Psychiatrist contemplates patient's file

The Algorithm Will See You Now

by Justin C. Key

This original story from Vital was selected for The Best American Science Fiction and Fantasy 2022, edited by Rebecca Roanhorse and John Joseph Adams. (Read more in WIRED). It has also been made available here in honor of being a finalist for the Walter Dinjos Memorial Award For Disability In Speculative Fiction in the Disability Representing Works category (Read more in Locus).

Alaina Harris didn’t look depressed. The twenty-eight-year-old Black woman smiled at our receptionist and showed bright interest in the paintings on the waiting room wall. Why was she here? The algorithm assessment of her neural scans from her primary care doctor were unhelpful. Her referral note simply read: “odd presentation, in need of therapy, no medical issues.” I sighed. ‘Odd’ wasn’t a treatable disorder.

I pulled up my own emotional calibration app on my phone, brought my heartrate down a few beats, and flattened my anxiety curves. They spiked whenever a Black woman like myself came through our door for a new appointment. The noise cleared. I called her in.

“Dr. Hairston.” Alaina offered a warm, light handshake. “You’re Black.”

“Last time I checked.”

“I’m sorry. It’s just, this is great. I didn’t know what to expect and . . . oh god, I’m rambling.”

“It’s nice to meet you, too,” I said.

There was so much to gather from that first human interaction. From how she addressed me, to where she sat in the room, to her palpable energy. She wore a sweater despite us being at the height of summer. She took in what seemed to me every corner of my office, noting the decor, checking for the windows and the doors. Cautiously curious. She paused at her neural display gracing the wall behind her seat. A patient’s response to this was also informative.

“So,” I said. “What brings you to see a psychiatrist?”

Off that one question, she told me about growing up in the city, her parent’s loveless marriage, her difficulties in college, the way her mind often worked against her. An open book, she was yet uninterpretable. The way she described her childhood in vague, distant terms suggested a repressed trauma. I didn’t expect to get there in the first session.

She finally sat back and sighed. “I just feel like everything is hard, you know? Work is hard, friends are hard, living is hard.” She glanced at me, as if just remembering where she was. “Not that hard, though. Don’t get me wrong. I love life.”

I smiled. She relaxed.

“You mentioned things at home being stressful,” I said. “Tell me about that.”

“I live with my best friend. Lauren. We’ve been besties since college, and I love her. I really do.”

“I sense a ‘but’ coming on.”

Blues shifted to orange in some of her neural clusters. I focused on her body language, which spoke a similar message. The change in position. The nervous smile. This was the topic.

“We’re very different people,” she said. “I love her. I need her. I just … I don’t know if she’s a good friend for me, you know? If I’m good for her. Seems I can never do enough.”

“You feel as if you’re not being a good friend?”

“She says I’m not.” She laughed, not pleasantly. “Lauren always ends arguments by going on one of her drives. And when she’s upset she’s probably drunk or high or both and . . . it’s just not smart. It’s selfish.”

A faint blue light flashed in the bottom corner of Alaina’s display. I shifted to hide my distraction and tapped the side of my chair twice.

Are you sure you want to disregard this clinical warning?

I tapped again. Yes.

“That sounds really hard to deal with,” I said.

“It is. Because I try. Really hard. It’s a lonely place to be. I’m never alone, though, not really. I’m always the one listening. Except here, I guess.”

“I’m glad you’re having the chance to be heard,” I said. A beat of silence hung between us. “There may be times where you feel differently in our sessions. Alone, unheard. If that happens, I invite you to let me know. It could be important for us to work through.”

We finished. I didn’t mention interventions. Frankly, I wasn’t sure she needed it and, if she did, I didn’t yet know what we would be treating.

Once she was gone, I skimmed the automated intake draft, which included all the essentials for billing and legal purposes. Most of the data—like eye movement analysis—only needed review when flagged for significant abnormalities. The meat was in the formulation, diagnosis, and proposed treatment. I frowned. The algorithm honed in on abnormalities in the brain’s language and emotional centers and interpreted this as a psychotic process, which was clearly wrong. The algorithm could be way off base, especially with Black patients. I deleted the assessment and wrote my own, spending some extra time noting that the benefits of continuing with her as a patient outweighed the risk of the compatibility flag. 

I checked my emotional state readout. I was slightly angry and anxious, foreign attributes in my own office. I recalibrated myself, went out to our reception area, and poured myself some herbal tea to enhance the calming effect.

“A tough new?” Michael said from his doorway. We had started the practice together out of residency, decades ago, right as the cluster-based treatment revolution swept through psychiatry. We were some of the only private psychiatrists left who still did face-to-face interactions.

“Straight forward, actually,” I said. “Algorithm pegged her as psychotic, but she’s definitely not. Just some depression and anxiety.”

“The algorithm conflated psychosis and trauma with one of my patients the other day.” 

He gestured towards the blue warning lights through the office door I’d failed to completely close. “You want me to take her? I have space on my panel.”

“Oh, that? No, nothing significant. She’s African American.”

Michael nodded and left it alone. The blue indicator warned of a potentially undesirable result from a patient’s neural network paired against the provider’s. Subconscious biases, uncanny similarities, all could theoretically interfere with a healthy therapeutic alliance. For years the algorithm had conflated race with shared experience. The latest iterations supposedly addressed this, but old glitches died hard, and Black patients were still underrepresented in data pools because of continuing disparities in mental healthcare access and engagement.

