Living with Uncertainty

(An excerpt from a new unpublished book)

Chapter One

Part 2

That closed the deal for Charley. At once he scheduled the earliest available appointment for Dr. Bellini. Never having had surgery he did not know what to expect, but what he did not expect was an observing Jew who wore a yarmulke on his head. But who was also perhaps the most humorous and friendliest doctor he had ever encountered and given the circumstances, the most reassuring: when Charley asked frankly what were his chances for survival, Dr. Bellini, as though he had been waiting for the question, leaned forward and said, “ninety-nine point nine, nine, nine, nine per cent.”

It was good enough for Charley and even more important, Jill was on board. Three weeks later, the operation was scheduled to be performed by Dr. Bellini. A world class heart surgeon in NYU hospital. But before that, there was much to be done. An angio CAT scan to determine if his major arteries were free of obstructive plaque buildup. X-rays to see if he were free of masses. Blood-drawing to see if he were carrying an infection.

It was all morbidly fascinating to my patient, but nothing could match his dread of having to undergo an MRI test (courtesy of Dr. Moretti.) Charley valued his mind and on more than one occasion he would point out that ‘he liked to think.’ But there were too many things that could go wrong in a human brain and to surrender to the mechanical functioning of a MRI just seemed to be “pushing your luck.” Perhaps because he had been loath to face his demons and survived unscathed, he was eager to tell me about it:

“It wasn’t what I expected. I was nervous but I wasn’t nearly as nervous as I thought I’d be. It helped that I liked the technician who very carefully walked me through the procedure and didn’t mind answering my questions…”

“No it wouldn’t hurt, it would take about half an hour. Just about everybody can tolerate it. I should be prepared for some very loud mechanical grinding sounds which is just the clashing or clanging of the powerful magnets of the MRI machines at work. Not to worry, the most important thing is to try not to move, to be as still as possible.”

“To help me relax, I had a choice of music- pop, classical, modern, or jazz. I chose classical, it didn’t matter, I was more interested in being able to hear the voice of the technician, who would be operating the machine out of sight in another room.

“Somehow it was made to sound all so simple. Before I knew it I was lying flat on my back on a white panel like a conveyor belt that slowly began to ride me into the mouth of a very large tube-like structure….”

“I had been afraid I would be claustrophobic, that I would chicken out and be unable to bear the feeling of entrapment, but that did not happen, the enclosure was not nearly as confining as I had imagined it. There was at least a foot between my face and a small glass panel, like a miniature skylight with a clear view situated above and slightly behind my head. I could look through that or I could close my eyes and listen to the music. I chose to wait for the voice of the technician that periodically would check in with me: ‘How are you doing? …Are you O.K.?’”

“I didn’t mind the clanging and the banging of the MRI magnet. What surprised me even more then the noise were the vibrations. At times, I could feel the panel beneath my shoulders. I tried to imagine a causal chain from clanging magnets to multiple images of differentiated parts of my brain to a reliable medical prognosis for what might be in store for me.”

“Those thoughts and my resolve not to move were what helped the time go by. In twenty minutes, a voice announced that the test was finished.”

“How did I do?”

“We have some beautiful pictures.”

“Does it look okay so far?”

“The doctor will look at these and get back to you”

The only specific thing the technician would say to Jill was that Charley had done exceptionally well, so far as not moving a muscle during the periodic clanging and banging of the MRI magnets. A week later the MRI results were in and so was the verdict. Charley had a normal brain for a man fifty three years old. A normal brain to go along with his normal lung functioning, his normal arterial blood flow, the normal pumping of his heart and the normal infection, — free condition that was a prerequisite for major surgery.

He was so healthy in fact that Dr. Bellini, after he had received Charley’s pre-op results, had told Dr. Rosol that Charley was “an ideal candidate for this particular surgery.” And as he would tell Charley himself minutes after meeting him, “nothing I will ever do”, referring to the complicated reconstructive heart surgery for which he was famous, “will ever be this easy, I’m just going to take it out.”

One other thing that wasn’t normal and they could not have not seen coming was Hurricane Sandy. Just days before the operation was set, the rising water level of the East River had catastrophically invaded the basement of NYU hospital, all but flooding it. Back MRI generators failed, the finest high-tech machinery in the city became useless, patients that could not be moved were moved, premature babies that could not breathe on their own were- as captured in a dramatic series of photos that has become famous in New-York — carried by nurses, late in the night down many flights of steps, each of whom provided life-saving oxygen through hand held devices. One of New York’s greatest hospitals for the first time in history had gone dark.

