Perimenopause, Burnout, and the Octopus: What Nobody Tells You About Falling Apart at 46

Tales from the burning building: midlife, a practice that died, an octopus, and the thing that actually breaks you.

The burning building

There is a particular kind of ruin that arrives slowly enough that you keep getting dressed and showing up to work inside it, and that is the kind I had.

For a good while before it, I was doing well, and I want to say that plainly because I think we rush past it when we tell these stories, as though the good years were merely setup. I had built a seven-figure practice out of nothing at all. No investors, no safety net, no family money, no playbook, just a license and the particular brand of stubbornness that tends to run in women who grew up watching their mothers make something out of very little. Forty-five employees. A thing I had made with my own two hands. There were whole seasons in there where it felt less like a business than like a game I had somehow figured out how to win.

Then the ground moved, and it turned out I had been standing on it the entire time.

The administrative weight on clinicians had been climbing for years, the way water climbs a wall so gradually that nobody thinks to move the furniture. And then the payments simply stopped arriving. To keep paying the clinicians who were still doing the work, I took out a business loan, the full amount available to me, a quarter of a million dollars, and I did it believing the debt was secured against the practice. I did not read closely enough. It was secured against my house.

I signed that paperwork genuinely certain that the insurance money would come through and I would quietly pay it back and this would become a story I told later, at a dinner, as an example of a close call. The money did not come through. And by then there was nothing left to borrow against and nowhere left to go.

But the loan is not really the part I want to tell you about, because the loan was just arithmetic. What I actually want to tell you about is what I did next, which is the most human and least intelligent sequence of my professional life.

First, I tried working harder, because of course I did. I am a woman who has solved every single problem she has ever encountered by working harder, so when the building caught fire, I reached for the only tool I have ever owned and I stopped sleeping. Sixteen-hour days, then eighteen-hour days, on the theory that if I simply refused to rest for long enough, the structural collapse of an entire payment system would notice my commitment and reconsider.

Then I tried holding it together with my hands, which is what micromanagement actually is when you strip the business language off it. Clearly people were disengaging. Clearly money was leaking somewhere I could find if I just looked hard enough and often enough and at everything at once.

Then I went looking for the magic person. The right biller. The right EVP. The right assistant. Somewhere out there, I was sure, was a single hire who would walk in and make this stop, and my only real job was to locate them before the money ran out.

None of it worked, and none of it could have, because you cannot out-work a structural problem and because nobody on this earth is ever going to care about your business the way you do. They shouldn't. You are the one whose name is on it, and you are the one wearing the orange jumpsuit if it goes badly.

My clinicians left, one after another, and I understood completely, because why would you stay aboard a ship you can plainly see taking on water. But the patients did not leave with them. We were a testing practice, and those evaluations were owed to real families who were waiting on real answers about their real children, so I did all of it. Every intake, every battery, every report, myself, at two in the morning, for months.

I was inside a burning building and I could not find the door.

Meanwhile, my body filed its own resignation

All of that was happening in the world, out where other people could see it. What was happening inside my own body was quieter, and in some ways worse, because at least the business collapse had a cause I could point at.

I did not know I was in perimenopause while I was in perimenopause, and I want to sit on that sentence for a moment, because I am a doctor and I still missed it entirely. I did not think, ah, this is a hormonal transition with a name and a literature. I thought I had become a diluted version of myself, the way a drink goes watery when the ice melts, and that this was simply who I was now.

What that actually looked like, day to day, was this. Fog that never quite lifted. A mind that had been reliably sharp for two decades and now arrived late to its own thoughts. I would find myself staring at a screen with no real sense of how long I had been sitting there. I started forgetting appointments, which, if you knew anything about me, is roughly like a lighthouse forgetting to turn on. No motivation for anything, including things I used to love. Zero libido, which I mention plainly because everyone experiences it and almost nobody says it out loud. My arms went soft seemingly overnight, which I consider a genuinely rude thing for a body to do without a conversation first. Short-tempered with people who did not deserve it.