Regardless, some things we didn’t challenge each other on. We knew where my Blackness ended and his Whiteness began. It’s why we’d always worked well together.

Back in my office, I replayed the part of the intake that sparked the warning: Alaina recalling Lauren’s criticism. The printout identified neuronal clusters indicating shared experience, similar neuroanatomy, and a high percentage of paired firing between our respective mirror neurons. The computer essentially posited that our brains were too much alike to achieve a successful balance of objectivity and subjectivity. Specifically, the algorithm predicted that I would deter her from getting ablation therapy despite analysis showing it to be the most beneficial treatment long-term.

I read it over again to be sure. 

I considered Michael’s offer. The International Psychiatric Association hadn’t released any official recommendations since the seminal study on the pairing technology showed a clear parabolic correlation between therapist-patient neural pairings and outcomes. Like many things, the algorithm gave no insight into the ‘how’. Many speculated that the lack of boundary setting, regression, and poorer physician decision making contributed to this phenomena. 

But handing over her case was the last thing I wanted to do. Because, for the first time in years, I was intrigued. 

* * *

The ride home was a good in-between time to reflect, rediscover, and digest the day’s patients. Today, though, I needed some me-time to recalibrate.

I waited until I was on the freeway to run the anxiety module. I gritted my teeth against the pressure emanating from my temporal implant and swiped through the files that came up on the car’s display, sorted by emotional state, impact, and then date. Ah, there it was. I frowned at the algorithm’s attempt at a title: Fear of Misdiagnosis.

“Play back, quantity thirty.” My fingertips dug into the well-earned grooves in the main passenger seat’s armrest as the machine soaked my brain in the sensory input that provoked anxiety.

It’s all your fault.

A woman with brown, fluffy hair and dazzling hoop earrings sat in the seat beside me. When I looked at her, she was gone.

I gasped and reflexively yanked off the probe.

What the hell had happened?

A notification blinked on the frozen display. 

Origin of emotional dysregulation identified. Would you like to link to it?

Yes. A crude representation of my own neural network materialized in a faint hologram that zoomed into a black, foggy void with only scant, roaming particulates. I’d seen this many times before, but never in myself. The visual representation of an ablated past. 

The ablation procedure had been pivotal in my development and making it through the second half of college. But, what else was there? I blinked. I couldn’t recall. First generation, on scholarship, my family’s expectation of ‘there goes Dr. Hairston!’ followed me from childhood to college. Neural Cluster Ablation had only just entered clinical trials. The procedure hoped to magnetically target select neuronal clusters correlated with distress and remove them permanently. The study gave me my first neural probe, a device now ubiquitous for neural self-regulation, especially amongst mental health workers.

You were never good enough. Not then, not now.

Softer now. The faintest shadow of a woman’s image lingered and then disappeared with a blink. I began to reach out and then stopped. 

Sensory hallucinations were known artifacts from memory recalibration. My connection with Alaina had somehow stirred up a random remnant from that black void. The ghost of a past I decided not to think about. I paid not to think about.

I shut off the program.

* * *

Alaina was early to her next appointment. I turned off my neural upload as she walked into my office. She wore a sweater similar to the week before.

 “I’ve been thinking about your situation with your roommate,” I said after we had settled. “How was it talking about her?” 

“Exhausting,” she said. “We’re just different people. ‘If you can’t do anything about it, then why worry?’ That’s what my dad used to say, at least.”

“It’s obviously been affecting you.”

“Sometimes I get really upset about the things Lauren says. I try not to let her see that it gets to me.”

“You must let it out somehow.”

“I’ll go for a walk. Play the piano. Sometimes I snack a little. Well, a lot, if I get stressed enough. But that’s a whole thing.” She waved a hand. “Mostly, I just deal.”

“This relationship means a lot to you.”

She smiled, then sobered herself. “It does. Me and Lauren always been like this. We helped each other through some shit coming up.” Scant blue and orange lines cascaded through Alaina’s limbic system. “I screwed up. And I can’t leave it like that, you know?”

“How did you screw up?” I said.

She shifted. Distress grew.

“Can we talk about something else?”

My usual response would be to explore this resistance. The real work of therapy happened in these moments. But I, too, was uncomfortable. And I was afraid of losing the patient’s trust. What if she didn’t come back to her next appointment?

I didn’t press. We spent the rest of the session talking about whether she would call her mother for her birthday even though they hadn’t spoken since her mother cursed her out for forgetting her birthday the year before.

I cancelled my next patient and ran provider analysis on Alaina’s session. My heart rate and temperature had peaked several times. The suggestion to change topics threw me, yes, but what else caused a response? I zoomed in on one of the spaces. When Alaina said I messed up, my parameters leapt.

Would you like to flag these for future sessions?

I closed the app.

* * *

Tunde worked with an investment company based overseas. His days started as mine ended. I entered quietly, changed into evening clothes, and found myself in the kitchen. Nini, our house’s virtual assistant, suggested a vegan salad with light dressing from The Rude Girl, a new place just down the street. I no longer wondered how the machines came to their decisions, much less if they were right. The algorithm knew my blood markers, genetic risk, the daily change in body composition, and a slew of other factors that, when put together, predicted this specific meal would give me the best chance to live until I was old enough to regret living. How could I argue with that?

