promise for many sufferers. The study also yielded many ancillary insights. For example, several participants experienced what doctors call the "nocebo effect": even though these patients were in the group randomly assigned to take a chemically inert placebo, they reported suffering from side effects associated with taking Prozac, like insomnia and indigestion. These hypochondriacs had likely read their informed-consent forms, which detailed all the possible symptoms that could arise from taking the anti-obsessional drug, a bit too carefully.
    One patient who fell prey to the nocebo effect had become aware of the symptoms that can arise when a person stops taking Prozac. "She came to me with all these troubling withdrawal symptoms," Fallon said, including profound nausea, recurrent nightmares, profuse sweating, and pounding in her chest. The patient feared that she had been taken off the drug midway through the trial. In fact, she was still taking Prozac, but her suspicion that she had been switched triggered a florid reaction. "Because of her negative assumptions, she was convinced that she would be unlucky," Fallon said.
    In another surprising result of Fallon's study, nearly thirty per cent of the patients who took a placebo had some improvement in their hypochondria. This high rate caused him to reexamine his initial hypothesis, that hypochondria was exclusively a form of obsessive-compulsive disorder, since the latter rarely shows such a high rate of improvement in placebo trials. Fallon has reconceived hypochondria as a heterogeneous disorder: some sufferers are indeed obsessive-compulsives, whereas others are experiencing a prolonged reaction to a traumatic event, like the death of a loved one. He also believes that people who are labeled hypochondriacs can behave in diametrically opposite ways in terms of seeking medical care. For some, the fear of illness is so great that they avoid all doctors. These patients indulge in the fantasy that if a doctor doesn't examine them, then the illness won't appear. Another group needs to see doctors constantly, even when these visits cause more anxiety or humiliation.
    One of Fallon's patients is Amanda. At the bookstore where she once worked, the manager gave her a copy of "Phantom Illness," by Carla Cantor. It had a preface by Fallon, which describes his work with drug-therapy treatments. "It was a revelation," Amanda told me. "After all those years, I finally knew what I had." Amanda entered into another pilot study that Fallon was conducting. The trial was centered on Luvox, a drug related to Prozac but considered to be more beneficial for O.C.D. Luvox muted some of Amanda's most extreme anxieties about illness, but it did not erase them. "I still have anxiety and am too scared to check my breasts regularly," Amanda said, although she has been on the Luvox treatment for three years. "Certain things still set me off. I read `Fast Food Nation' and learned about mad-cow disease. I didn't eat beef for a long time." But Amanda believes that she has developed some perspective and can better cope with medical problems, particularly if she knows they are not life-threatening. "I had kidney stones three times, and they are really painful, but I said that it's O.K, because you don't die from them."
    Arthur Barsky, a psychiatrist at Brigham and Women's Hospital, in Boston, is another of the country's few hypochondria researchers. He takes a highly pragmatic approach to the problem. He doesn't think that it really matters whether hypochondria is a product of nature or nurture; what's important, he believes, is doing something to get rid of a patient's distorted perceptions. Though he acknowledges that a person's brain chemistry may contribute to hypochondria, he generally avoids drug treatment for the disorder. Instead, Barsky focuses on changing destructive behavior through rigorous, sustained therapy--a structured regime that is more refined than, but similar in spirit to, Delbanco's improvised approach.|
    Recently, Barsky conducted the most ambitious to-date controlled study of cognitive-behavioral therapy for hypochondria. "We teach patients to argue against themselves," Barsky said. That is, the therapist consistently reminds the patient that it is possible for a healthy person to have symptoms but no actual disease: a headache is almost always a headache, not a sign of a brain tumor. The therapist also tries to reduce the amount of attention that the hypochondriac pays to bodily sensations. (Hypochondriacs are unusually attuned to physical sensations; studies have found that they are better than other patients at measuring their heart rates, and can more accurately distinguish between two flashes of fight delivered in rapid succession.) Research has shown that focusing on some minor physical symptom amplifies the sensation. For example, if a person holds a sheet of paper between his thumb and forefinger, he will notice a tiny, natural tremor in his hand. A person who stares at the tremor will start to shake more, whereas a person who is diverted by conversation or watching a video will tremble less. "I also tell people to pay attention to their throat," Barsky said. "If you do it long enough, you'll probably start thinking, well, it feels a little dry. Then it starts to feel a bit scratchy and itchy, and you may even cough. The more attention you pay to your body, the more uncomfortable your symptoms will become."
    These scientific insights are shared with the patient, who participates in such simple experiments. Barsky works to reform specific behaviors. If the patient rushes home to turn on the six-o'clock news to hear the latest reports on SARs, Barsky instructs him to stop watching television. If he begins his day by reading the obituaries, then he must skip that section of the newspaper.
    After an initial medical and psychiatric evaluation, a hundred and eighty-seven hypochondriacs entered Barsky's study, which ran for a year. A hundred and two were assigned to the program of cognitive-behavioral therapy; the eighty-five others served as controls. Those who completed the program improved significantly, experiencing far less frequent bouts of hypochondria.
    Barsky is the first to point out problems in his study. The data on the benefits of cognitive-behavioral treatment were drawn from questionnaires filled out by the patients, and these self-assessments were not corroborated by an objective observer, such as a spouse. There was also significant improvement over time in the control group. Barsky says that this effect is common in clinical trials: sometimes the mere act of participating in a clinical trial--that is, receiving a diagnosis from an authoritative figure and being assessed by trained professionals--can have a positive effect on a patient's disorder.