And underneath all of it, running like a low hum, the thing I now think is the most dangerous symptom on the list precisely because it never made the list: a steady, reasonable-sounding pull toward isolation. Not sadness exactly. Just a quiet voice suggesting that the sensible thing to do would be to go somewhere by myself and stop trying so hard at all of it.

Which is around the time the octopus showed up in my head and would not leave.

If you have never encountered this particular piece of biology, it goes like this. A female octopus lays her eggs, and then she stops eating. She stays with them, guarding, wasting, and by the time they hatch she is gone. It is one of the bleakest arrangements in the animal kingdom, and at three in the morning, with a business burning down and a body that had gone strange on me, it did not feel like a nature documentary at all. It felt like a diagnosis somebody had handed me without saying it out loud.

And I want to say something here about being forty-six, because I think the number itself is doing damage that nobody has bothered to correct.

Forty-six is not what forty-six used to be. We are not talking about the middle age that television sold my mother, where a woman this age was quietly issued a cardigan and a supporting role in her own life. My honest suspicion is that we will look back and understand the forties as the peak of the whole thing, the stretch where you have finally accumulated some judgment and some nerve and have not yet run out of road to use them on.

But nobody tells you that while you are inside it. While you are inside it, you just feel like the octopus.

Then somebody took the gland out

I carried that octopus around for the better part of two years, and it was only recently that I learned how her story actually ends, which turned out to be nothing like the version I had been telling myself.

She does not stop eating because she is finished. She stops eating because of a small structure sitting behind her eyes called the optic gland, which functions as something like her pituitary. Once she lays, that gland undergoes an enormous shift in cholesterol metabolism and floods her system with steroid hormones, a process researchers at the University of Chicago and the University of Washington mapped out in 2022. Her own body hands her an instruction, and she follows it all the way down.

And then here is the sentence that stopped me where I stood.

When those researchers removed the optic gland, the mothers, and I am quoting the study directly here, "abandoned their clutch of eggs, resumed feeding, and lived for months longer."

Take the gland out, and she eats again.

Which means she was never finished at all. She was receiving a signal that felt, from the inside, precisely and indistinguishably like being finished. And a signal is not a verdict, however much it sounds like one.

Now, I want to be careful with you here, because there is a version of this idea that becomes wellness nonsense in about two sentences, and I have no interest in writing that. I am not telling you hormones are imaginary. I am not telling you that you can reason your way out of your own endocrine system. I live with treatment-resistant depression. I am the very last woman on this earth who is going to stand here and suggest that brain chemistry is a matter of attitude or effort or gratitude journaling.

What I am saying is narrower than that, and I think considerably more useful. The feeling of being done is produced by something. It has an author. And the author, whatever it happens to be in your particular case, has no access whatsoever to your future. It is a chemical and circumstantial process generating a mood, and that mood then arrives in your mind wearing the costume of insight, which is the part that fools all of us.

At forty-six I had four of these running at the same time, in unison, like a choir that had rehearsed. My hormones were telling me I was finished. My burnout was telling me I was finished. A business coming apart underneath me was telling me I was finished. And a stack of mail I did not want to open was telling me the same thing in legal language. Four separate signals, perfectly synchronized, all delivering one sentence in a voice that sounded a great deal like my own.

The octopus has no vote in what her gland decides. That is the entire difference between us, and it is not a small one.

It turned out to be weather

For two solid years I understood the collapse of my practice as a referendum on me. Not on the market, not on an industry, not on a moment in American healthcare, but on my judgment and my competence and, underneath those, my worth as a person. I had the kind of identity crisis I had spent twenty years gently walking other people through, and I could not get so much as a fingernail of purchase on my own.

Then, somewhat late, I went and looked up the numbers.

In February of 2024, a ransomware attack took down Change Healthcare, which is the claims clearinghouse sitting underneath an enormous portion of American medicine, the plumbing nobody thinks about until the day the water stops. The disruption reached roughly nine hundred thousand physicians. By the American Medical Association's survey that April, eighty percent of practices had lost revenue from unpaid claims, and seventy-eight percent could not submit claims at all. Small practices took it worst, as small practices always do. The relief fund established to help ran dry while providers were still waiting in line for it. The legal analysis notes, in the flat register that legal analysis always uses for the worst sentences, that some practices "will almost certainly be forced to shut down."