After his work, right when I was beginning to doze beneath the now-warm sheets, Tunde slid into bed beside me. The hum of some television series leaked from his earbuds. I stirred. A soft click as Tunde switched to his reading app.

I noticed a long time ago that Tunde feigned reading financial periodicals around me. I’d looked for couple’s therapy but gave up when I couldn’t work in both our schedules. Hell, what had that been? A year ago now?

My hand went to my phone and the regulation app. Instead, I put it aside.

“Can’t sleep?” Tunde said.

“Why do you always read in bed?”

“Because reading in the shower would be silly.”

“Is talking to me not enough stimulation for you? Am I not enough?”

Before Tunde could respond I got out of bed, took some sheets from the closet, and went to sleep on the couch.

* * *

I continued to see Alaina weekly. Our topics ranged from her loving but misguided single father, her fluctuating motivation to execute on a long-standing business idea, and wondering if life out in the country would ‘be much simpler.’

Branching lines sprouted and thickened after every session, a testament to the connections made. I felt genuine joy when Alaina, who had come to me without experience expressing herself or her emotions, began to consciously make these connections. 

“Maybe that’s why I let this Lauren thing bother me so much,” she said after recounting a best friend who moved away in the third grade. Alaina glanced back at her neural map and lightly traced the new, thin tendril as it branched out from her current cognitive state to the memory cluster highlighted on that very first session. “Because I’m afraid of being alone, see? I just wish I could make things right.”

 I didn’t speak. Many things—good and bad—were born in silence.

“She was dating this guy. They were engaged. He was an asshole. The type who hit on her friends when she wasn’t in the room. She must have known about it. In fact, I’m sure she did. He tried to kiss me while she was throwing up in her bathroom. I had to say something. She confronted him, and he broke it off.”

“She blamed you?”

Alaina wiped her eyes and then laughed at her wet fingers. “Not at first. She started dating again and seemed genuinely happy. She was definitely a lot better. Stopped drinking, too. Then those relationships didn’t work. She’d say little things here and there. ‘Another Saturday night, me and you, just like you wanted.’ Drinking got bad again, and then we’d argue about that.”

“Does she drink a lot?”

“Not anymore. Just when she gets really upset. Then she goes for her drives.”

I made a mental note to return to one of Lauren’s ‘drives’. “You mentioned rectifying the relationship. What do you think that would look like?”

“Being here, for one. It was her idea. She thinks that if I get help, her life will be easier. That, and I quote, she’ll be able to ‘live.'”

“So it’s your responsibility to make her happy?”

Alaina smiled. “Aren’t we all a little bit responsible for someone’s happiness?”

* * *

Tunde and I committed to a home-cooked meal one night a week. Our calendar chose the day well in advance, and it usually coincided with Tunde’s sometimes erratically scheduled days off. I got home later than usual. Tunde sat on the couch, reading his periodicals. A dirtied dinner plate rested beside him.

“You ate already?” I said.

“Was I not supposed to?” I put the plate in the sink and, as I left, Tunde rose. “I didn’t know when you would be home. You didn’t send me any—”

I closed the door behind me. No one yelled. No one threw anything. I often heard of those types of antics when patients talked of their childhood. For us, only silence.

Sometimes, I wondered if that was worse.

* * *

“Insurance notice,” Michael said one morning. Both of our nine o’clocks had downgraded their in-person sessions to neural upload review and treat. He flicked the notification over to my device. “That new one you’ve been seeing. You going to take her on pro-bono?”

“You know we can’t afford that.” I quickly read the notice. I’d expected this, sooner or later. Had it already been twelve sessions?

“I want to explore your relationship with Lauren,” I said once Alaina was situated in my office.

“I don’t want to talk about her today. She gets on my last nerves.”

“I think it would be beneficial to bring her into the room with us.” At Alaina’s look—and her reddening neural map—I spoke quickly. “Not the real her. Just your experience of her to help us get to the root of the issue.”

“The issue is she’s stubborn as a rock. Will it hurt?”

“It won’t hurt,” I said. “It’ll be emotionally uncomfortable. But that’s the point. Discomfort, we can work with.”

I picked up the remote to the neural simulator and held it for her to see. “May I?”

She nodded. There were no probes to place. The same functional-MRI sensors used to create her neural map could tell the molecular structure of the nutrient from her breakfast that made it across her blood-brain barrier.

“Think about your last altercation with Lauren. Try to remember it exactly as it happened.”

As the patient explored her own memory, I ran the Neural Amplification and Recreation Protocol. The system used Alaina’s sensory input and neural response data to create a personalized ‘key’ that could reverse engineer experience from Alaina’s memories. 

A soft triple beep warned of impending output. Then, a new voice came to life.

“It’s all your fault,” a woman said. The tone was incongruently friendly. “If you had just minded your own business everything would be fine. You always thought you knew best.”

The NAR protocol was one of the most jarring experiences for patients in any setting. It essentially took one’s memories and thoughts and brought them out into the open. So I expected a reaction. Only not this one. Because Alaina wasn’t frightened or surprised or scared. Alaina was angry.

“He wasn’t good for you,” she said.

“Is anyone?” the NAR produced. I moved to turn the program off, then stopped myself. “You just want me to be alone. Like you.”

