What's the right thing to say to someone with cancer?
A young woman who was diagnosed with cancer was dismayed by the lack of greeting cards that expressed how she truly felt - but now she's on a mission to help others find the right words in times of crisis.
Emily McDowell was diagnosed with Stage 3 Hodgkin's lymphoma in 2001, when she was only 24.
While she was enduring the months of treatments that would eventually lead to remission, she noticed that friends and acquaintances often didn't know what to say - and that the greeting card industry wasn't helping.
"The sympathy cards were really… interesting," says McDowell, who lives in Los Angeles. "There wasn't much out there that spoke to the situation I was in."
The cards she received fell into a few categories. There were the "get well soon" cards that seemed like they made more sense for someone recovering from a broken leg than someone newly diagnosed with cancer.
"It felt almost like a challenge - like, 'um, okay… I'll try!'" McDowell said.
Then there were the cards that skewed religious or philosophical. These adages - "it's all in God's plan" or "everything happens for a reason" also seemed to strike the wrong note.
"In the moment, it's almost insulting to hear," McDowell said.
"How is this the plan? Maybe with time and perspective the person can come to that conclusion on their own - but it's just not helpful to hear in a time of crisis."
McDowell realised that while the cards she received were clearly sent with the best intentions, they didn't really help the sender express how he or she was feeling in a genuine way.
She filed that information away while she pursued a successful career in advertising.
But when she left the industry, she resurrected her idea of creating greeting cards that she felt reflected the messy reality of life.
The first cards she created were general greeting cards - and the first to go truly viral was an "awkward dating" Valentine: "I know we're not, like, together or anything but it feels weird not to say anything so I got you this card…"
McDowell's latest project hits closer to home. "Empathy cards" are designed to provide an emotionally frank counterbalance to the aspirational - and often sugarcoated - sentiments she saw expressed in mainstream greeting cards while she was ill.
"A lot of cards represent the relationships we wish we had," McDowell said, adding that the big greeting card companies might feel it is too much of a risk to produce "alternative" cards that were anything but upbeat.
"It's a traditional medium that didn't necessarily evolve psychologically with the way our culture did, and now it's playing catch-up."
McDowell says she hopes her line of cards provide a springboard for genuine connection and conversation when a friend or loved one is going through a crisis.
"A lot of the time when you are sick or grieving, people stop treating you like the friend they've had for years. They suddenly start treating you differently - like you're defined by your illness, or your grief.
"I wanted to help people feel like 'this is a card I could laugh with my friend over… it addresses my illness, but doesn't tiptoe around it."
In addition to her cards, McDowell's recently released a book, No Good Card for This, written with the help of compassion expert Kelsey Crowe to help people be empathetic when a loved one is going through a difficult time.
She may have made her life's work out of knowing what to say in a time of crisis, but McDowell says simply being honest with a person going through a hard time is always the best thing.
"It's totally fine to say, 'I'm shocked, I'm upset, I don't know what to say except I love you and I'm here for you.'"
Even if the words come out awkwardly or aren't well-received, McDowell says it's a lot better than saying nothing at all.
"The worst thing you can do is not to say anything - even if you just don't know what to say, that person is going to interpret your silence as not caring.
"The longer the time goes by, the worse you'll feel about it… and eventually you'll run into that person six months later at a grocery store and it'll be horrible. It's just not a good enough reason to put that kind of pain on yourself and someone else."
As for her own story, McDowell says that cancer taught her lessons that were unwelcome at the time, but have proved valuable in the years since.
"I will never say having cancer was such a gift, because having cancer sucks. But one of the things that going through a crisis does - it enables you to deepen your relationships.
"It makes you less afraid of talking about hard things. And the perspective I got - that really helped me figure out how to help people."
McDowell says she's been touched by the stories from both givers and receivers of the empathy cards - anecdotes about relationships revived and healed because of them.
She told the story of a woman who approached her while she was promoting No Good Card for This.
The woman's husband had died a few months back, and her two children were struggling, and the wall full of cards from friends and family weren't exactly helping.
One day she got home from work and all the cards had been taken down - except for one.
"One of the children said, 'This one gets it - but all the other ones don't. The one that was left was one of our cards'," McDowell recalled.
"It doesn't get more meaningful than that."