Open Heart

by Jay Neugeboren

  “Now remember—I come at most things from the point of view of trust, and the way we get on with one another, and the work I do when it’s effective is a function of trust, and I think trust is something very, very, very hard to come by,” Arthur says. “I mean, how can you have it in today’s medicine? It’s my belief that it usually takes years of reliability, consistency, authenticity, maturity, and empathically resonant dialogue for patients to begin to trust therapists so that they will take some risks they wouldn’t otherwise take.

  “Look. At my best—in my snappiest suit and with my smartest verbiage, I could never engender trust, real trust, fundamental trust, in ten sessions. The idea that people can do that in a managed-care setting is just not comprehensible to me.

  “There are times—when I was in the army, for instance—you see people six or ten times, and you do what you can do. But having seen many people for between one year and five or six years, I know the difference. When I work with somebody over a long period of time, I get to know that person so well I can feel that person’s pain—and I do, and, like that person, I find myself up late at night sometimes, trying to think and feel my way through the pain. And it’s the same in medicine, though I didn’t used to think so. I’ve seen studies saying that across the board somewhere between sixty to seventy percent of what a doctor bases his treatment on is the report from the patient. But if there’s no trust, how good is the report?

  “Let’s say I have some funny pains in my chest and go to the physician who’s been treating me for twenty years. Now he knows I’ve never said this before, so he’ll take it more seriously than a guy who’s seeing me for the first or second time, doesn’t know if I’m a whiner, or if I’m just having some gas—and that’s where trust comes in. You trusted the cardiologist and the surgeon because they were an extension of Jerry, and you trusted Jerry.

  “But trust is also a function of time, and of age.” Arthur goes to his bookcase, and comes back with a book. “I think part of growing older,” he says, “is that we’ve given up illusions of control—of what we can and can’t control. And that makes life easy—with our children, with everything. As certain responsibilities—raising our kids chief among them—start to slip away, we begin to use time and to think about it differently, and there is something peculiar and wonderful, I think, when time becomes our ally. But read this—it’s from a speech Adlai Stevenson gave to a class of college graduates.”

  I read:

  What a man knows at fifty that he did not know at twenty is, for the most part, incommunicable.* The laws, the aphorisms, the generalizations, the universal truths, the parables and the old saws—all of the observations about life which can be communicated handily in ready, verbal packages—are as well known to a man at twenty who has been attentive as to a man at fifty. He has been told them all, he has read them all, and he has probably repeated them all before he graduates from college; but he has not lived them all.

  What he knows at fifty that he did not know at twenty boils down to something like this: The knowledge he has acquired with age is not the knowledge of formulas, or forms of words, but of people, places, actions —a knowledge not gained by words but by touch, sight, sound, victories, failures, sleeplessness, devotion, love—the human experiences and emotions of this earth and of oneself and other men; and perhaps, too, a little faith, and a little reverence for the things you cannot see.

  Arthur and I talk about how time, age, and experience, whether in psychology, psychiatry, or medicine, relate to clinical judgment.* “Let’s take depression,” he says. “Somebody comes to me depressed, and what I can do is make a judgment, probably within a couple of sessions, as to whether that person is a candidate for a psychopharmacological agent that, maybe within three to six weeks, will be helpful. Secondly, I can assure him, based on my clinical experience, that virtually everyone who has been placed on antidepressants, over time—and when he gets the mixture right—will feel better. I can assure him of that because it has been my clinical experience. Third, I can tell him that if he takes the medicine, it will make it easier for him, without the pain and depression, to talk about some of the things that have led to the depressed feelings.

  “So now, with that out of the way, I can begin a relationship with him where I learn about how he became the person he is—how the kind of family he grew up in, and the way he chose to deal with his childhood home, led him to feel less about himself—to have thoughts he’s ashamed of—and I can help point out how that was happening, and is still happening, and he can begin to look at himself somewhat differently. And maybe three or four years from now he’ll have a thirty to sixty percent better feeling about himself that will make the rest of his life better.”

  In a World Health Organization study that covers the period from 1990 to 2020 (actual data plus projections), unipolar depression (also called major, or clinical, depression) is second, behind ischemic heart disease, in the rank order of the global burden of disease (a measure of health status that quantifies not merely the number of deaths but also the impact of premature death and disability on a population).* In addition, of the ten leading causes of disability worldwide, five are psychiatric conditions (depression, alcoholism, bipolar disorder, schizophrenia, and obsessive-compulsive disorder). Moreover, I say to Arthur, his field—psychology and psychiatry—has proven at least as effective in diagnosing and treating these conditions, and in enabling recovery from them, as medical disciplines have been in the diagnosis and treatment of, for example, neurological, infectious, and heart diseases.*

  Arthur says that even though he knows this is so, he cannot shake the belief that psychotherapy is more of an art than a science, and less of a science than medicine is. And this belief, we agree, derives, at least in part, from the reverence with which, when we were growing up, we were taught to regard physicians.