“Leave, then. Go back to him. You two deserve each other.”

“I will.”

I stopped the protocol.

“How—” I cleared my throat, took a deep breath. “Excuse me. How is it hearing that?”

“Hard,” she said. 

“How often does that come up with her?”


I can’t leave because I’m all you have. Without me you’d probably kill yourself. 

I spilled my tea fumbling for the controller. “Sorry, I thought I had turned that . . .” But the NAR was off. Alaina hadn’t spoken. What’s more, the voice wasn’t quite the same as Lauren’s.

“She says that all the time. That I’d be alone without her.”

“You heard that, just now?” I said. 

“Of course I did,” she said. “Am I not supposed to?”

“No, you are, it’s just . . .” I shifted. “It sounds like there’s a lot of conflict with her. You really value this relationship. That’s why it’s taking such a toll on you.”

As I said the last my mind tallied up the truth of it, what I had been gradually noticing over the last several sessions. The way Alaina’s clothes hung loose, something I noticed because she wore the same weeks before. The steady decline in weight every week. The picking of her fingers. The soft rock back and forth in her chair. Alaina wasn’t doing well. Perhaps the insurance was right to push me.

“Treatment can help,” I said.

“I thought this was treatment.”

“It is. But it may not be enough.”

“I don’t want pills.”

I smiled. “No pills. We’ve come a long way.” 

I pulled up her display and showed her the highlighted area in her amygdala linked to the cluster of memory and association cells that represented Lauren.

“This is your friend. This is the effect your friend has on you.” Thankfully, there were still strong positive associations that connected to pleasure and joy. I focused on these first. “You would still have your positive responses to her. All the things you enjoy about your relationship. It’s these areas, where you’re experiencing anxiety and distress, that we can dampen.”

“To make me numb?”

“No, not numb. More resilient.”

“Is this what you did?”

I frowned before I could stop myself.

“There are other, stronger treatments, but I don’t think you need them right now. The dampening process is a lot less invasive. It basically takes all of the data we’ve gathered here in therapy, the work we’ve done, and multiplies the benefit a hundred-fold.”

“I don’t want to care less,” she said. “I just need to be better.”

I tried another angle. “You think Lauren’s criticisms are valid?”

“I do.”

We agreed on no treatment for that day. I noted that I was still assessing the need for intervention and uploaded a small clip of our in-session conversation, which I knew insurance would request. I marked the NAR protocol as a procedure. I hoped to delay the conversation of out of pocket payment as long as possible. Insurance often cared little about my hopes.

That done, I considered replaying the moment of the unexpected voice. I can’t leave because I’m all you have. Did I really need to? Without me you’d probably kill yourself. No. The explanation was simple: NAR often created echoes in a patient’s mind as part of the neuronal intervention.

Why, then, had I heard it as well? 

* * *

The algorithms responded to some change in me. Nini suggested food with more carbs and eliminated some morning and evening workouts to increase my sleep. Self-regulation increased. I checked my regulation app constantly, adjusting as soon as it swayed from normal. I did this so often that security asked me to verify my identity to make sure the app hadn’t been hacked. 

Tunde and I were intimate for the first time in years. Afterwards I felt a sense of emptiness, like giving someone deprived of sugar just a taste of some blandly sweet thing, a shadow of what used to be. 

“Something’s on your mind,” he said as I got up to shower and get ready for work.

More like something was in my mind. The voice inspired by Alaina’s neural recording was full and near constant now. What’s more, it had evolved from the original stranger to something more familiar, something from my past.

“If you could remove your worst memories, would you?” I said.

“Is this a philosophical problem or a practical one?”

“I’m asking you, would you?”

“If I needed it, I would,” he said. 

“You don’t know this, but I overheard you talking about it back in college. You said it was like killing a part of yourself. You compared it to The Ship of Theseus.”

A pause that he tried to cover with a cough. He should know better. 

“Hey, you needed it. You did what was best for you. What was best for us. As for the ship, I’d rather ride around in one with a few stand-out patches than rotting wood.” He put his tablet screen-down on the bed. “What brought this on, babe?” 

I ignored the algorithm’s pre-set outfit choice for the day, neatly centered in my closet, and picked out an older blouse in need of ironing. “Nothing.”

* * *

“You seem distracted,” Alaina said in the middle of our session, less than two hours later.

She was right. My mind was elsewhere. I brought my full attention back to Alaina and smiled. This was what I trained for. 

“You’re right, I am a little distracted. I’ve had a couple rough nights lately, and it’s harder to keep my mind from wandering. How does it make you feel, thinking that I’m not listening?”

“It feels like criticism. Like you have better things to do, and I’m a waste of time.”

“I wonder where you’ve learned such a reaction?”

After some thought, Alaina talked about Lauren’s drinking and driving. The session was back on track. I offered to see her a second time that week on Thursday. She obliged.

Although handled well, in truth Alaina’s observation annoyed me to no end. I unsuccessfully attempted to adjust my modulation many times that night. After another bout of unfulfilling intercourse, I used Tunde’s snoring as cover and went into the den to access my patient records. I pulled up the moment of distraction with Alaina, viewed it from her perspective, and cursed. My eyes were glassy, my gaze off. And when she called me on it I looked less in control and more like a pupil being reprimanded.