It meant that Charley’s operation had to be switched several weeks later to Lenox Hill Hospital. And that meant overcrowding, which in turn meant under staffing. Had he known, he might have taken Dr. Bellini’s hint that perhaps he should postpone the operation until after the New Year. As it was he arrived on schedule at 9 a.m. at Lenox Hill Hospital admittance, got undressed, put on a gown and was on a gurney by 10:30 a.m. For an operation that was scheduled approximately for 12 p.m. If possible Jill, who simply could not get off from work, was going to try to see him, before the operation, on her lunchtime.

As Charley would say:

“I wanted more than anything to see her before I went in. I didn’t think it might be the last time I would see her, but you never know. I loved her more than anyone on the planet. I was touched how worried my sons were, how they kept calling me from Denver to check in with me, but no one could comfort me like Jill.

“When noon passed and no Jill, and no sign I was about to be operated on anytime soon. I began leaving word that she was on her way and please direct her to me as soon as she arrived. It never occurred to me that all the while Jill was waiting one floor above me, having been misinformed I had already been admitted to surgery.”

“At about 2 p.m., an unknown heavyset youthful man introduced himself as my anesthesiologist. It was time it seemed to start prepping me for my surgery. Apparently it was also time for him to tell me that I would be having, although minimally invasive, major surgery. It is also open-heart surgery. When I protested that I had been reassured that they would not be breaking open my chest bone, he partially explains that it didn’t matter. What matters was, that in order to do the operation they would have to open up my heart. And to do that they would have to stop my heart, do a bypass around my heart, during which time they would do the operation.

“Since I would not be able to breathe on my own for the duration of the operation, they were going to insert a tube, a respirator down my throat and breathe for me. With his fingers he showed me how fat the tube was going to be.

“When I asked him when they would take the respirator out, he said when you show us you are ready to breathe on your own.

“When I asked him if I would be able to talk when I woke up he said that depends.”

“It was more than I could process. Remembering that Dr. Bellini had promised he would see me just before I went in for surgery, I said first I want to see Dr. Bellini.”

“Now?” asked the anesthesiologist, surprised by the request.

“Yes, now.”

“Can we at least prepare you in the room while we get him?”

“No I want to have a private conversation with him first.”

Within minutes, my famous heart surgeon arrived, now transformed into the world’s most charming man had arrived. There are two kinds of open-heart surgery he explained, one in which the chest bone is broken and the other, the least minimally invasive way, in which we go in from the side. Your heart is stopped because you cannot operate on a beating heart, because of that a bypass is needed and a respirator is placed in. If he told me everything that was going to happen to me in the operating room, that might happen to me on the operating table it would take twelve hours.

“He said all that in less than 10 minutes, but it was more than enough. I had gotten the attention and of course the reassurance I craved.

“Let’s do it”, I said.

“It was all the team needed to hear. Within minutes I had been wheeled into the operating room. I had never been fully anesthetized, never completely unconscious, and in my mind that was the first dramatic hurdle I had to pass. What would it be like to go under? Could I really be sure I would ever wake up? And if I didn’t wake up, would I at least have some fleeting sense, some intimidation of what it was like to die?

“Try as I might, I do not even remember what it was like to be anesthetized, to go under. I do think, though, that it was in no way an unpleasant experience. The five hours I was under have been erased from my mind as efficiently as if they had never happened. Of all the fears, the anxieties I had about this operation, those five hours are the most peaceful.”

“The best moment was waking up in the recovery room knowing I had survived with my mind intact, with no respirator in my throat and fully able to use my voice. I was thrilled to see Jill waiting for me, the look of joy on her face as she watched me fully come to; and moments later when first one son, then the other telephoned long-distance to congratulate me on my recovery. — I felt like a character in a soap opera.”

Dr. Bellini had been there, true to his word. He had removed the tube from Charley’s side as cleanly as though it had never been there. The faint pink sear on his right side was barely visible. He had been in and out of Lenox Hill hospital in barely two days, just in time for Thanksgiving.

But that would be the high watermark. It was downhill after that. Despite continuing reassurance from his doctors, Charlie was not the same after his release. He was thinner and paler and slower in his movements, as though fearful of placing undue stress on a heart he no longer trusted. He had become, not surprisingly, more prone to anxiety, more susceptible than he had ever been to night spasms in his legs, sensations of pins and needles in his hands, a passing numbness in his arm which in the past he would brush off. Now they were a cause for incipient panic that they were in the beginning of a stroke, a full blown stroke that would leave him paralyzed. Someone who had never expressed suicidal ideation, who would boast he could not conceive of a situation in which death would be preferable to living, would now proclaim “If I ever do get a major stroke I hope it kills me.”

