Rabbi Nachman of Bratslav (1772-1810) is a brilliant and controversial figure in Hasidic Judaism, perhaps best known for his spiritual “tales” (Steinsaltz, 1993). One of Rebbe Nachman’s most famous stories, as re-told by Rabbi Alan Lew (Lew, 2008), is about a Prince
“…who came to believe he was a turkey. He took off all his clothes and got under the table and lived there on scraps and crumbs and bones. The King called in many doctors, but none of them could cure him. Finally, he called in a certain wise man, who took off his own clothes and sat down under the table with him. I am a Turkey, the prince told him. ‘I am a turkey too,’ the wise man said. The two of them sat there together for a very long time and then the wise man said, ‘Do you think a turkey can’t wear a shirt? You can wear a shirt and still be a turkey.’ So the prince put on a shirt. ‘Do you think you can’t be a turkey and wear trousers?’ So the prince put on his trousers too, and in this way, the wise man coaxed the prince to put on all his clothes, to eat real food, and finally to come up from under the table and to sit at the table, and in the end, the prince was completely cured.”
Rabbi Lew goes on to cite Avraham Greenbaum, a contemporary Bratslaver teacher, who elaborates on Nachman’s tale:
“The wise man went under the table, and the very first thing he did, his first lesson, was just to sit there. You might have thought he would have been anxious to get started and take the first steps in his plan to cure the prince, In fact, sitting was the first step. Indeed, if you think about the story as a whole, you notice that most of the time the wise man took to cure the prince was spent just sitting with him. This is because the ability to sit calmly is one of the most important prerequisites of clear-headedness.” (Lew, 2008, italics added).
Now, I have never actually gotten under the table with any of my patients, and I suspect my supervisors would have frowned on the practice. Nor do I believe it is generally wise to enter directly into the delusional world of psychotic patients. (Most of them, very quickly, would sense a certain insincerity in this, or else feel vaguely patronized). But there is a lesson in Rabbi Nachman’s tale that I applied, in a very attenuated way, when I was working with an extremely provocative and hate-filled psychotic patient. This was a man I described in a piece for the New York Times (January 31, 2006) as a “brilliant and tortured” individual with chronic paranoid schizophrenia — and a virulent form of anti-Semitism. One of the quirks of his delusional system was the idea that, if he increased his dose of antipsychotic medication by even a single milligram, it would injure or kill him. As a result, he insisted that he would take only 30 milligrams of Thorazine, a “first generation” antipsychotic that is almost never used anymore. Now, thirty milligrams is about one-tenth of a therapeutic dose. It might have been better than nothing for this patient’s schizophrenia, but just barely so. I spent hours, during our first sessions, trying to persuade Mr. A. to increase his medication, even by a few milligrams. The answer was always the same — any increase would kill him. What else could I do but — in a sense — get “under the table” with Mr. A.?
No, I didn’t affirm his delusions in the way the “wise man” of Rabbi Nachman’s tale did. I judged that to be too risky. But I did sit with Mr. A. — a lot. I also talked to him about the things he most cared about: theology, philosophy, and the “hidden meanings” of words. Sometimes he would send me letters in which he would subject my comments to a kind of mystical, Kabbalistic analysis, along the lines of,
“You use the term “paranoia”, Doctor. Paranoia is derived from the Greek, para- “beyond” + noos “mind.” Note the similarity between “noos” and “noose”. The mind is what hangs you, doctor! So I must go beyond the mind.” (This is just a re-creation of Mr. A’s mode of thought, not an actual quotation).
Getting “under the table” with Mr. A. meant, in part, giving him the freedom and safety to explore these preoccupations—and the respect of a civilized debate. Indeed, I often gently sparred with him on his interpretations of my words, and he seemed to relish this. This, after all, was a man whose forensic skills had been honed by the Jesuits, in the years before his calamitous illness struck.
As for his medication, I continued to prescribe the feeble dose of chlorpromazine. I decided that struggling with Mr. A. over this would lead only to his leaving treatment. At least, with our regularly scheduled meetings, I could monitor his general state of health. In fact, he actually agreed to get some routine laboratory tests done, which allowed me to rule out any serious metabolic disturbance.
Sometimes, “getting under the table” with psychotic patients means taking their words very seriously, but not literally. This means being willing to meet the patient’s language “half way”, rather than responding too concretely. For example, if John, who has paranoid schizophrenia, says, “My mother is poisoning my coffee,” the therapist might be tempted to take the orthodox approach and say, “Well, based on your lab results, and what I know of your mother, I think that’s very unlikely.” There is nothing necessarily wrong with this approach, and sometimes it helps. But more often than not, the psychiatrist’s attempt to be the “Ambassador of Reality” tends to alienate the psychotic patient. It is better, at times, to get part-way “under the table” with the patient. So I might say, in response, “John, it sounds like you and your mother have a very bitter relationship.” I am deliberately picking up on — almost punning on — the image of the poisoned coffee. I am also using a highly-charged sensory term to characterize the patient’s relationship with his mother: bitter. In my experience, this is often a more promising approach to resonating with the patient’s emotive world than meeting it with the full force of Western logic and reason.