The computer flagged this section for ’embarrassment’, ‘resentment’, and ‘doubt’. I selected ‘doubt’, saw a cluster of neurons glow in the frontal lobe, and then connect to another cluster in the thalamus. 

I looked up. “Babe?”

Soft snoring answered. I pulled up the security system. All entryways were locked and there was no recent spike in noise levels. 

Two voices. Whispering. Far away, but clear. I crept out of the den and into the kitchen.

You’re drunk. 

No shit. A good friend would take the keys. But not you. You only act like you care. 

The closer I got to the door leading out to the garage, the louder they grew.

Give me the keys, then, Laura.

Don’t be concerned now.

I crept up to the door. Soon I’d be leaning against it. The voices were clear now. I knew they came from inside me somehow, but that didn’t make them feel any less real. I touched the reinforced metal and flinched at the initial, wood-like feel of it.


I jumped. Something behind me shattered. The voices stopped. I didn’t go to the app to analyze my emotions or cluster connections. I just left the kitchen as fast as I could without panicking. As the door closed behind me, underneath the slide of metal was the faintest rev of a gas-powered engine.

* * *

I didn’t sleep more than twenty minutes that night. Thankfully, the next day was one of my virtual algorithm consultant days, a gig I picked up that paid well and offered some intellectual curiosity in a sea of monotony. I reviewed algorithm assessments and briefly checked in with patients. At times there were glaring errors, like recommendations based on misgendering, but mostly I was just there to give a human face to medicine.

A light ping startled me as I turned off the monitor. Just my secretary. On an adjacent display, her likeness materialized in a hologram. 

“Zachary Parker called. He’s demanding an earlier appointment because his ‘life is falling apart’.” My schedule appeared under her.

I responded to such requests with a five-minute video call to explore boundaries and ultimately deny. But after a night of phantom memories and tortured dreams, I took the easy way out.

“Give him Alaina’s Thursday slot,” I said.

I immediately knew what was happening. Alaina had gotten to me, I’d failed at hiding it, and now I was punishing her for it. She was evoking in me the role that Lauren played in her life.

I dialed my secretary.

“Let’s keep Alaina’s appointment.”

“Oh. Dr. Hairston, I already rescheduled her for next week.”

“I see. How’d she take it?”

“Fine,” she said. “She wasn’t upset or anything.”

The week went on at a crawl. Zachary Parker didn’t make it to his appointment. I cleared the hour after Alaina’s next visit so that we could spill over past our time if the topic allowed.

But Alaina never came. She was a no show.

* * *

She didn’t show up the next couple of weeks. My secretary called at first, and then me. Voicemail. I considered calling from either a blocked number or pretending to be someone else, but quickly shot down both ideas. That was crossing the line. Patients fell off all the time. 

* * *

Self-recalibration increased; I surrendered some of the settings to automatic adjustments. Sleep came easier. Home disagreements quieted. My thoughts were once again clear. I distracted myself with work. Helping others with their problems allowed me to postpone the need to address my own. 

If scheduled outpatient appointments were a kind of cruise control, then working in the emergency room reminded of the power and the stakes of being active behind the wheel. It also reminded of the cost of hospitalizing someone. I made sure to do at least one shift a month.

I put out a call to the community hospitals with my hourly rate and requested length of work. Of the several options that appeared almost immediately, I chose Michelle Obama Memorial. With fewer resources, the work would naturally be more involved. As a Black provider, the unique patient experience often made it worth it.

I started with clearing out the holdovers from overnight. Individuals in need of sobering up, others contemplating the knife or the phone until the early morning, and the manic episodes that seemed immune to treatment. Each had a computer read-out that aggregated data from all their medical care across the country and analyzed them against a global database of various clinical presentations, treatments, and outcomes. This produced a nice little table of risks, scores, and suggested interventions.

I only looked to the notes for guidance on the last three. One I discharged because their craving for death had been induced by alcohol, another I marked for admission to a sister hospital with open beds, and the third I set up for in-house guided psychedelic therapy. This last patient, a social media influencer, recently lost half his followers after his now ex-partner posted a video of his candid, transphobic rant. His elaborate plan for suicide included a livestream.

Inpatient admission, the algorithm suggested. Though he was a clear candidate for guided psychedelic therapy, the algorithm considered available resources in its calculations, and Obama Memorial didn’t have any licensed therapists. It would be way too much at my hourly rate for me to sit and do it, so I called a video service I contracted with. After a six-hour trip I could reassess him on my way out and, if I was right, potentially discharge him. 

“Busy morning,” I said as I entered the shared work-room just outside the overcrowded emergency department.

The senior emergency medicine resident sighed. “Always. Air quality’s been low the last week. Lot of algorithm-induced anxiety around lung cancer predictions. So a lot of these ‘shortness of breath’ should be in and out.”

“What you got for me?” A purple tag—psychiatric services—marked several of the triage bay video feeds.

“I discharged a few. Secondary gain, most of them. Their suicidal thoughts magically resolved when they heard we didn’t have a guide.”

I leaned forward and tapped the icon in blue, still pending evaluation. Lauren Roberson, Room Three. “And this one?”

“Young Black woman picked up by the Community Response Team. Crashed her car into the guardrail, got out, and tried to enter passing cars. They found an empty bottle of liquor in the car. She reeked of the stuff.”

