You can say “I’m fine” so often you forget what your truth feels like. You can look calm and still be collapsing inside. The performance is perfect but the person is gone.
I said it for the first time in earnest somewhere between Sengera and Eldoret, between the boy who was called ekerentane and the medical student who had learned to respond to any query about his wellbeing with a pleasant, untroubled “fine.” I said it to classmates and to professors and to myself in the mirror of the men’s toilet in the clinical building before ward rounds. I said it with such conviction and such repetition that I began to believe the word. “Fine” became a clinical finding I had certified in myself. Dr. Job has been examined. Dr. Job has been found to be fine. Examination complete.
The performance was perfect. The person was disappearing.
There is a clinical term for what was happening underneath the performance, and you deserve to have it with its plain-English translation before we go further. Alexithymia is the reduced capacity to identify, describe, and process one’s own emotional states. The word comes from the Greek: a, meaning without; lexis, meaning words; thymos, meaning emotion. Without words for emotion. It sounds clinical, and in its more severe presentations it is a clinical finding. But in the high-performing population where it appears most commonly, it is something more mundane and more pervasive than a disorder. It is a coping strategy that compressed itself, over years of use, into a personality trait (Lumley et al. 2007, Journal of Psychosomatic Research, https://doi.org/10.1016/j.jpsychores.2007.09.006; Honesty Scale: Promising). You learned to function so efficiently in the external world, to produce and to deliver and to meet the expectation, that the internal world went dark. The word “fine” is not a lie exactly. It is what you say when the lights are off and you cannot see what is actually in the room.
I watched this play out in clinic often enough that I stopped being surprised by it. In Kenya, I had a patient, I will call him Francis, a secondary school headmaster who came to see me with chest pain that had been present for eight months. Eight months. He had told his wife he was fine. He had told his colleagues he was fine. He had, with the efficient self-management of a man who had run a school of two thousand students on four hours of sleep and categorical self-discipline for twenty years, told himself that whatever this was, it was manageable, it was minor, it did not require the attention of a physician because he was not, fundamentally, the kind of person who required that kind of attention.
When I asked him what the pain felt like, he said it was “not that bad.” Not that bad. The diagnostic precision of the man who has removed himself from his own diagnostic process.
When I asked what “not that bad” meant, he was quiet for a long time. His hands settled in his lap in the particular way that hands settle when the person to whom they belong is doing something unfamiliar, something like feeling. Then he said, very softly: “I have not been asked that before.”
The question itself was a kind of medicine.
Alexithymia is not a psychiatric disorder in most of the people who carry it. It is a coping strategy that became automatic. The research makes clear that people with higher alexithymic tendencies carry more somatic symptom burden: medically unexplained pain, fatigue, gastrointestinal symptoms that trail through multiple specialists and never find a satisfying pathological explanation (Lumley et al. 2007). The body is doing the articulating that the vocabulary has been forbidden to do. The stomach knot is the sentence the mouth would not form. The shoulder that will not unknot across three rounds of physical therapy is still carrying the conversation that was never had. Francis’s chest pain was real. The question was what it was a report on.
There is a related thread in the clinical literature on what is sometimes called smiling depression, the presentation of clinically significant low mood under a surface of social functionality that can appear, to observers and sometimes to the person themselves, as contentment (Akiskal & Akiskal 2005, Journal of Affective Disorders; Honesty Scale: Early, given significant heterogeneity in the literature). I am cautious about that specific label. What I am not cautious about is the observation, made in enough consultations over enough years to constitute a pattern even without a clinical trial measuring it, that the people who say “I’m fine” most fluently are frequently the people who have the longest and most complicated distance to travel to their own truth. The fluency of the performance is itself diagnostic.
I know the flavor of the performed fine because I performed it for years and became, in the way of all performers who work hard enough at their material, genuinely good at it. In Illinois, you meet the Kenyan kid who got to America on his own merit, trained at Kansas, did his cardiology fellowship at Oklahoma, and is now on the Carle Foundation Hospital floor in Urbana, and you assume the story has a happy ending. The story had a resumé. A resumé is not a life.
What “fine” cost me was not dramatic. That is the insidious thing about this kind of loss. I did not collapse. I did not have a crisis that made the cost visible to anyone around me. I lost things slowly, in the quiet erosion that happens when you stop checking in with the part of yourself that tells you what is true. The quality of presence with my family. The ability to notice, in the middle of a dinner, that I was genuinely tired rather than performing vigor for an audience of people who love me. The capacity to sit with a patient, the real capacity, to be in the room with them fully rather than already scheduling the next thing while I appeared to be listening. These losses were quiet. Quiet losses are the most expensive kind because they do not trigger an alarm. There is no presenting symptom for them. They show up later, when you look around and realize you are not sure when you last felt real.
In the Ekegusii language, the word irana means to return. Not to arrive somewhere new. To come back to where you actually are. The person who has been saying “fine” for four years is not lost. They are at a distance from themselves. Irana is the name of the walk back. It begins with the question Francis finally let himself hear, the question I finally let myself sit with in my driveway: what is the honest word for this?
Here is the experiment I want to offer, not a program, not a prescription, just an experiment that costs you approximately two seconds per day. The next time someone asks how you are and you prepare to say “fine,” pause. Ask yourself: is that the accurate word, or is it the convenient one? You do not have to change your answer. The person asking may not be the person for whom you have the sentence underneath. You only have to know the difference in your own register. Fine-as-truth has a particular quality of ease. Fine-as-performance has a particular quality of effort, brief and nearly invisible, but there. Begin to notice the difference.
Over time, knowing the difference is everything.
The cost of saying “I’m fine” eight times a day is that the ninth time, when it would have been the truth, you can no longer find it.
I want to say one more thing before the assessment, because it matters. The failure to name your own state is not a character flaw. It is a learned competence that became, in your particular environment, a structural requirement. The professional cultures that most high-achievers inhabit, medicine, law, executive leadership, the pastorate, do not reward the person who says “I am not doing well” in the forty seconds available between the end of one obligation and the beginning of the next. The performance of fine was the rational response to an irrational demand. You were solving the right problem. The problem has changed. What worked in the residency hallway, in the boardroom before the investor call, at the family dinner table where your parents needed to believe you were succeeding, does not work in the interior room where your body is trying to tell you something real. The performance has outlived its context. This is the moment to begin noticing the difference.
A Mirror
When did you last say “I’m fine” and genuinely mean it, with no compression underneath the word? How long ago was that, and what were the circumstances that made it possible?
If “I’m fine” is the visible surface, what is the sentence underneath it right now? You do not have to share it with anyone. Just name it to yourself, in as plain language as you can.
Who in your life is allowed to hear that you are not fine? If the answer is no one, what does that cost you per week? Per year?
Letter from Dr. Job
Subject: What “fine” was hiding
You have said “I’m fine” enough times that the word has become load-bearing. The performance holds up the ceiling. The fear, sometimes, is that if you stop performing it, something comes down.
I want to tell you something I know from years in cardiology. The ceiling does not fall when you tell the truth. It gets lower for a moment while the truth moves through the room. Then it lifts.
The sentence underneath “I’m fine” is not a catastrophe. It is a person. A real one, with actual weight to them, real texture, real hunger for something the performed calm cannot give them.
This week, I want you to say the underneath sentence to one person, even just one sentence of it. Not to explain it or defend it. Just say it. You do not need to qualify it. You need to stop paying the cost of carrying it alone.
Not for them. For you. So the word “fine” can have its actual meaning back.
— Job