The writer Anatole Broyard once commented that, “Inside every patient, there is a poet trying to get out.” Sometimes, in order to hear the patient’s inner poem, the therapist needs to take advantage of unusual acoustics: those found only “under the table.”
Ron Pies, M.D. is a Professor of Psychiatry and Lecturer on Bioethics & Humanities at SUNY Upstate Medical University in Syracuse, NY; and Clinical Professor of Psychiatry at Tufts University School of Medicine in Boston. He is the author of several textbooks in psychiatry, as well as the new book, Everything Has Two Handles: The Stoic’s Guide to the Art of Living.
Resources:
Broyard, Anatole. “Doctor, Talk to Me.” In On Doctoring: stories, poems, essays, edited by Richard Reynolds and John Stone, with Louis LaCivita Nixon and Delese Wear, 166-172. New York: Simon & Schuster, 2001.
Lew A: Choose This Life, Rosh Hashanah II 5758. Accessed 5/14/08 at: http://www.bethsholomsf.org/CBS/pages/page.phtml?page_id=240
Steinsaltz A: The Tales of Rabbi Nachman of Bratslav. Northvale, Jason Aronson, 1993.
Wield the Pen, Yield the Soul: Examining the role of literature in medicine: Essay by “Linda”.
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24 Comments to
“The Psychiatrist Under the Table”
I rate this article a 5. I too, work with a client who has delusions and have naturally worked out a way to make connections by relating to the feelings underlying the delusions as opposed to always challenging the literal reality of the expressed delusions. For example: a client might say they have been traveling to a popular vacation spot (they don’t have the money, means or opportunity) and I respond by saying, sometimes, people need to get away from the stress in their lives and wish they could escape their circumstance.
I am moved by the rabbi’s parable that speaks so eloquently to the value of people and their thoughts, and about stretching so far as to see into their souls.
[...] The writer Anatole Broyard once commented that, “Inside every patient, there is a poet trying to get out.” Sometimes, in order to hear the patient’s inner poem, the therapist needs to take advantage of unusual acoustics: those found only “under the table.” [...]
From a client’s perspective, I would be thrilled to have a therapist as artful and sensitive as this writer. My condition is non-psychotic, but I often work myself mentally into narrow corners. The best way out is often not by being told that my expectations are unrealistic but by being empathetic enough to catch the nature of that reality I’m caught in while helping me see thing a little differently. Both the coffee example and the wiseman under the table get that spirit of guiding someone to a different grasp on reality rather than blinding them with a noonday view of the real world.
Wonderful post!
good one !!I would like to send this one to all the mental health professional
I would like to thank all who have written in regarding my article. I very much appreciate your thoughts and perspectives on this topic. –Best regards, Ron Pies MD
I went through a rough patch a few years back and started therapy. It got so rough that I couldn’t even go to work; in the worst of it I was calling in sick every three days or so. I explained to the shrink how I couldn’t get myself out of the house much of the time. What are you afraid of?, he asked. I said that it wasn’t so much like fear but more like paralysis. I see, but what are you afraid of? It doesn’t feel like fear, I explained, but more like inertia. I see, but what are you afraid of …?
Arghhh! The guy couldn’t even speak my language, much less get under the table with me. Ultimately it was Lexapro that finally did the trick, and I now know that what I had was a major depression — but how I would have loved a therapist like Ron Pies MD back then!
Many thanks, Heather. I appreciate your candor and also your compliment. Of course, we all make mistakes, and I’m sure I haven’t listened well either, at times. Those of us in the profession like to invoke Theodor Reik’s expression, “Listening with the Third Ear”. It describes a particularly empathic kind of listening. But it helps to have at least two “ears”, and, sadly, it sounds like maybe your therapist didn’t! –
Best, Ron Pies MD
I would rate this article a 10, and I am trying to be modest, here.
You know, I don’t know if everyone does this, but it seems to me ‘not’ to be the case. So much of what you say is written, and heard by me, in-between the lines. Thee is so much ‘meaning’ surrounding all you say, and I guess this is why you often get ‘weird’ criticisms. I have the feeling that some rather insert their own meaning in-between the lines rather than hearing yours.
What I really like about you, doc, is that you are ‘real’.
I take my own research very seriously, and I am constantly doing research.
It has taught me, that nonverbal communication is not exclusive to two or more people being together, and talking, in the same room. it also works over the Internet.
Dr. Pies says: ‘Getting “under the table” with Mr. A. meant, in part, giving him the freedom and safety to explore these preoccupations—and the respect of a civilized debate.
‘the respect of a civilized debate’!!
You also give that respect to people/patients who comment, and who share their problems with you/us.
Almost ‘NO’ therapist does that. When they hear someone mention a personal problem, they flee…literally ‘take flight’, as if dealing with a spider. They cannot handle it. Only in the secure little private office.
Thank you, kind Katrin…to me, listening respectfully is part of a larger moral fabric that we must all weave. A saying from Rabbi Abraham Joshua Heschel comes to mind:
“When I was young, I admired clever people. Now that I am old, I admire kind people.”–R. Pies MD
P.S. I may not always write back, but I am listening.