    Barsky is hoping to hone a treatment regime that can become the standard therapeutic approach for hypochondria. Linda, a sixty-nine-year-old retired businesswoman, is one of Barsky's patients. (Linda is not her real name.) She is slim and notably fit for her age; she makes a point of exercising, and loves playing golf. When she was in her thirties, she lost both her parents within a matter of months, her mother dying of stomach cancer and her father of a heart attack. Soon after their deaths, she began having indigestion, and worried that it was the first manifestation of the malignancy that had killed her mother. Similarly, while driving in heavy traffic or conducting a business meeting, Linda felt fleeting chest pains and was certain that she was having a fatal myocardial infarction, like her father. Following each episode, she would visit her doctor, who would perform a few basic tests and then send her home.
    Finally, Linda's doctor ordered a chest X-ray. At the end of her appointment, the doctor showed the film to Linda; although he said the image was normal, he mentioned in passing that he had noticed a faint shadow, which he thought was of no significance. "I crashed leaving his office," she said. She couldn't shake the notion that the shadow signified cancer. After her primary-care physician retired, Linda found a new internist, who spent more time with her, addressing her fears in long, specific discussions. But his solicitous manner seemed only to magnify her concerns. This past winter, for example, she noticed a small, firm lump on her foot. Her new doctor told her that it appeared to be a benign ganglion cyst, and tried at length to calm her. But, when pressed, the internist refused to say that such a lump could never turn out to be cancerous. He treated Linda with a variety of psychiatric medications, but none had much effect. This spring, she learned of Barsky's study and sought him out.
    I spoke with Linda this June. She was fashionably dressed in a black pants suit and a coral sweater set. She was seeing Barsky as an individual patient, not as part of a clinical trial, and it was early in her therapy. He was still gathering information about Linda's beliefs, and how she tried to cope with her fears. Barsky asked her to report on how she had been feeling since they last spoke, some weeks earlier. "I wish better," she said. "Something triggers me and then it consumes me." Linda explained that, like many postmenopausal women, she had taken hormone-replacement therapy to prevent heart disease and to preserve her bones. The therapy had been discontinued last year, after the results of the Women's Health Initiative trial were released, indicating that the treatment did not prevent cardiovascular disease and appeared to increase the risk for heart disease, stroke, and breast cancer. Just before Memorial Day weekend, Linda had read in the newspaper, and seen in reports on television, that new data from the W.H.I. study showed that the hormones also failed to prevent dementia. The news riveted Linda, and not long afterward she felt tenderness in her breast. "I started checking myself, in the shower in the morning, and my breast was painful," she said. As she spoke, her quivering hand moved to the left side of her chest.
    Barsky asked if she felt any lumps. She said that she didn't, but that she couldn't get her mind off the discomfort in her breast. She had taken the hormones for nineteen years, in the hope that they would prevent sickness; now she was convinced that the result of her efforts would be cancer. She called a neighbor who had had breast cancer, and asked her whether breast tenderness might be a symptom of malignancy. The neighbor thought it could be. "That sent me into a tailspin," Linda said. She began to cry. Barsky handed her a box of tissues, and gave her a few minutes to compose herself. He then asked what she did over the long weekend to deal with her anxiety. "I took a Xanax, and it helped a little," Linda said. "I didn't talk to my husband about it."
    "Good," Barsky said. "And I cleaned the house like a maniac. "Good, that's fine." Barsky had recently introduced to Linda the idea that specific activities could divert her attention during a bout of hypochondria. "But I couldn't get on the golf course," Linda said. She had found that immersing herself in the game was a way to relax. "The weather was awful the whole weekend long." "And the past experiences, you can't draw on them?" Barsky asked. "They are not reassuring? You could say, `I've been through this fifty times, and now the odds are that, with the fifty-first time, it also won't be something bad."' "I try to think of that," Linda said, "and I thank God every time I get a good report. But I can't stop it. I think, Is this the time I won't be lucky?"
    Barsky asked what would be the worst thing about having breast cancer. "Well, I would die," she said instantly. "You're supposed to get wiser when you get older, but not for me. As I've got older, it's got worse. I'm more afraid of dying. Everything you hear is about cancer or heart disease. My young mother, and my father.. ." Her voice trailed off. The session was almost over. Barsky said that they would begin working on practical strategies to help divert Linda's attention when she noticed vague bodily symptoms. Her impulse to worry would probably never go away--hypochondriacs almost never lose the impulse to worry about their health. Barsky's studies, however, had shown that a patient's anxiety could often be controlled. Linda thanked Barsky for his help. "Hypochondria is not at all funny, like people think," she said. "It's not a `Seinfeld' episode. It's a horrible, horrible way to live."

Untying the Knot
Melanie Thernstrom, New York Times Magazine- 8/24/2003

In most public accounts of divorce, there is no confusion as to why the couple is splitting up. The reasons are so sound -- the trails of manipulation, exploitation and betrayal so thick -- the only mystery is why the couple were together in the first place. Is it possible to imagine that Ronald loved Patricia or that Donald truly cared for Marla? What does love mean to someone who presents his bride with a prenuptial on the eve of their wedding, stipulating that she would get many millions of dollars for a marriage of four years, but only $1 million for less than that -- and then discards her on the deadline? And what does love mean to a woman who'd sign on that particular dotted line?
    In contemplating these questions, however, we neglect the more difficult ones. The truth is that most Americans do not marry for power, money and status. Nor do they marry out of social and economic necessity, as in an earlier era. They marry for love. Yet an enduring truth of our time is that marriage dissolves as often as it holds. So how is it that ordinary love ordinarily fails? If love is, as Wallace Stevens suggests, a dwelling ''in which being there together is enough,'' how does silence fall on a thousand evenings and the possibility of intimacy flicker and die? How do lovers become lonely?