I was not uniquely bad at running a business. I was standing in a very large building with nine hundred thousand other people, and the money stopped arriving for all of us at roughly the same time.

That was weather. And I had spent two years prosecuting myself, thoroughly and with real skill, for the weather.

There is an idea I have handed to patients more times than I could possibly count, and it goes like this. When something painful happens, that is the first arrow. It lands, it hurts, and there is no arrangement you can make with the universe to avoid it, because that is simply the cost of being a person who is alive. The second arrow is the one you pick up and fire into the same wound yourself, and it is made entirely of story. This always happens to me. I should have seen it coming. There is something fundamentally wrong with me that other people do not have.

Pain is not optional. The second arrow is.

I know this. I have said it out loud, in a calm professional voice, to people who were paying me for the privilege of hearing it. And then I spent two years drawing that bowstring on myself with a precision that frankly only two decades of clinical training can give you. I have an entire trained apparatus for locating the pattern in a person's life, and when my own life came apart I turned that apparatus around, aimed it squarely at myself, and concluded with great confidence: well, there is a common denominator in all of this, isn't there.

That is not insight, though it wears insight's clothes beautifully. That is the second arrow with excellent credentials and a doctorate.

Where I actually go rigid

Every Eastern tradition I have ever spent time with arrives, eventually, at the same unglamorous conclusion: rigidity is the thing that breaks. The tree that refuses to bend is the one that comes down in the storm. Attachment to how things simply must go is not a moral failing, it is just the machinery by which ordinary difficulty gets converted into genuine suffering. Alan Watts spent an entire career, in that wonderfully amused voice of his, pointing out that we are not passengers being carried through the universe but expressions of it, and that gripping the steering wheel is both exhausting and entirely beside the point.

All very lovely. Very calming. Now let me tell you about the actual conditions under which I become rigid.

I am rigid when I am scared. That is the whole of it. There has never been a second cause, not once, in forty-six years.

I grew up poor, in a small town in Indiana, in the particular way where you learn early which bills get paid and which ones get moved to next month. I got out. I built something. And running underneath every single decision of my adult life, like a bass note you stop consciously hearing, is the fear of going back. So when I found myself looking at losing the house, that fear stopped being a background hum and put on a suit and sat down at my kitchen table.

What I do when I am that frightened is try to run the universe. I decide precisely how every piece of it needs to go, and mine becomes the only acceptable plan, and everybody else's job is to get on it. I grip. I stop sleeping. I start micromanaging, which if you strip the business vocabulary off it is simply gripping with extra steps and a spreadsheet.

So when I tell you that flexibility is the thing that saves you, please understand that I am not saying it from a meditation cushion with my life in order. I am saying it as a woman whose native factory setting is clench, and who has to be talked down off it, repeatedly, most often by herself.

What I have, after all these years, is one question and one practice.

The question is this. When I catch myself being rigid, I have learned to stop asking what is the right plan here and start asking what am I actually afraid of. Because rigidity is never the problem itself. Rigidity is the smoke. Something is burning underneath it, and in my experience it is almost always fear, and you cannot negotiate with a fear you have not yet agreed to name.

The practice is smaller and older. Every morning, before the day has a chance to get its hands on me, I give it away. A short prayer, an intention, and a single request: show me where I am supposed to go today. And then I do my level best to take the path of least resistance rather than the path I had already decided on at four in the morning.

You are welcome to call that faith, and you are equally welcome to call it a perspective-setting ritual that reliably moves me from the narrow threatened view to the wide one. I have stopped minding which. Man plans and God laughs, and somewhere in the last two years I decided I would rather be in on the joke than be its subject.

The gray hair is the moat

Which brings me around to the question I hear most often from people my age and older, usually late in a conversation, usually in a lowered voice, as though it were slightly shameful to ask.