I was already looking over the drug screen, which included analysis of blood and urine. “Alcohol level is zero.”

“Crazy, right? No pun intended. No drugs in her system, bizarre when I talked to her, rambling, kept going on about some issue with her friends. Seems like the real deal.”

“They’re all the real deal,” I said, not unkindly. I expanded her room’s live feed. She was in the standard hospital gown; a blue sweater lay across the foot of the bed. Red lines ran the length of both forearms. I squinted, though there was no need. With the video quality, she might as well have been right in front of me. 

“Did she come in with some other name?”

“Huh?” the resident said.

“Like Alaina or something like that?”

“No. Is that a psychotic thing?”

I reviewed the video uploaded by the Community Response Team. Shortly after contact she rushed at the main responder, yelling Where is she? Where is Lauren?

“It is, isn’t it? I thought it was weird she was screaming her own name when the CRT picked her up. You’re thinking multiple personalities?”

Blue and red lights flashed in the background of the feed. A characteristic siren just touched the audio. 

“Why did they send the police to get her?” I said.

The resident frowned and leaned forward. “That’s the CRT.”

“That was definitely police. See.” I rewound the video. “Huh. Weird. I thought there were lights—never mind.”

I continued to watch. The community responder pulled out a gun as Alaina closed the gap. I blinked. No, not a gun. I closed my eyes. 

Get on the ground! Get on the fucking ground!

Pain in my knee and wrist. The smell of hot tires and spent gas. 

I paused the playback, checked to make sure the resident couldn’t see, double-tapped, and then circled my neural chip to mitigate the anxious thoughts. 

My pulse and my breath slowed. I resumed the playback. There was no gun. There were no police. The response team restrained my patient and safely got her into the padded car. 

“She’s drunk,” one of the responders said after.

“No shit. Let’s take her to MOM. They’ll know what to do with her.”

I watched it again and then sat back. It looked like Alaina. Sounded like Alaina. If I checked her neural print against Alaina’s, it would be one and the same. But Alaina wasn’t homeless and Alaina wasn’t psychotic. What was she, then?

“Uh oh. She’s not happy.”

Alaina approached the front of her room, which was off screen. She screamed soundlessly and waved her arms.

“First cranial pulse of the day, you think?” the resident said.

“Not yet. Charge it up, but wait.” At the resident’s baffled look, I clarified. “I know her. She’s one of my private patients.”

When I arrived, Alaina stood on the opposite side of Room Three in full defensive stance. She wielded one of her shoes while two orderlies tried to talk her down. 

“Alaina,” I said. Her eyes widened and then welled with tears. She dropped her shoe, sat back on the bare bed, and began to weep.

“She got me good,” one of the orderlies said. He had a long, thick scratch down the middle of his arm. “I wouldn’t get too close.”

I nodded and pulled a chair up to the side of her bed.

“You heard it, too, huh?” she said.

“Heard what?” I said, though I wasn’t surprised at the accusation.

“I have to know if Lauren’s here. If she’s okay. Did she tell you where she was going?”

“Why would she tell me?”

“Because you heard her, that day in the office. You didn’t ignore her like everyone else.”

“I work here,” I said. “No one told me to come.”

“Yeah, okay,” she said. “I know when I’m being lied to. I don’t fucking like being lied to.”

Anger: a newcomer in our therapeutic relationship. I wished we were in my office. I felt blind without the insights of the neural mapping. She must have taken something that wouldn’t show up on the drug screen. With a change so quick, there really was no other explanation. But if I went that route, I might lose her.

“You checked in under Lauren’s name,” I said. “Why?”

“Because she should be here. Not me!”

I looked away, let the air cool. 

“What happened between you two?”

“She ran off again because I wasn’t going to take her shit. I was looking for her, and they brought me here. I don’t know what she wants.” She put her head in her hands, massaged her temples, then squeezed. “What do you want?”

On a whim, I asked, “Is Lauren here right now?

Alaina laughed. “You’re really trying to play me. She’s not here, even if she should be.”

“Can I talk to Lauren? Do you have her number?”

Alaina shook her head. 

“No, I can’t talk to her or no, you don’t have her number?”

“She doesn’t have a number. She doesn’t need one. I don’t want to talk about this.” She shook her head, looked around, and shrank. “Are you keeping me here?”

“Do you want to stay?”

“You ask like I have a choice.”

“Because you do.” I could easily petition for a Treatment Despite Refusal claim. Given her presentation so far, the lack of drugs, and already what would be considered a violent act, the algorithm would grant me permission to force a wide range of treatments. “You’re on a hold now, yes, but I can release that hold.”

“What do you think I should do?”

“Spend a night or two in the hospital. Get some rest. Figure some things out.”

“Will you be here?”

“No. But they . . .” They what? Would take good care of her? They’d offer her a bunch of treatment options that would all seem scary and big, and she’d leave the hospital in a couple days never wanting to see a psychiatrist again. Though studies on neural overlaps between provider and patient showed clear negatives, there were less discussed positives. The automatic rapport between two Black individuals, for example, present from our very first handshake and laughter of relief. I was her only mental health provider, and this was her first emergency department visit. I didn’t yet know what to make of her symptoms, but if it was something long-term, it probably wouldn’t be her last. I couldn’t abandon her to the mercy of the system.