Marriage: The Spaghetti
''It was a good story -- a story we liked to tell when we were together,'' Max says, in the slightly droll drawl he uses when speaking about his marriage now, as if irony will obscure his sentiment when its actual effect is more like chiaroscuro. Yet the story that Max tells of meeting Kate is simple. (Both of them asked to be identified only by childhood nicknames.) Fourteen years ago this fall, Kate showed up at an opening at the museum where Max was working. They seemed to have a lot in common; they were both 32, with graduate degrees in education and experience working in nonprofit agencies, although Kate was already on a corporate track. She was visiting from the Midwest; he invited her to lunch at an Italian restaurant near La Guardia, before her flight the next day. ''She had a slightly wicked sense of humor,'' Max says. ''She was from a rural town and had these appealing colloquialisms, such as 'cold as a witch's elbow.' '' He gropes for adjectives. ''She was energetic and enthusiastic, intelligent, athletic . . . beautiful. She surprised me. And as I got to know her, she continued to surprise me.''
    It's not hard to picture them together: everything each recalls liking about the other still seems true. In fact, if you met both of them today, you might think to introduce them. They are equally distinctly attractive, in differing genres: Kate looks a bit like Dorothy Hamill, with short, silky brown hair, fair skin, impatient blue eyes and a trim, compact build. Max looks like the man who ruins or rescues the heroine: dark, tall and lanky, with a languor about his body and voice. Kate remembers being drawn to his attentiveness and intensity. ''He had cool interests, jazz and wine and art and literature,'' Kate says. ''And he was very cute.'' She laughs, her voice lingering in the ''very'' in which she once fell in love.
    But the story she tells of their first date includes a layer absent from the one that Max tells. Like Max, she felt an urgency in their conversation -- a possibility of intercourse, in all senses of the word. But at the same time, there was a way in which she was already dropping out. When lunch was over, Max insisted she take the remainder of her spaghetti home. He must already have cared for her, he explains now; he had never done such a thing on a first date before. ''It was so him,'' she says, in the way that the fondest of phrases -- it's you, darling! I understand you! -- can metamorphose into the bitterest, as caring begins to be seen, through the lens of years, as controlling. ''I hate leftovers; I was hardly going to lug that damn spaghetti back to the Midwest. But I said, 'Fine,' and threw it out when I got to the airport. So there you have it, that's the whole thing -- the beginning and the end.'' It was the first of 11 years of things she said 'Fine' to while thinking something different.

Divorce: A Failed Conversation
In his radical address to Parliament in 1643, ''Doctrine and Discipline of Divorce,'' John Milton argued that ''in God's intention a meet and happy conversation is the chiefest and the noblest end of marriage,'' and that divorce is not only necessary but right when that special conversation fails. Does it follow, though, that divorce must maintain silence? Or is there a possibility of dialogue even in separation? Can two people come to a shared understanding of fractured love? And if so, is that valuable? What is the good of a good divorce?
    The questions have grown only more urgent: four centuries after Milton urged that divorce become a civil right, American matrimonial law is still punitive -- protracted, expensive, confusing, damaging. Yet divorce is now an ordinary -- perhaps even a likely -- outcome to marriage. Over the last two decades, the proportion of failed marriages had held stable at around 50 percent, but (while national data lags) some experts suggest that the rate may be tipping over half.
    Historically, periods of economic hardship tend to keep couples together; the current economic downturn, however, appears not to have had that effect. A survey by the American Academy of Matrimonial Lawyers found that 78 percent of divorce attorneys say that their caseloads are steady or increasing. Several studies, according to The Wall Street Journal and others, show that divorce filings have increased in many areas and, moreover, that there is an increase in the number of contentious divorces.
    Kate and Max vehemently disagreed on the terms of their separation. But they avoided the quagmire of litigation through an increasingly popular alternative to handling disputed divorce: mediation. Although mediation began in the 1970's, it is now beginning to reach critical mass. In California, Maine and other states, mediation is mandated in custody disputes in divorces, and other states are considering similar legislation. Oklahoma, which has one of the highest divorce rates in the country, has recently instituted a program that refers couples to free or low-cost mediation. If the trend continues, someday soon people may look at litigation as a last resort only for unusually contentious divorces (cases in which one partner is abusive or absent), rather than the norm.
    Jack Himmelstein, co-founder and co-director of the Center for Mediation in Law, which trains mediators, says that the trend is spurred by the grown children of baby boomers who were victims of their parents' 80's ''Kramer vs. Kramer''-style divorces, and who want their own divorces to be less damaging. And there is a growing interest in a concept that has newly made its way into our culture, ''the good divorce'' -- a phrase that once would have sounded not only oxymoronic but also unseemly -- something that implies permission instead of punishment, like ''happy hooker.''
    Litigated divorce inherently fosters enmity. In litigation, ''meet conversation'' immediately ceases: the first rule a lawyer conveys to the client is literally to not talk to his or her spouse -- lest self-scrutiny prove contrary to self-interest. Refusing to join the modern ''no fault'' trend, New York continues to require one of three extreme grounds for divorce: cruelty, adultery or abandonment. (Milton advocated that the 17th Puritan Parliament liberalize grounds to include incompatibility.) Individuals in contested divorces have to pay lawyers to establish grounds by creating false narratives about their spouses. Thus insensitivity becomes cruelty, a busy father turns into a negligent one and so forth. By the time litigation is completed, the anger -- if not the accusations -- becomes reality.