  “My first experience with a physician was, literally, with the man next door to us, who was an old-timer even then, probably in his seventies,” Arthur says. “And he would always cure me! Not hard to do given that I was getting sore throats and minor stuff. But he would also take time to affirm things—like how well I could tell time at whatever age I could tell time.

  “So there he was—a safe, concerned, benign person who I thought was omniscient. And in my case he was omnipotent too—he could do things that made me better— and so I came into my adulthood assuming that doctors possessed all kinds of secrets, and knew everything, and this intimidated me. I think I was afraid to go into medicine, in fact, because then I’d have to see if I could know everything.

  “But his presence also drew me, which is partly why I ended up in psychology, which is a healing field. And you know, when I was in Florida during my mother’s final illness a few years ago, and I was getting into the elevator in the hospital and there was this promo poster for the head of the cardiac surgery unit, with all his credentials—he was bar mitzvahed in 1952, he played quarterback for Tulane, he did his residency at Harvard, he’s done six thousand angioplasties—I said ‘Whoa!’ because this was so at odds with the model I’d had in my head, which was the doctor-as-teacher— a wise, caring, rabbinical practitioner, and not somebody in Nike sneakers who’s on the front page of the Yearbook. All this advertising in subways and newspapers—these are not the doctors I knew.

  “But if not an M.D., why a psychologist, right?—and this had to do with my wanting to understand myself better. I started out in Yale Law School, you know, and made a decision after three days there to get out—that being in an adversary profession was not for me. Probably because it would have put me in touch with my anger, which I was afraid of, though I didn’t realize it then. Law school—and being a lawyer—that seemed like a life where I’d be fighting under the boards for rebounds again and again, and I didn’t want to do that.

  “Now in my home I never heard, ‘You should make a lot of money—go out and become rich.’ And I never heard it in my friends’ homes. Once, when somebody asked me what I was going
to do when I grew up, thinking I was very clever, I said I was going to make a lot of money. And my mother got upset, and my father spoke to me and said this wasn’t the way one should move toward a vocation. So it was my assumption always that I would do something that would be of service, would save me from mediocrity—that enormous fear of being ‘average’—and make me into a professional: a teacher, doctor, lawyer, engineer—and that the money would follow, and it would be enough for me to be able to live a good and decent life.

  “But from a psychoanalytic point of view, since as a young person I was very competitive and ambitious, I think I was also ashamed of the competitiveness, and when I got into Yale and realized I was entering into a profession where I would be making a living from the competitiveness, I said ‘Stop!’—and then I thought about how much I loved being involved with people, and recalled that in my second year of college I took a psychology course I loved, and that I had decided then to go into psychology, and it was like ‘Whoa—I can play basketball and get paid for it!’ and so, at twenty-one, I left Yale—I measure my time there in hours and not days—went back to Columbia, and to CCNY, and took the necessary undergrad courses.

  “After that, I went to Clark University, in Worcester—the place where Freud gave his lectures when he was in America—but I didn’t like the way they looked at psychology there, so I came back and went to Columbia for my doctorate, and I never looked back or second-guessed myself again. If I had to make a decision today for a new life, I can’t imagine doing anything else.

  “And this was always connected to the idea of being a professional—and my idea of a professional was a guy who was a .320 batter year after year, a regular sixteen-to-nineteen game winner, a man who routinely pulled down fifteen rebounds a game. One of the things I took enormous pride in during my years as a shrink was that I almost never did not get to my office and do my day’s work. It’s like Ripkin and Lou Gehrig being out there, game after game—something about consistency, the doing of the work and not letting minor colds or sore throats interfere.

  “Now I was blessed with good health, I didn’t have horrific accidents—though I once did a whole day of therapy with cotton swabs sticking out of my nose after it was cauterized for a nosebleed—nothing that compromised me in terms of getting to the office. Because the notion of consistency and reliability is something I associate with the idea of a professional, and this is bound up with a certain measured, thoughtful way of going about one’s life—of a consistent availability to the people one serves. When people are exploring and risking themselves, consistency is very, very important.”

  I say that Phil says Arthur is really just doing the same thing in his sixties that he was doing when we were teenagers—being on call to his friends, listening to our problems, talking with us, giving advice, getting us through.

  When, for example, after my move to New York, I am upset about the deterioration of a relationship, Arthur assures me I have given the relationship every chance, that I have been generous and open—a mensch—and that there are no issues I am blind to in the situation, or in myself. It is his judgment—both personal and professional—that I should get out. He also speculates, briefly, about what he thinks may be going on in the woman, in terms of what psychologists call “projective identification.” “But look,” he says then. “Let me put it another way: if we were walking along Flatbush Avenue and you told the guys what you were going through, they would say to you, ‘Neugie, she’s busting your balls.’”

  When I remind Arthur about how helpful he’s been to me, he shrugs off my gratitude, says he is a lot less sure of things—of what he truly knows— than I might think, and he talks about his clinical experience and its relation to the education of therapists.