“I think you can go home,” I said. “But I’m worried about you. I want to see you in my office this Thursday. And we should start treatment. More treatment.”

Her eyes widened. “You think I need it?”

“You’re stressed. And whatever reason it may be, whether some imbalance in your brain or you ate something that didn’t quite agree with you, I think it’s time for some relief.”

She considered in silence. I let her.

“I’ll think about it,” she said finally, her voice a little more sure. “If I can go home, I’ll think about it.”

“Where will you stay tonight?” I said.

“Family. I’ll stay with family.”

I debated with myself. I needed to know more, and this wasn’t the setting to do it.

“I need to talk to Lauren.”

“I told you, she’s hard to contact.”

“Let me be the judge of that. I’ll sign the discharge papers and drop the hold, I just need a little assurance here. Give me her full name.”

“Lauren,” she said. “Lauren Daniels.”


“January twenty-fourth, two thousand forty.”

I went back to the workroom. The resident was finishing a call. When he saw me, he checked the video feed.

“I knew they taught psychs magic,” he said. “I swore she was going to swing on you.”

“Sometimes patients just need a little talking to.”

“You said she was yours. I didn’t know you treated psychotic patients.”

“I don’t,” I said.

“Should I put in admission orders?” 

“No. Discharge.”

The resident lifted an eyebrow. 

“No hospital’s going to take a psychotic patient refusing treatment, so she’d likely be here all night. You’re working a twenty-four, correct?”

He lifted his hands. “Discharge it is. You know I’m with it.”

I sat at the computer to see if I could track down this Lauren Daniels. I put in her name and the DOB. Nothing. I tried just the name. There were a few matches. I picked one in proximity to Alaina’s age. I opened her chart.

A warning popped up. Ice went down my spine. 

It’s your fault.

I turned. “What did you say?”

“Nothing,” the resident said. Then he laughed. “Careful, or I’ll have to admit you.”

“Then maybe I could get some rest,” I said, going with it.

I went back to the warning. This patient is deceased. D.O.D 01/24/2040. Are you sure you want to open their chart?

Was I sure?

I opened it and, while I waited for it to load, checked the transcript of my interview with Alaina. I’d heard two-thousand fourteen but, no, she said forty.

My insides turned to stone as I read the details about the motor vehicle accident that had taken Lauren’s life seven years ago. 

“Get Acute Ablation Therapy ready for Room Three,” I said. I repeated it, this time louder.

“Is it a little soon? He just got here.”

I sat up, scrambled at the controls, and brought up Room Three. A man with lazy eyes in need of sobering occupied my patient’s bed. 

“Where’s Alaina?” I said.


“Alaina. Lauren. The damn woman who was in Room Three!”

“She left.”


“You told me to discharge her.”

I ran out of the room, down the hall, and threw open the back fire escape door and went out into the night. I yelled for her, but it was of no use. 

Alaina was gone.

* * *

The rest of my shift was uneventful.

* * *

Tunde and I rented a private boat off the coast of Playa del Rey and were well out into the ocean just in time for sunset. I left my dampener in the car. Whatever I felt was far from pleasant, but it was necessary. The rest of the shift had been uneventful. 

“Something’s on your mind,” Tunde said as we walked out onto the deck. Dinner had been quiet. He ordered his usual at seafood restaurants: crab legs and coleslaw. I tried something new, the seared scallops, and hated them. 

“I had a rough shift,” I said.

“Not just today,” Tunde said. He looked out to the sea. Judging from the nervous tilt in his voice, he hadn’t self-regulated in a while. “When you’re with me it feels like your mind is someplace else. Or wants to be. Part of me wonders if you’ve had any inappropriate relationships lately.”

I laughed. Sneaking in an affair while trying to figure out Alaina and the effect she had on me? Absurd. “I should be offended.”

“Offended is good,” Tunde said. He laughed out toward the darkening horizon. “I’ll take offended.”

“Something has been going on,” I said. I continued to smile to keep my husband at ease. “Does the name Lauren mean anything to you?” I saw the lie forming behind his eyes. “Whatever it is, it’s out there already. I didn’t know my ablation therapy included a memory wipe. I guess that was the point, though, huh? Who was Lauren?”

“Laura,” Tunde said. “You were roommates. In college.”

“Laura. Laura Chisholm.” I tasted the name, felt its tremble on my lips. I hadn’t spoken it in decades. “She always had the big hoop earrings and the hair everyone wanted.”

“That’s her. Everyone knew Laura.”

“Did she die?” I said.


“Car crash?”

“You remember a lot more than you should.”

I shook my head. “I don’t remember.”

“You lost me.”

“One of my patients. Her best friend died in a car crash seven years ago. The friend’s name was Lauren. She was intoxicated.”

“Jesus,” Tunde said. “Laura was killed by a drunk driver. That’s definitely too close to home. You’re going to stop seeing her, right?” 

“Yeah,” I said. “Definitely.”

Silence. Whatever Tunde and I had become, he knew when I was lying. 

“You used to tell me about your cousin having schizophrenia,” I said. “That it came on after she lost someone. You told her story sometimes when my path got hard, and I thought about giving up.”

“I remember,” Tunde said. 