    Mediation, by contrast, ''relieves couples of the need to demonize each other,'' says Barry Berkman, a matrimonial attorney and mediator who drafted the final agreement with Kate and Max at the end of their mediation. Couples employing mediation have been shown to be significantly happier with both the process and the results than couples using litigation. As an article in St. John's Law Review noted, one study found that 73 percent of those in mediation were satisfied or highly satisfied. Trials yield little satisfaction, and even attorney-negotiated settlements were satisfactory to only 23 percent of divorcees. Himmelstein, who acted as the mediator for Kate and Max, says, ''In mediation, you have the opportunity to tailor the law to your own needs.'' Kate and Max ''wanted to create a separation that reflected the relationship they had.''
    The only problem was that Max and Kate had profoundly different notions about what that relationship had been. Like most divorcing couples, they found themselves disputing not so much their desires for separate futures as their beliefs about their common past: the nature of the marriage they shared -- or thought they shared.

Marriage: A Dangerous Intimacy
How do we describe the arc of a failed marriage? In one model, a period of happiness would turn into unhappiness, as if the marriage were a plant that bloomed and then withered. There might be identifiable adversities -- weather, soil, pestilence - and turning points, or at least a progression, as in a snowfall. The accumulation of moments might be too numerous for each to be observed, but the trend would be clear: you look once and see a light dusting, and the next time you look, it's an impossible snowdrift.
    Another model of a failed marriage holds that the crucial elements are written into the marriage contract from the beginning, and like genes, express themselves over time. Those elements -- the strengths of the bond -- might even prove to be the weaknesses, the way a certain kind of intimacy, for example, might protect against loneliness while weakening autonomy, the way a gene that protects against malaria also causes sickle-cell anemia.
    In the 11 years they were together, the dynamic between Kate and Max changed very little. But in the early years, the dynamic worked. Soon after that first lunch, their lives began to merge. Kate relocated to New York, and they moved to an apartment on the Upper West Side. When Max describes the joy of their relationship, he stresses their easy unity: the interests they cultivated together -- the pleasure of finding a partner. For Kate, the joy was one of transformation, as Max's world opened up to her. She had grown up in a rural town, the eldest daughter of a construction worker and a housewife in a Protestant household where money was tight, whereas Max was the doted-upon child of cultured, Jewish intellectual New Yorkers who reared their children in Westchester. Kate began to learn about bird-watching, baseball, wine and theater. They baked bread, went camping and tried to practice tsedakah -- acts of loving kindness -- by boxing lunches for homeless people in their neighborhood. They got involved in a local temple, and five years after they met, when they were both 36, Kate converted to Judaism, and they decided to marry. They went to a jeweler on 47th Street and picked out a ring with a modest row of small diamonds. Then they went for lunch to a Chinese restaurant where Max, teasingly, proposed. They each recall having paid for the ring. ''I told myself it didn't matter who paid for it,'' Kate says. After all, from the beginning Kate made more money, working in finance at a large corporation, than Max did at a nonprofit organization -- a gap that would grow.
    Their intimacy was sufficiently consuming that neither of them bothered to develop other friendships. Kate loved spending all her free time with Max. But while she was genuinely engaged by their joint hobbies, she secretly suspected her level of interest was slightly inferior to his. She'd find herself gamely tramping along on daylong bird-watching expeditions, when she'd rather have kept it to a morning and gone out to lunch, or she'd observe the Sabbath when she would have preferred to watch birds. And she never quite forgot that each of their shared interests had originally been Max's idea. When I ask Max, he exclaims, wounded: ''I can't believe she's trying to put these things on me. I wasn't into Judaism before her. These were things we discovered together.''
    A few years into their marriage, Kate had brief flirtations with hobbies of her own invention -- singing and horseback riding -- but they never really took. Kate had one close girlfriend, and sometimes in the summer, she'd take the train to see her on Fire Island, play tennis and come back late. ''He hated that -- he'd always be in a bad mood when I got back,'' she says. ''I guess I wasn't entirely sure I had the right to want that,'' Kate adds. ''I feel like it was very important to him that we have the same interests and do everything together.'' Max now acknowledges, ''Perhaps I was a bit threatened by it.''
    While Max found his job satisfying, it had fewer demands than Kate's did. She worked long hours, concentrating so fiercely she'd sometimes not eat or go to the bathroom. Max would pack a lunch for her or thrust an apple into her hand as she walked out the door, and then call her at work and urge her to take a break. He wanted to take care of her while she was away from him, and he wanted her to take care of herself, and those two things seemed indistinguishable to him. ''Good lord, the idea of deciding what you're going to eat in the morning is so unappealing,'' Kate says. ''Perhaps he didn't go to school every day for 12 years and take the same boiled-ham sandwich on white bread, but I did. You want caretaking, but you want it in the way that's meaningful to you -- which, for me, is not in a brown paper bag.'' Max does recall Kate mentioning she didn't want the food. ''I heard it at one level,'' he says slowly. ''But I didn't really hear it -- you know?''
    The only aspect of their home life that wasn't communal was finances. Kate insisted they keep their earnings separate and divide their bills proportional to their salaries -- a formula that shifted with Kate's raises. Each year when Max's parents gave them each a tax-deductible gift toward a down-payment on an apartment, Kate put hers in a separate account. The arrangements struck Max as a bit odd, but he tried not to think too hard about it. After all, he knew Kate was compulsively organized, and he reasoned, since they were spending their lives together, all her money was really theirs. If Kate preferred to have her name on an account, what did it really cost him?

Divorce: Balance of Power
It makes no sense to say that a good marriage requires parity, as most marriages in the world and throughout history have been based on entirely different principles. You might even conclude from America's unusually high divorce rate that the expectation of equality and personal fulfillment is itself a more problematic prescription than that of honor and obedience.