As his therapist, I could not help but notice that in addition to his recent open-heart surgery, Charley had suffered a traumatic wound to his psyche. As Jean Paul Sartre in his great short story, The Wall, showed, once someone in their bones, comes face to face with the inevitability of their eventual death, they are changed forever. It does not matter if they are granted a last minute reprieve, as was the protagonist.

What does matter is that the person has begun to understand the meaning of their own mortality. That something is waiting for them. The extinction of their existence in the only world they have ever known. That ever can be known. It is something that cannot be comprehended by even the greatest mind. It involves the complete negation of everything that comprises one’s being including the consciousness of the meaning of such catastrophic extinction. Death in the pure existential sense, is the absolute absence of not only the physical world but of everything that is distinctive, human, subjective or related in any way to the person that you were. Seen this way, the contemplation of one’s death is like attending one’s funeral. It’s the flip side of asking where everything came from, or on a more sophisticated plane- the classic philosophical question- why is there something rather than nothing? — How can something that was you become nothing?

Because Charley was an fledging existentialist — more prone to brooding about issues of his own morality, than to side step them, he offered a window into a taboo that is studiously avoided by organized religion. Raised as Catholic, by patriarchal parents, he had managed to break away, to become someone for whom no topic was immune from doubt. When that subject was his first encounter with the idea of original sin, that he had been born with a stain that required the absolution that could only come from a full confession, he was quick to see the link with therapy. I asked him to tell me how he would feel upon leaving the confession booth.

It had been decades since his last confession, but the answer came instantly, he would leave…

“Feeling light as a feather…. The weight of the world lifted.”

So I had to ask:

“What about the shelf life? How long does it last?”

Charley knew the answer to that one too:

“Not long, until the next temptation.”

Now I was into it, and the rest of the conversation had a life of its own.

Me: “Then what? Do you feel worse knowing you’re already been forgiven?”

Charley: “Yes, worse.”

Me: “Is there ever nothing to confess?”

Charley: “Never, there always something.”

Me: “Even for a priest?”

Charley: “… A priest, anyone. Man is sinful, always.”

Me: “So even if you prayed from morning to night day in and day out, you’d still confess?

Charley: “Maybe your mind wandered… you are always, to some degree, sinful.”

Me: “Forgiveness sounds more addictive then effective, like a forgiveness high.”

Charley: “Yes, an addiction — a forgiveness addiction — that’s a good way to put it.”

I had long been struck by the parallel between the rites of confession and the ritual of a therapy session and here was one opportunity to obtain an inside view.

“Does the priest explore sin — other than present the correct path to forgiveness?”

“Only in a literal way. If you say you stole something — the priest might say’… what? …How many times?’”

Me: “No other exploration?”

Charley, enjoying himself now, “There’s no psychology.”

Me: “Sounds like any priest can do it.”

Charley: “Any priest can.”

Me: “Isn’t there a special skill?”

Charley: (pausing) “No, well maybe some are better than others.”

Me: “They just establish a conduit between sinner and the hope of forgiveness?”

Charley (smiling), “Yes… are you going to write this up?”

I told Charley what I always told patients when this came up. I would never publish anything he said or did in therapy without his full approval. I almost never write about patients, without disguising them very well, and so far as I know, no patient has ever recognized themselves in one of my portrayals.

One year after doctors had promised him full recovery from his open-heart surgery, Charley abruptly stopped therapy. It was time for a fresh start, to put what had happened behind him and move on. Although I wondered as to the real reason, I had to respect his decision. And make our final session as meaningful as possible.

His account of his brush with death, his dread of turning into a paralyzed vegetable, had been so weird that I could not forget it. Was that symptom of a floppy hand a portend of something for more hideous lying in wait? Could even a world class heart surgeon say with certainty what the future held in store?

Although I kept the door open, encouraging him to stay in touch, I did not hear from him for several years. Was I relieved I would sometimes ask myself? And then one afternoon, out of the blue the telephone rang. Almost immediately from the sound of his voice, I recognized that it was Charley. He wasted no time getting to it.

“Last week, I had a heart attack.