  “My most energizing experience—my highest level of gratification—comes from my involvement with people,” he says. “Now, in my field there are three variables in the treatment process. There’s a patient, there’s a therapist, and there’s a treatment modality. If one of the three isn’t appropriate—wrong patient for the right modality and the right therapist, right patient for the wrong therapist, et cetera, psychotherapy will not be a success. And in my field we have done far too little scientific investigation of the match—of the integration of proper therapist—by age, life experience, psychotherapeutic skills—with patient. And the failures in my field—what you and Robert have experienced in spades—or a high percentage of them certainly, are a function of our inability to put together the three variables in a way that’s synergistic.

  “My sense of things is that it’s different in medicine—for Rich, let’s say—and that in your prototypical heart arrhythmia situation you’re pretty sure you’re as good as the next guy in town. But I don’t know if people in psychology or psychiatry can feel the same way. Or maybe this is just my fantasy about doctors—that here is somebody who’s sure of things, and that there are answers, and that if only I studied harder, had been smarter, I would have gotten it.” Arthur smiles. “It’s like believing WASPs don’t sweat.”

  Like our physician friends, Arthur laments the premium that has been put on speed. “At least since the mid-eighties,” he says, “more and more people were saying to me, ‘Look, I really don’t want to spend four years here, Doc. Listen less, tell me what to do, and help me make things okay’ And on top of the pressure coming from the patient, managed-care people are saying, ‘You get six sessions for a buck-and-a-half and then you gotta pay the guy’s regular fee,’ so they want it even faster. Maybe in a medical situation there’s a quick resolution, but not always in my work.

  “Because the work I do is very private, and depends upon confidentiality—a place where people can talk about their most private thoughts, feelings, fears, experiences—and it seems to me that in a cultural way, unfortunately, there are almost no sacred private areas anymore. Everything—like those ads for doctors and hospitals—is for public consumption, and I don’t really know what that means. It is what it is, I guess, but it certainly is not good for the doctor-patient relationship.”

  Vietnam was for Arthur what Nigeria was for Jerry. “It changed my life forever,” he says. “And it changed it forever even before I got there. Because I was a young man who did everything the way his mother and father wanted him to: I wore a white shirt to school, I went to the right college, I was a doctor, I married a Jewish girl, I had a piano and a nice house, I had a lovely daughter, things were all working out terrifically, and all of a sudden I was one of two people chosen in the entire U.S.A. in my specialty to be sent to Vietnam.

  “So this was the first time I fully understood that life was neither good nor fair—that you can do everything right and the way you’re supposed to, and still get fucked. Now that’s a big thing to take in at any point in your life, and I should have been weaned from it earlier, but I was twenty-eight years old and it hit me like a ton. I mean, if being a good boy was not going to pay off, why should I marry a Jewish girl? Why should I be polite to my Aunt Sophie?

  “I did my clinical internship at Walter Reed General Hospital—this was just before I was chief of psychology at Fort Monmouth—and the head of psychology at Walter Reed became the head psychologist in the army. Now, for reasons I absolutely to this day cannot fathom, he said to himself, ‘This guy Rudy, out of the two hundred fifty or three hundred psychologists in the army, will be somebody who I think will do a good job in Vietnam.’

  “And I know this, because I said to him, ‘Why’d you pick me? You have a lot of psychologists who want to go there and get medals and ribbons so they can build up a career in the army’ And he said, ‘Because I believe in this war and I believe in you.’ So I became one of only two people who did my work in Vietnam, and it was truly transformative—and traumatic.

  “I was with a Mobile Army Surgical Hospital—the 98th Medical Detachment, 8th Field Hospital—and I was chief of the Psychology Section, and even on the boat going over there I knew that I was alone in a way I had never understood alonenes
s before. I couldn’t be bailed out by people who loved me. I was an interchangeable number, replaceable by some guy who was at that moment sitting down to dinner with his wife in Topeka or Des Moines.

  “The other thing I realized was how provincial my vision of America had been. I’d grown up in an insulated parochial convent of middle-class Jewish kids, and most Americans viewed the world differently from the way I did. From that point on—in Vietnam, and for the next six or seven years—I began to realize that no matter how much you are loved or cared for, and no matter how much people want for you, you are ultimately alone—whether in your dying, in a serious illness, in childbirth, in the pain that comes from failure with your child.

  “I saw the kinds of things I never wanted to see—ghastly stuff: people burned up, people being carried out of helicopters with pieces of metal sticking out of them, and it’s one thing to see that in an ER, but another thing when you know the metal was put there on purpose. You go down to the psychiatric unit and on one side there are American boys who’ve lost limbs and on the other side there are Vietnamese prisoners who’ve lost limbs. And they look at each other across the unit, and it’s okay. Now that they’ve been mutilated for the rest of their lives, no one’s killing anyone.

  “Not only did I experience feelings about the potential for my own mutilation, but my feeling of insecurity—of being separated from everything that made me feel safe—was very intense because I also knew that the doctor I saw was as scared as I was, and was running from his own diarrhea, and that we could all be dead in the next millisecond. And I don’t know if I have ever felt secure since. But maybe security was an illusion. Maybe it was always an illusion.