    Or perhaps the problem lies not in equality, but in the ambivalence that inevitably surrounds a titanic cultural shift only decades old. Many women today still sign up for marriages in which the man, to some extent, dominates. Traditionally those marriages have ended when the stronger party tires of the dependent. When Harriet Newman Cohen began practicing matrimonial law three decades ago, her clients were mostly women whose breadwinners had walked. But she and others have observed that today, it is as often the weaker party who calls it quits, tired of a role that is no longer culturally sanctioned. And, once equitable distribution laws -- which forced the higher-earning spouse to share the wealth equitably -- were passed in the 80's, there was no longer any financial penalty for divorce.
    Today, almost as many women as men file for divorce. Infidelity, in addition, is no longer a primarily male province. One divorced investment banker discovered that, within his circle of male friends, it was their wives who cheated, not they. ''In the culture of my firm, having affairs is just bad behavior, like drunk driving -- something that could harm your reputation,'' he says. Female infidelity, on the other hand, he says, reads differently. ''They're finding themselves, exploring their sexuality,'' he observed bitterly. ''She was fragile and neurotic and I was the white knight. I made her feel taken care of and she made me feel strong -- right up until the day she left.''

Marriage: The Smart, Interesting One
Max did not wish to oppress, repress, subsume or engulf Kate. He did not subscribe to traditional sex roles, and if he were to describe what he valued in Kate, he might have listed strength of spirit, competence, perhaps even independence. Like many contemporary men, he never would have been attracted to someone who conceived of herself as Adam's rib. But there was a current in their marriage that ran in a different direction. And for reasons neither of them can fully account for, it was that current, rather than any other, that gathered momentum over the years and began to erode their lives. ''She talks about the relationship like she's Anna Karenina or Madame Bovary,'' Max complains. ''It's a cliche.''
    The very thing that Kate admired about Max -- his sophistication and sensibility -- made her feel bad about her own tastes. Max found some of the music and movies and TV she liked lowbrow. Although he grudgingly conceded that they could get cable, he'd give Kate a hard time about shows she enjoyed, like ''Alias.'' '' 'Why does it always have to be great art or film?' '' Max recalls Kate complaining. '' 'Why can't we just enjoy mindless entertainment?' But I don't enjoy mindless stuff,'' he says. ''Did I think she was less of a person for liking them?'' Max asks himself. (While Kate tends to speak crisply and definitively, Max's words circle back, his thoughts evolving as he speaks.) ''I don't know, maybe to an extent.'' Later, he says: ''The thing is, TV was not what I needed. And the way the relationship was set up, we did everything together,'' he adds softly.
    Once, Max gave Kate a book of Shakespeare criticism after they had seen a play, and then began to read it himself. ''That angers me so much about him,'' Kate says, with surprising vitriol. ''I don't have two seconds to read it, and then it's too late.'' She says she felt she had been ''robbed once again of this opportunity to possibly be the expert. Max was such a know-it-all about everything. He always had more time and education and background and context. You could never win.''
    When they socialized, Kate found herself feeling slightly left out. ''I felt like he was the smart, interesting one, and I didn't have anything to say,'' she says. Max disagrees. ''Kate is very articulate,'' he says emphatically. ''At dinner parties, she was much more the raconteur.'' When I repeat Max's comment to Kate, she says: ''I'm going to start to cry. He never said anything like that to me.''
    Max says he felt basically content with the marriage and assumed Kate did as well. And Kate was content in many respects, but a small resentment pressed at her. Her feelings were intensified by the fact that she had no time to herself. She suffered the New Yorker's fate: she went from a crowded office to a crowded subway to a small apartment in which Max was always already waiting and often annoyed at the late hour.
    Like most powerful, pervasive dynamics, the tensions found expression in incidents almost too trivial to recollect. She'd get cross with him for not keeping the apartment as tidy as she liked. Or she would rebel in an inchoate, pointless way, like leaving the bathroom door open while she dried her hair, a sound that Max found grating. ''Another way of describing the relationship was that she had more trouble compromising and being in a relationship than I did,'' Max says. ''It cost her more to accommodate me, so she resented it more. That's as much of a truth as that everything revolved around me.''
    Over time, they had sex less often, and when they did, they had less of a feeling of reaching one another. The shift was subtle enough that neither can place it -- did it happen in Year 5, 6, 10? Without saying so, each attributed the distance to the other. Max says that Kate didn't encourage him to be the physically expressive person he really is -- and has been in subsequent relationships. Kate laughs in astonishment to hear it. ''Oh, my God, that is so different from how I describe it,'' she says. ''He wasn't particularly cuddly or romantic at all. But I don't know, maybe I did that to him. Or maybe he did that to me.''
    Kate took on progressively more responsibility at the corporation, and her income grew from $80,000 to well into six figures, while his merely rose from $45,000 to $65,000. She was gaining confidence at work and managing large teams of people. But then,''I'd come home, and Max would pick on me for drinking whole milk or not eating the stupid health food he likes,'' she says.
    They never talked about how they felt about the difference in their salaries, but Kate sensed that Max believed his flexible, socially responsible, artsy job was superior to her corporate grind. Max interpreted Kate's long hours as a withdrawal from the relationship -- and she resented his resentment, which in turn caused her to actually withdraw and work harder. But while she craved the intensity of her work, it was also a constant source of anxiety. But she had her savings, she'd tell herself. No matter what happened with her job or with Max, she could take care of herself.