One early morning when he had been having coffee in a Manhattan diner with Jill, he had been startled by a stabbing pain and a pounding in his chest more intense than anything he had ever experienced. Once again, there was a race against the clock and Charley was fortunate he happened to be within walking distance of New York University Hospital. But could he make it even with Jill clutching his arm? More than once, as he trudged up the long hill heading to the NYU emergency room, he wanted to stop, sit down or lie down. When he did finally reach the reception area he simply put his head down on the desk and said, “I’m having a heart attack.”

He remembered drawing a crowd, being wheeled into an operating room where he would be told later they frantically searched for the cause of the heart attack. Over the course of six hours they would eventually find and repair the ruptured artery that had caused the heart attack, clean out the abnormal buildup of plaque and insert a stent.

When Charley woke from his emergency operation that had nearly killed him, the pain was gone. But three days later, again in the early morning the pain returned and again he visited the emergency room this time demanding, he be worked on once more. And once more to their surprise they found further unsuspected plague buildup which required a second stent in his heart.

And to my surprise — just when I thought it was appropriate to invite Charley back into therapy- he informed me the purpose of his call was not to see me but to request a referral. Did I by any chance know a therapist who specialized in patients who suffer from coronary heart disease and who woke up in the middle of the night as he now did with panic attacks? All his friends had advised him to join a support group and everyone including Jill, was in agreement it was essential that he only see a specialist.

I realized the fresh start Charley once again wanted, did not include me. To point out that the diagnostic category in which he was now including himself- nightly panic attacks concerning the status of his heart — did not properly exist, seemed futile. His erstwhile existential questioning had hardened into watchful somatization. The prospect of death brought with it inevitable if unanswerable questions of meaning; it was the desperate call to battle the ultimate enemy of life. Prolongation of life now became the meaning of life. The preservation of consciousness became the goal of both the conscious and the unconscious.

When I was seven in Bridgeport, Connecticut, I had a classmate and friend, Stanley Karlovich, who had a little sister whom he would sometimes mention. I had never seen her, but one afternoon I remember listening as my sister told my mother about a terrible accident that had just happened. A girl two years old had somehow wandered out on some thin ice, fallen in and drowned before she could be rescued. I knew drowned meant dying, but I didn’t know or really want to know what that meant, what it is like to die. I remember making a point of never asking my friend how he had felt when he heard his sister had drowned. But when I got older, when I had started thinking about death, it seemed there was nothing more important, yet more mysterious.

To be a therapist is to have a pure window into this greatest of all mysteries. One especially saw the dread of mortality, the avoidance of mortality and just how insidious the threat of death can be. One also saw how ill equipped the overwhelming majority of people are when it comes to realistically confronting the inevitability of their own demise. It is one thing to cope with the exigencies of dying, which can be all consuming. It is another to try to wrap one’s mind around the analogical, if profoundly different case of trying to contemplate one’s own non-existence. The best example I have come up with is to think about the time and the world before you were born, before you were conceived, before your parents and their parents and their parents — go back as far as you like — were even conceived and then try to imagine: where were you, how were you, what were you? The answer of course is obvious. You were nothing, nowhere, no how. In Jim Holt’s wonderfully simple phrase you (as nothing)… “We’re not anything.” That I believe is as plausible a picture as any of what it might be like to have died. But if that is the case why is it that no one seems upset, over huge stretches of eternity, not to have existed? The answer once again, is obvious: because there is no real loss involved. No abandonment of the only world, the only life, the only consciousness, the only experience, the only pleasure and sadness, struggle and ecstasy, the only love and anger that one has ever known. From that perspective, it matters as little that we have not existed for billions of years as it is that at this very moment in almost every corner perhaps over infinite space, we do not exist. What does matter is that our own patch of space time assigned to us is suffused with our personal consciousness. That is more than enough provided it is not taken from us. What is unbearable is not just the loss, but also the magnitude, the totality of such a loss. Death seems nothing less than losing everything. No one, until is happens, has ever experienced anything like that. No one can imagine what it might feel like to confront their mortality gradually, at first, or perhaps suddenly in one fell swoop. No one can prepare for that and no one really wants to.

Not surprisingly these patients, regardless of how intelligent or inquisitive they are, show little interest in questioning the afterlife. Ask about their beliefs and the most likely answer you would find is that they feel “Well, there is something”. Somewhere along the way the wonder that exists in every child gets quenched. There comes a time when it does not seem to make sense unless you are a professional cosmologist to pursue such questions. Better to deal with the world you know, than the world you don’t know- which may not exist, and which at best it utterly unimaginable.