They look at a twenty-four-year-old building a company out of a laptop in a coffee shop, and they think, with real dread: where exactly do I fit now.

I think that instinct is precisely backwards, and I want to explain why, with one condition attached that is not optional.

The gray hair is the moat. Lived judgment is the single thing that cannot be synthesized, because it was never written down in the first place, which means it was never available to be learned from at scale. Twenty years of sitting across from human beings in the worst week of their lives teaches you something that exists nowhere except inside a person who was actually in the room while it happened. That is not sentiment. That is a supply problem, and it happens to be in your favor.

There is an old story, almost certainly invented, that has survived a hundred years anyway because it is true about something. A factory shuts down and nobody can find the fault. Eventually they call in an old engineer, who walks the floor, listens for a while, and makes a single chalk mark on one machine. The bill arrives for ten thousand dollars. The owner, outraged, demands it itemized. It comes back: chalk mark, one dollar. Knowing where to put it, nine thousand nine hundred and ninety-nine.

Knowing where to put the mark has always been the asset. It is simply that for most of history nobody had to say so out loud.

Now here is the condition, and I want to be blunt about it because kindness here would be a disservice. Refusing to use the new tools is what will end you. Not the tools. The refusal. I watch people shrug and say they cannot figure it out, and I understand that impulse completely, and I am not willing to join them in it. Every person around you is quietly working out how to get their hours back, and if you sit that out, the gap does not stay a gap. It compounds, silently, until one morning it is simply a wall.

And if you are a clinician reading this and feeling that particular dread, let me be more specific, because I think the fear is usually pointed at the wrong thing. The trap was never your profession. The trap is the unit. Hours are a finite input and you cannot manufacture more of them, which means any arrangement that separates what you earn from the hours you personally sit is worth considering. A book. A course. A group model. Supervision. Expert work. A product. Licensing what you already know. Most of those are barely entrepreneurial at all.

You do not have to want a media empire in order to want out of the hourly trade.

And then it happened to me, last week

I want to show you how quickly this reflex moves, because I caught my own on film.

I have been building something called Doc Poppins, which is a diagnostic approach for founders and clinicians drowning in the parts of their work that were never their craft. Last week Meta launched a personal AI agent called Muse. I saw the headlines, and before I had finished reading the first one my entire nervous system delivered its verdict: it is over, Meta is going to swallow this whole, who do you think you are, stay in your lane.

Then somebody actually read the coverage.

Muse books travel. It lowers your bills. It turns recipe videos into grocery lists and sends out party invitations. It is a consumer errand-runner, and the reporting on it contains precisely nothing about professional services, clinical workflow, or small-business operations.

Muse can order my paper towels. It is not conducting psychological assessment.

So a large company shipped an unrelated product, and in under a second I converted that into a verdict about my own worth and very nearly acted on it. Same move as the practice. Same move as the octopus. A signal arrived, I read it as a sentence, and had I believed it, I would have quietly stopped eating.

Fellow passengers

I was folding laundry one night with A Christmas Carol on in the background, a film I have now seen something like forty times, and a line landed on me that I must have heard and failed to hear on every single one of those previous occasions.

Scrooge's nephew is defending Christmas to a man who has no use for it, and he says that at that time of year people seem to open their shut-up hearts, and to think of those below them "as if they really were fellow-passengers to the grave, and not another race of creatures bound on other journeys."

Another race of creatures bound on other journeys. Dickens diagnosed the entire human judgment reflex in eight words, in 1843, and then people put it on a tea towel and stopped noticing.

Because that is exactly what I used to do. My younger self ran a remarkably efficient sorting algorithm on everyone she met. Lazy. Not good enough. Brought it on themselves. I had categories, I was extremely confident in them, and I had essentially no idea what I was talking about.