Divorce: The Meaning of Money
The simplicity of divorce is that, in the absence of a custody dispute, there is only one issue that needs to be resolved, and that is finances. All of the impossible disputes in the relationship -- sex and lateness and whole milk -- become miraculously moot. The complication of divorce is that without the practical realm in which emotional conflicts are ordinarily expressed, the unresolved feelings compress into the single question of money. And so, money becomes everything.
    When Max and Kate decided to divorce, Max suggested they see a mediator. ''He always knows the cool, new thing to do,'' Kate says tiredly. She agreed to go for a session or two, but she didn't see why they needed a professional. Although they never talked about how they would divide their assets, ''it was so clear in my mind, I thought I would lay out the obvious facts, and that would be that,'' Kate explains. ''Then I got to mediation,'' she says, ''and I just couldn't believe it.''
    She sat on the couch in Jack Himmelstein's Upper West Side office and revealed her plan. Their finances had always been separate, so she would keep her money and he would keep his. When she moved out, she left Max their rent-stabilized apartment, their furniture and their pet, and she didn't want any of them back. What was there to discuss? ''My money was always mine,'' she said. ''We shared everything,'' Max said. That's the kind of marriage I was in. What kind of marriage were you in?

Marriage: Upgrades
It was the late 90's, the stock market was booming, Kate was earning a lot of money at her job, and like her colleagues, she wanted to play with it. At one point, she had her heart set on buying a BMW. Max said it was absurd; he was the one who drove their old car to work every day, and he says he felt uncomfortable with the idea of showing up at a nonprofit in a status-symbol car. ''I don't have that many vices or do many wild things,'' Kate says. ''We were at a time in our life where we had some disposable cash, and I felt like, let's get a cool car, a great car. His response was so predictable to me: 'Oh, it's ostentatious, it's impractical, it'll get scratched in the city, think of the maintenance, only Republican capitalists would buy a BMW, not socially responsible people like us who recycle.' ''
    Max began to warm up to the idea. ''I went down to the dealership with her and said, O.K., if she really wanted it, we should get it,'' Max says. He likes to talk things through, he explains, whereas Kate always wants to make quick decisions. ''He took all the fun out of it,'' Kate says. ''I felt like he was right and I was stupid -- I felt embarrassed for bringing it up, and exposing myself for being the kind of person I'm not supposed to be. But somewhere in my mind I thought, O.K., fine, maybe I am a Republican capitalist -- I don't know.''
    Kate's pet desire was to add diamonds all the way around her engagement ring, so that the band would make a complete, shining and invincible circle. It still bothered her that, according to her memory, Max hadn't paid for the ring. ''I think I thought it was O.K. at the time, but I don't know if that was true,'' she says. ''Maybe I want a man who'd buy me a diamond ring,'' she says. ''Does that sound superficial?'' She brought up the idea of adding more diamonds from time to time over the years, but Max always refused. He found the thought deeply disconcerting. ''Sometimes you see these very successful people with modest little rings that represents an earlier time in their life,'' he says. ''What was she saying by telling me that our ring wasn't good enough for her anymore? Did she want an upgrade on the marriage too?'' Kate couldn't understand it. ''He was so begrudging about it,'' she says. Over time, when Kate looked at her ring, she began to see not what was there, but what was missing. And the chinks in the ring became what Max feared: chinks in the relationship.

Divorce: The Back Door
Mediation exposed the fragile civility between Max and Kate. In the second and third sessions, Kate tried again to calmly articulate her guiding principle: the origin of the money should determine who would get it. The principle was not entirely self-serving: while she would keep her earnings, she would return to Max the gifts his parents had given her since they were intended for their future home. Therefore, in her mind, apart from the gifts, the fair amount that she should give Max was zero. Max had a different but equally clear guiding principle: mutuality. Drawing on the principle of communal property, Max says he thought that they should roughly pool their total assets and then divide them equitably. The impasse seemed absolute. ''I made too many concessions in the marriage,'' Kate says. She was getting a divorce precisely in order to stop making concessions.
    Max pointed out during mediation that he had planned his life around the assumption that her corporate salary would subsidize his nonprofit one. All the anger Kate had bottled up during the 11-year relationship exploded. ''Ohh,'' she spits, remembering. ''He looked down at me for having a corporate job -- he gave me a hard time for working late -- and now he wants my earnings? Well, I could have worked for a nonprofit, made $65,000 a year and gotten home at 5 o'clock, like he did.''
    Perhaps, Max suggested at one point, he might now go back to school and get another graduate degree -- an endeavor Kate could finance. ''I thought what Max wanted was completely preposterous, and every time we talked about it, it threw me into a rage,'' Kate says. It seemed especially unfair because in contrast to Max, Kate felt financially responsible toward her parents and siblings. And the marriage had collapsed along with the stock market; her job could disappear at any time.
    The morning after the third session, for the first time in Kate's life, she says she felt ''scarily depressed.'' She had trouble getting out of bed and going to work. ''A long time before the marriage started to fall apart,'' she explains, ''somewhere in my mind I had a back door in case things didn't work -- an escape plan by which I'd be O.K.,'' she says, referring to her savings. ''There was a horrifying loss of control when I realized in mediation that that back door didn't exist. I felt completely vulnerable.'' The idea that Kate had a back door all along made Max sick. How could he -- an insightful person -- not have known this about the woman he had slept beside for 4,000 nights? Then again, how could she have concealed it?

