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Romance novels are the money-makers of fiction publishing. Some readers expect steamy, explicit sex scenes as they watch a heroine wander through her amorous adventures. That’s one branch of the genre, and that image is often used to malign romances. But readers of Jill Santopolo’s new novel, Everything After, about a married therapist and her former boyfriend, don’t get much of that. Santopolo doesn’t eschew industry requirements, but her focus is elsewhere—mainly on miscarriages. Most romances don’t deal with this sad fact of life, but this one does. And because the heroine, Emily Gold, is a therapist, the psychological hardships a miscarriage can cause are thoroughly broken down.

In fact, this book features lots of therapeutic philosophizing and lots of maxims on how to survive crises. “It’s not what happens to you, but how you respond that determines your path in life,” the reader is told at one point. And while this might sound a bit trite, it also happens to contain a lot of truth for this novel’s characters. How does all this psychologizing mesh with the romance? By strengthening the books’ focus on the normalcy of love.

Jumping in perspective from the main narrative to Emily’s confessions in a journal, Everything After skips back and forth in time, but not space. It’s all set in Manhattan, mostly lower Manhattan, around New York University, where Emily attended college and now has her practice. So does her husband, Ezra, a pediatric hematologist. Both are dedicated, sincere, caring professionals. And if it seems like they’re too perfect at first, that changes as their relationship encounters obstacles.

Describing her profession, Emily says, “sometimes I feel like we’re sin eaters, consuming stories instead of food.” That said, we actually see very little of Emily’s patients, except for one named Tessa, who has a daughter with her rather cavalier boyfriend. Tessa is a minor character but well drawn; more portraits or even thumbnail sketches like this would push the novel beyond its sometimes claustrophobic focus on Emily, Ezra and the old flame, Rob. We learn every detail of how these three feel about each other, how they used to feel, how they want to feel and how they don’t feel.

Emily, the novel tells us, was made to play the keyboard. That is what she loves doing. She throws her heart and soul into it, and people cheered her. But this vocation was wrapped up in her first romantic relationship, so when that went south, she mistakenly abandoned both. Now, marooned in her mid-30, in a profession she respects too much for it to be merely a second choice, her world starts to unravel. She accidentally finds her way back to music: “Everything she’d been feeling over the past few days came out through her fingers.” And that opens the door back to her past.

“I threw away the future we had been imagining together. But after a long while, I found another part of myself. I wonder sometimes if there’s a way to have both. But if there is, I haven’t found it,” Emily records in her journal. That future she sacrificed was being a musician with Rob, and the book contemplates at length roads not taken. It offers a pretty good depiction of the uncertainties and blunders of the college years—the time when Emily had her love affair with Rob and how people in their 20s can get off to a false start or miss the boat on what they really care about. But what the story really zooms in on is how and why someone sacrifices their dreams.

The trigger for all this is a miscarriage, the description of whose emotional ramifications is the novel’s strength. Otherwise it’s certainly a well executed romance novel, but miscarriages aren’t discussed much in this sort of fiction; perhaps they should be. Santopolo’s meditations on this and her descriptions of Emily’s depression and downward spiral have more verisimilitude than generally encountered in the genre. The observations about loss and the mistakes that can cause ring true, and the journal sections bolster this.

Both Emily and her husband are committed helpers. They help other people for a living. Ezra has the famous quote stenciled in his living room: “Do all the good you can, by all the means you can, in all the ways you can, in all the places you can, at all the times you can, to all the people you can, as long as you can.” Clearly these are good people—or people who focus on being good. Does that goodness asphyxiate one’s true self? That’s a question Everything After asks with persistence.

Everything After. Putnam, 323 pages. $26.