“I don’t recall you ever having a cousin.” I turned to him. There were no sensors. No displays. Just the two of us under the dying light. “Was it me? When you talk about this phantom cousin, are you just talking about me?”

“You inspired me,” Tunde said after some time. “You inspired us both. You got help. And look how far you’ve come.”

A dorsal fin briefly broke the surface some hundred yards away. I waited for the rest of the dolphin’s pod to show. None did. 

“What was I like?” I said. “Before?”

“Smart. Beautiful. Creative. All the things you are now.”

“Liar,” I said. 

“It’s no lie.” Tunde shifted. “You were suffering. Before Lauren died, it was manageable. You had a light episode every now and then, but we got through it. No one knew, unless they needed to know. Lauren’s death was . . . tragic, for the whole school, but for you it kept happening over and over because you still heard her.” He shivered. “The stuff her voice would say . . . You have to stop seeing this patient. It’s taking a toll on you.”

The last of the day’s rays warm on my skin, I leaned over and kissed my husband. Our lips lingered long enough to let sparks fly between us, like all those decades ago when he proposed as we watched an ocean sunset. But, alas, nothing but stubble and cognition.

“That’s why I need to keep seeing her.”

* * *

Though the why of anything in life was complex, the how of the situation was clear. I had developed symptoms consistent with mild schizophrenia shortly upon college matriculation. My once benign psychosis dramatically worsened after the tragic death of my college roommate. The ablation therapy did its job, and core memories surrounding the psychosis—including Laura—had been purged. Decades later, the pairing of my cognition with Alaina’s facilitated a free stream of emotions between the two of us. Her experience gave life to dormant parts of my past, similar to the classic case studies describing late-stage dementia patients showing transient moments of awareness and memory. I hallucinated because the awakened part of my brain also facilitated bouts of false sensory information decades ago.

Alaina and I started in very much the same place. If I wasn’t specially equipped to help her, who was?

* * *

I came into the office two hours early to prepare for Alaina’s next appointment.. I went over her files, algorithms, and used the cognition extraction technology to see an emulation of my own logic analyze the details of her case.

Alaina was fifteen minutes late. She wore the same baggy sweater from the hospital three days before. She stank of insomnia.

“You look how I feel,” she said.

“We both had a rough week. I wanted to bring up a sensitive topic. How did Lauren die?”

“She told you she was dead?” Alaina said.

“I saw it in her records.” I leaned slightly forward. “What goes through your mind when I say that? When I mention her dying?”

“She’s manipulating you. To get what she wants. Everyone thinks she’s dead. Everyone gives her sympathy.” Alaina huffed disgust. “She wasn’t ready to go. And she didn’t. I keep her alive.”

“Maybe that’s true. But do you think she wants to live at your expense?”

Alaina began to cry. I handed her a tissue. When she was done, I showed her where Lauren’s voices lived in her brain. Delusions—or fixed beliefs—were the hardest things to combat in psychiatry. For some people, showing their physical derivatives went a long way.

“This is the sensory part of your brain lighting up when I talk. It comes all the way from the nerve anchored in your eardrum and links back to here, where memories are.” I switched from live feed to a previous recording. “See, here, that’s your sensory portion lighting up independently. No input from the outside nerves. It does, however, have an intimate connection with this cluster, where your memory of Lauren lives.”

I turned off the recording. “Do you hear her now?”

“I only hear you.” She kept my gaze for only a few moments before looking past me. Her neural read shifted. 

I leaned forward. “I am not here to judge but to explore.”

“She needs me.”

“She’s gone,” I said. I turned off the session recording device. “I had a friend, too. She died in a car accident after one of our arguments, like Lauren. I can help you be at peace. I think she would have wanted that.”

I clipped the earpiece behind her ear. 

“You think I’m crazy,” Alaina said.

“Oh, no. No, no, no.” I shook my head. “I think you need help. And I have help.”

“Will I be like you?”

I shifted. “I don’t understand.”

She took the earpiece off and gestured around her. “All this, just to function. I see you dampening yourself and dampening yourself. Do you even feel anything anymore?”

“Alaina, I know this is upsetting, but—”

“You’re broken,” she said. “And I’m whole. It might be a rotting whole, but it’s my whole, and it’s all there right now. You had a piece of you taken. And now you have to depend on technology just to get through the day. I’ve seen you!”

For the first time in our many sessions, I was unintentionally silent. Alaina looked to me for the same therapeutic expertise I had shown before to make this moment into something productive, but I had nothing.

“I’m sorry, I—” Alaina began to say.

I held up a hand. “It’s fine.” 

* * *

Alaina missed her next three appointments. I took on more shifts at Obama Memorial and kept an eye out for her. She popped up from time to time in the medical charts. Still presenting under different names, still refusing treatment, still looking for her friend, Lauren.

Three months later I had another ablation treatment. Not only to eradicate any resurfacing remnants of Laura but to also clear my memory of Alaina.

I made sure my notes on her were airtight in case of any unlikely future litigation. As I waited for the machine to do its work I took the final chance to reflect on Alaina’s words. The Ship of Theseus was replaced piece by piece until it was something completely new. Was I the same person as before the ablation? Of course I wasn’t. Would I have become a doctor?

Alaina’s choice bothered me the most. We were so alike and yet chose completely differently at the most pivotal junctions in our lives.


No answer came, only ignorance, and therefore, bliss.