Marriage: The Miscarriage
Kate and Max had been ambivalent about having children. They were both anxious about the time and money and attention a child would require. By the time they decided to try to have a baby, Kate was nearly 40 and she couldn't become pregnant. And so they proceeded to fertility treatment. Even more than that of a divorce court, the atmosphere of a fertility clinic is thick with desperation: the exquisitely costly torment of drugs and invasive procedures made bearable by the taunting hope that if they work, the suffering of the process will disappear in memory like labor pains. Yet, as Kate sat in the waiting room day after day, it began to dawn on her that she felt different from the other women there -- that the frightening odds against the success of fertility treatment were not the only thing that frightened her.
    Unlike many of the other women in the clinic, Kate didn't regret having devoted herself to her career. Nor did she wish to cut back now; she says she felt Max already wanted more from her than she wanted to give. Or perhaps the real issue for both of them was that their relationship would have to change, their fused twosome divide into three. Would the relationship survive? ''Throughout the whole process, I used to worry: 'Good God, what if I do get pregnant?' '' Kate recalls.
    Through insemination, she eventually did become pregnant but she miscarried within a few weeks. After the last of the fetal tissue was scraped from her cervix, she found herself feeling, along with sadness, strangely freed. ''I realized, Look, I'm never going to have children. It gave me a different perspective on the future. I started thinking, So what am I in this thing for?''
    While she and Max began to discuss donor eggs and adoption, she was engaging in a much more complicated conversation with herself. At the same time that she was trying to envision a hypothetical adopted child, her other desires gathered around the figure of a new man. As it is for most people who commit adultery (studies vary greatly -- between one-quarter and three-quarters of divorces are thought to involve infidelity), the affair was and wasn't about the new person.
    The man made her aware of a profound sense of absence: how ''desperately lonely and tragic and unbearable it was -- being in a marriage and not having that.'' Yet she's hard-pressed to define what that is: intimacy, as it were, the thing that makes people feel close -- makes sex feel real and living together meaningful. The affair was ''like a gift that presented itself and I wanted to give it to myself, because I wasn't getting that out of the marriage, and because I wasn't sure I would ever have that in my life.''
    For Kate, the affair was a signal not just that the marriage should end, but also that, in a sense, it actually already had. She had broken her marriage vows; she wasn't the kind of person who would do such a thing; she needed to leave to become an honest woman again. ''I felt, Oh, my God, I'm cheating on my husband,'' Kate explains. ''And after that, there was no turning back.''
    Max was stunned. ''In August we were signing up for an adoption workshop,'' he recalls darkly. ''In November, she told me she was leaving.'' How could Kate present their separation as a fait accompli before they even discussed it? He says that the affair was a ''destructive thing to do,'' but he ''didn't think it necessitated the end of the marriage.'' Through his anger, he could see how hard Kate was struggling to be candid, and her candor held some sense of possibility for him. ''I felt like: Wait a minute, let's talk. I want better sex, too.'' It was Max who finally asked her to temporarily find someplace else to stay; he was crying all the time and sleeping alone. He says he hoped that some space would make it easier to communicate. But Kate says, ''I knew once I moved out, I was never coming back.'' She had wanted to go, she realized, for such a long time.

Divorce: Finding a Figure
The insight of mediation is that neither party's satisfaction bears a definite relation to the settlement's dollar amount, and therefore the mediator should not focus on a monetary figure -- as litigators do -- but on how money figures. Thus the solution that emerged in mediation to Kate and Max's stalemate was actually a mental shift: instead of thinking that Max was plundering her savings, could Kate imagine choosing to give him a supplement -- for a certain length of time -- for rent and other expenses so that he could continue the lifestyle they had developed together?
    The idea indeed was much more palatable to Kate -- even if the amount she might end up paying would be around the same amount Max had asked for in the first place. Even working with that concept, though, the details of the settlement took many more sessions to hash out. ''Over the months there'd be cycles of progress, impasse and anger,'' Kate recalls. ''I'll pay this; I won't pay this.'' She often found herself too angry after a session to meet again for many weeks.
    At moments, some of their old compatibility would spark; in the midst of a difficult negotiation, they could still make each other laugh -- something Himmelstein had rarely observed in couples. ''We both have irrepressible senses of humor,'' Kate says. ''As awful as the sessions were.'' Max, however, didn't find the sessions awful; he half looked forward to them as opportunities to examine the breach and perhaps even to mend it. Sometimes, they'd go out for coffee afterward. Once, they parted after the session, only to board the same subway car by chance an hour later. The coincidence taunted Max. They got off at different stops, a few minutes later, but did they have to? ''I felt like, If we can work these things out in mediation, can't we work them out in the relationship?'' Max says. ''But Jack said: 'Not necessarily. The work can be about trying to create a good ending.' ''
    The turning point, they all agree, occurred during the fifth or sixth session: when Kate alluded in passing to her pain in losing the marriage and Himmelstein asked her to talk more about it. ''Normally we were fighting and accusatory -- 'You're causing me to lose this,' '' Kate remembers. ''There we were able to come together and I realized how tragic it was for Max, and he realized how tragic it was for me -- even though I was choosing it. And that we were both overwhelmed by the enormity of what happened. We both got married fully expecting. . . . '' she says, her voice trailing off as she loses the thread of what she had expected, and what she had gotten. ''Marriage obviously meant very different things to us,'' Max says. He liked being married. Perhaps Kate, on the other hand, ''not only didn't want to be married to me, she didn't want to be married at all.''
    The mediation sessions were often in the evening, and Kate would arrive in her conservative business attire, looking peaked and tense -- like ''a corporate drone,'' Max says. He'd be relieved to feel the pull of his attraction slacken, as he'd glimpse her not as his wife but as just another person -- and one whose life was becoming foreign to him.