What softened it, in the end, was nothing more sophisticated than living longer. I judged a great many things about parents before I became one, and then went on to do every last one of those things myself, usually within the first eighteen months. I learned that enormous wealth is frequently unrelated to whether a person is good or clever, and that sometimes they simply had the right parents and the right decade. And I came to understand that God does not hand things out with both hands at once. There are lazy people with the heart of an angel. There are people of genuinely towering intelligence who are a complete misery at a dinner party. Everyone turns out to be a complicated character on a show with an unusually large cast.

Life is softer to walk through when you hold people that way. Everybody was once a baby in somebody's belly. Everybody has lost someone they did not expect to lose. Everybody has had their heart broken, and been frightened, and been alone with it. Every person you pass today is carrying something you know nothing whatsoever about, and often the most useful thing available to you is simply to look at them in a way that lets them know you assumed so.

I have started doing this deliberately with older people, who I think are made invisible in a way that has become almost a policy, and who are carrying most of the accumulated wisdom in the building.

Which, I notice, is the identical argument I was making two sections ago about experience and moats. The people our culture is busiest informing that they are finished happen to be the ones holding the thing that cannot be replaced. They are receiving the octopus signal at scale, from every direction at once, and an enormous number of them are believing it and going quiet.

The part I have not solved

I hand this grace out to strangers for free. I do not give any of it to myself.

Put the two lists side by side and you can see it immediately. Here is what my younger self thought about other people: lazy, not good enough, brought it on themselves. And here is what I have said out loud about myself this year: maybe you are not so clever after all, there is clearly a common denominator, who do you think you are, stay in your lane.

It is the same voice. I retired it for the entire rest of the world and quietly kept it running on one person.

I have not fixed this, and I am not going to pretend otherwise in the last third of an essay. I am not writing to you from the far shore with everything resolved and a tidy framework to hand you. I am in the water. I am burned out, I am in the middle of several things I did not plan for, and I have never in my life felt this stuck. I am also grieving somebody specific, which is the woman who had piss and vinegar and howled at the moon, and I genuinely do not know where she has gone.

But I know this much. If she were sitting across from me as a patient, describing herself in exactly the terms I have been using, I would not let her get thirty seconds into it. And nobody gets out alive has to include me, or else it is simply a generous thing I say about other people.

The bus

Here is where I have landed, at least for today, with the full understanding that tomorrow is its own negotiation.

I did difficult things for a very long time on a theory that seemed sound at the time: most people will not do difficult things, so if I simply kept doing them, I would win. And I did win, by the one measure I had bothered to track. I was also miserable, spread impossibly thin, permanently braced, and sleeping about four hours a night. Which raises a question I did not think to ask for two decades, namely what exactly was being won, and for whom.

Health is wealth. Your relationships are wealth. I will have the rest of my life to work, and I will not have this particular stretch with my children again. They are in the funny part right now, the part where they are genuinely good company, and that window is not coming back around.

Life is going to be difficult on its own, without a single bit of assistance from me. It does not require my help. Which makes the question fairly simple, in the end: why am I volunteering for the harder version? What exactly is the prize for that?

We are all on the same bus. Nobody knows what they are doing, everybody is a little frightened, the route keeps changing without notice, and every one of us is getting off at the same stop.

Some people ride it with their headphones on, bopping along, watching the scenery go past.

And some people ride it with their jaw clenched, braced hard against whatever is coming around the next corner.

Same bus. Same stop. Identical ride.

I choose the first one. Not because I have stopped being frightened, and not because I have arrived anywhere. I go rigid when I am scared and I will almost certainly do it again before this week is out. I choose it because I have finally understood that the clenching purchases nothing at all. It does not shorten the journey and it does not change where the bus is going. The only thing it reliably costs you is the view out the window.

And somewhere in the ocean tonight there is a mother octopus who has stopped eating, because a small gland behind her eyes has informed her that it is over.

It is not over. It never was.

Eat something. Look out the window. We are all just fellow passengers here, and it is a very short trip.

Dr. Colleen Long is a licensed clinical and forensic psychologist (CA PSY23911). This essay describes her own experience and is not medical or psychological advice. If you are in real trouble, please talk to someone, and if you are in crisis, call or text 988.