In my book, God and Therapy what we believe when no one is watching, I explore in great depth what I call the theology of the unconscious. To a remarkable degree, it turns out this bears little resemblance to the real world and the world of organized religion, to the answers that are given routinely when questioned by pollsters about their beliefs: and to the ongoing assessments of professionals. Daniel Dennett, I think is right when he says that essentially people “believe in belief”. He means they are invested primarily in the various social benefits that are afforded if one adheres to a religious creed and if one manifests behavior that is seen as proof of the commitment one is ready to make. Dennett makes the crucial point that as long as one “professes” the belief and partakes to a sufficient degree, in the actual rituals — it does not matter if one really believes at all in the theological underpinning. From my own professional standpoint, I am struck that in over thirty years of private practice — after listening to hundreds and hundreds of patient’s dreams — I had not once encountered the presence of God, the joyful fantasy of an afterlife, the radiant appearance of an angel. Why, I had to ask myself in the outpouring and welter of wishes, secrets and hopes to which a therapist regularly attends, was heaven never mentioned?

I came to realize that the relationship that ordinary people including religious people of every stripe, have to a supreme being, master of an invisible world, even in the best of times is tenuous. It is a relationship that only comes to life when there is a compelling need for cosmic intervention. Although I don’t know if it is true there are no atheists in fox holes, I do believe there are no skeptics — in desperate times — when it comes to believing in hope. No matter how demoralized we may be, we never wish for extinction, for pure nothingness. To wish for freedom from fear, for an escape into nirvana, to hope for an end to all our suffering, is to wish for something not nothing.

At such times, we are susceptible to the premature yearning for what might be called a cosmic parent. A being that is masculine when it comes to destroying everything that wants to harm us, feminine when what we want — against all the dictates of reason, — is for the implacable indifference of the laws of the cosmos to be suspended in our behalf because a god like being has just taken pity on us, because he loves us.

There is a huge gulf between what people profess to believe and what they seem to believe. From that point of view, the theology of the unconscious is like no other theology that has ever been studied. There is no one monotheistic God in the unconscious, no omnipotent, omniscient, supreme being. If anything there is a kind of cosmic parent neither masculine nor feminine, an ever watchful invisible support called upon in desperate times.

I have never had a patient who heard the voice of god, who had a conversation with their guardian angel. Who made contact with someone from the dead, who encountered a ghost. Being neither a psychologist nor a neurologist. I am not privy to the kind of patients that are susceptible to hallucinations. But over decades of practice, with thousands upon thousands of patients, I have surveyed a broad spectrum of human pain and suffering. I have come to the conclusion that people, including people of faith, are for more interested in this world than any other. They tend to be superstitious rather than religious. To believe in spirits and paranormal phenomena rather than in gods. In thirty years I have never had a patient who expressed an earnest desire to go to heaven or a dread of being condemned to hell. No one has ever considered what they would say if summoned to the pearly gates. James Lipton’s (of Actors Studio) celebrated question to famous actors-

“If you were to die and go to heaven and meet God, what would you say to him?” — is famous, because it is something no ordinary person would even bother to ask.

Charley, who in spite of his skepticism, was no exception to the constant questioning about the meaning of life, would stop short at the threshold of death. It was enough now, to focus on everything he had learned that could go wrong with the human heart. He had heard every heart had only so many beats in it. It made sense that patients threatened with death become hoarders of the life that is left. The sicker they become, the shorter becomes their bucket list: until finally they only want “another good day… or a month…or a year.”

Charley never sounded as forlorn as when he informed me he had just suffered his very first heart attack. He never sounded so removed from me as when he asked for a referral. Faced with a possibly terminal situation if he could do nothing else he would choose to terminate whatever relationship he could.

This is a book about living with uncertainty; of which there is none greater than the prospect of death and especially the question of what if anything comes afterward. As mentioned that’s another book (God and Therapy). Far more prevalent however, is the pervasive uncertainty that informs every corner of our psychic life. As Sartre put it, “we are doomed to freedom.” And as William James noted long ago, we choose because we want to feel that “we have a say in what the world does to us.” We want in short as the great psychoanalyst Christopher Bollas once wrote, a life of “destiny not fate.” Or as Leslie Farber said in Ways of the Will, we want to “control what cannot be controlled.”

Premature closure, Wilford Bion, once said “is a defense against uncertainty”.

There is another way. By acknowledging but not surrendering to uncertainty, to learn to live with it.

Gerald Alper

Author

God and Therapy

What We Believe When No One Is Watching