    At some point around the 12th session, when they'd been in mediation for almost a full year, Max and Kate arrived at a tentative settlement, but one that didn't feel right to either of them. It was less than what Max had originally asked for but still represented about a third of Kate's assets. Moreover, the payment from Kate plus the gifts that Max's parents had given them would mean that Max's total assets would actually exceed Kate's.
    They each decided to consult lawyers about the proposed figure. Kate's lawyer conveyed to her that a legal remedy was unlikely: that were she to take the case to court, given the equitable distribution laws, she might end up paying Max more and she would certainly pay steep legal fees as well.
    Max's lawyer, in contrast, let him know he could probably do better -- advice he found equally unsettling. On the one hand, he felt guilty taking money from Kate. ''What am I entitled to?'' he says, as if the question still haunts him. ''Am I entitled to anything Kate doesn't want to give? It felt strange and uncomfortable and embarrassing, and it still does.'' (He didn't want the settlement figure printed in this article, whereas Kate did.) But disregarding his lawyer's advice also made him uneasy. ''There's the chump factor,'' he says. ''You want to make sure you're not being a chump by not getting everything you're legally entitled to.'' Kate snorts. ''Yeah, he told me that,'' she says sardonically. ''But I felt: I have to fork over money so you don't feel like a chump? You're not a chump, all right, so don't make me give up my savings.''
    Max decided that making Kate happy -- or, rather, less unhappy -- was a legitimate factor in his decision to accept the settlement they were considering. Kate, for her part, decided she'd ''rather give the money to Max than to a lawyer,'' although she says it in the tone of someone for whom the decision is still fraught. Kate was aware that although it was a compromise, it felt profoundly different from the silent concessions she had unwittingly made throughout their marriage. ''In retrospect, it was powerful to come to terms with something I thought was unfair,'' Kate says, ''and move on.''
    The number on the separation agreement was one neither of them would have chosen, but one both of them could live with, precisely because they did choose it. Kate agreed to supplement Max's rent for several years and pay their taxes and legal and mediation bills. He would keep the car, and she would also keep him on her health-insurance plan and pay his premium. They both agree that had a judge given them that same number, they each would have felt cheated -- and blamed their attorneys.
    During their final meeting, they were both drained and blank when they went to sign their legal agreement at Barry Berkman's office. On the wall is a print of ''The Desiderata,'' urging clients: ''neither be cynical about love; in the face of all aridity and disenchantment it is perennial as grass.'' Afterward, they went downstairs, and Kate finally gave Max her keys to what was now his apartment -- something she had held on to throughout the sessions -- and Max cried. He says he thought Kate teared up, too. But a few weeks later, she needed to pick up something in the apartment, and she told Max she would let herself in while he was gone. He was stung to realize she didn't recall having given him her keys: that relinquishing their life had finally become for her an automatic gesture.
    There is a moment in the marriage that they each sometimes think back on. They were in Costa Rica, looking for the classic keel-billed toucan they called Froot Loops, from its depiction on the cereal box. They had been in the jungle for several days, and had fallen into a rhythm together -- ''learning to see in a different way, knowing when to keep walking and when to stand still,'' Max remembers.
    Max spotted the toucan with its surrealistically large rainbow beak, perched on a hundred-year old tree. He passed the binoculars to Kate, whereupon she told him it was not Froot Loops but a more common chestnut-mandibled toucan. He looked again, and disagreed, and then ''we began to get really mad at each other,'' Kate says. Neither recalls who realized it first, but they both remember being caught short by truth: they had been looking at two different birds in the same tree.

The Marriage: The People They Would Become
Kate moved downtown, where she always wanted to live, and began looking for an apartment to buy. Now she does things she never did when she was married. She eats what she likes at work, throws out her leftovers and dries her hair with the door open. She invites groups of girlfriends over. ''Friends who used to know me before are surprised at how much I have to say now,'' she says. Recently she was invited to a baby shower that Max was attending, too, and she found herself moving easily around the room by herself, in a way she didn't when they were together. She goes to movies Max would consider cheesy. Once, she and Max were talking about getting together and she said that, whenever it was, it couldn't be Sunday at 9, because that's when she watches ''Alias,'' and she felt a delicious relief that she finally didn't care what he thought.
    As for Max, he surprised himself by keeping cable, and now he watches some TV, too. Kate is annoyed to see, when she goes over to pick up something, that Max now keeps his apartment neat, as he never did when they were together. Neither of them keep the Sabbath anymore, and Kate isn't sure she considers herself Jewish. And, although they both miss doing it, and say they hope to again, neither of them bird-watches any longer.
    Most of the divorce lawyers I interviewed seemed taken aback by the question of whether their clients still loved their spouses. A group of mediators at a round-table discussion, on the other hand, all answered with qualified versions of yes. ''To the extent to which they ever genuinely loved each other, they continue to,'' Berkman says. ''For most of them, if you search hard enough, you can find that.''
    When I ask Kate about this, she says flatly: ''I don't want to go there.'' There's a long silence when I ask Max. ''I think so,'' he says faintly. ''When she left me, she accused me of never having really loved her.'' He recalls how devastated he was by the accusation. ''I think something about the way that she felt about herself made it hard for her to believe I loved her. But I did love her,'' he says, in a stronger voice. ''We loved each other for a long time, so there will always be that connection between us, I think.''
    He remembers a fantasy Kate offered him once during mediation. One day, she said, in some now unreachable future, they might meet at a cafe, and forgetting they had been married, begin to talk and hit it off all over again. (Max recalls how they did fortuitously meet on that subway, as if destiny were seconding the idea.) Why couldn't they do that now? ''We'd need to be entirely different people first,'' Kate said; the people they would become by getting a divorce.