You reminded me of what I wanted to say to you before, but I really overdid it with commenting these past 24 hours…that won’t last, mostly because I have said the most important stuff already. But I wanted to let you know that I do not expect a comment back to me for every time I say something. I am totally fine with that and actually prefer you did not because then it would become too automatic and forced. You, as I, have also expressed the most important to me already? xxx Katrin
Just remembered this one, and if I don’t write it down this instant, it will be gone.
‘Kindness is the language which the deaf can hear, and the blind can see,’
Mark Twain
PS: When I was really going through a rough time, and there was nobody who would listen, never mind not blame, quotes became my best friend and therapist. Here, in this world, I felt understood.
The quote that became my favorite, and which I never understood before, but now it became so profound, was the following by Picasso.
‘Every act of creation is first an act of destruction.’
And in the end, it was those people whom I had put on the ‘black list’,(as in, they would be the very last, ever, whom I would ever confide in, because I knew they would be horrible, and not caring, nor understanding, and judgmental), that turned out to be the exact opposite of what I had thought when I did talk with them, and the ‘only ones’ that helped, and understood. (and none of them were even close to being therapists, or in the ‘helping profession’.)
And whenever I think that by now, nothing else, or more, can ever surprise me again, it always does, again, and again.
Dr. Pies, there is a website where I spend much time called NSB.
Dr. Andrew Schmookler, and I, have over the years become good friends, and we in many ways enhance each other through our differences and similarities.
I sent him your article, and he in turn posted it on his websiste.
I wanted to bring this to your attention as you may be interested in knowing this, and also reading the comments.
Best, Katrin
Greetings, Dr. Schmookler, Katrin, and all the readers who have commented! I’m most appreciative that you have all taken the time to read and comment on my “Psychiatrist Under the Table” parable. Thanks, Katrin, for passing it along to Dr. Schmookler.
I would like to clarify the matter of “trickiness” and how it does–or does not–enter in to the kind of encounter Rabbi Nachman describes, and how it relates to psychotherapy.
In order to “get under the table” in an effective and meaningful way, one needs to avoid trickiness or even too much cleverness. In order to inspire any degree of trust in another human being–particularly a disturbed person–one needs to see the person as a “fellow human being”, not some ninny who needs to be “tricked”.
This is what the philosopher Martin Buber had in mind in his “I-Thou” relationship, as contrasted with the “I-It” relationship. If you “get under the table” with a patronizing or deceptive attitude, the other person will sense that at once and the encounter will be ruined. On some level–even if it is a very deeply-buried one–you must be willing to entertain the idea that perhaps the person who says he is a turkey is, in some sense, right–and perhaps you are a bit of a turkey yourself! Of course, I don’t mean this literally. I mean that you must believe sincerely that we are all in the same boat–we are all fallible, suffering human beings. If I am not psychotic today (which claim I believe accurate), it is “by the grace of God”–and that could change tomorrow, God forbid!
No matter how psychotic the patient, there is a core of enduring humanity that unites him or her to me. No matter how “sane” I may be at the moment, there is the potential for physical or mental catastrophe at any moment. In short, “getting under the table” means opening yourself up to the human predicament–not being “tricky”, but being human!
Thanks to all….Best, Ron Pies MD
Dear Dr. Pies, I wanted to ask you a question and I understand if you don’t answer. (I am taking a risk, and don’t want you to feel uncomfortable) So, no need to answer or respond.
If you had a patient who had been taking prozac for some 25+ years, (40 mg) and she was told that prozac may interfere with Tamoxifen, a hormonal drug used for breast cancer prevention. She is to switch to Lexapro because the latter does not create conflict?
Would you anticipate a smooth transition? (The prescribing MD is an oncologist with really not that much experience, never mind that the patient already mixed prozac with Tamoxifen for over a year?)
Should this be done very slowly? any thoughts?
Either way, thank you, Katrin
(and yes, I am the patient)
Hi, Katrin–That’s a perfectly reasonable question to put to a psychiatrist, and I’m honored that you would think of me as someone to provide an answer. In fact, you raise the kind of intelligent treatment question that good doctors should welcome from patients!
In the circumstances you describe, the best source of information and advice, ordinarily, would be the psychiatrist who has been prescribing the Prozac all these years. But if (1) a psychiatrist has not been prescribing the Prozac; or (2) the prescribing psychiatrist is unwilling or unable to answer the question; or (3)the oncologist is making changes in the antidepressant without careful consultation with a knowledgeable psychiatrist, then the patient would be best advised to seek a second (”consultant”)opinion. That would involve the consultant’s discussing the matter with the primary prescribing physician(s) already involved in the patient’s care.
Ideally, the second opinion should come from a psychiatrist with a strong psychopharmacology background, or a consultation-liaison psychiatrist who has experience working with oncologists. An academic medical center’s department of psychiatry, or C-L service, could probably provide names of appropriate physicians to consult. –With all good wishes, R. Pies MD
Thank you so much, Dr. Pies.
I completely forgot to tell you that I haven’t had a psychiatrist in over six years, and that my PCP just took over prescribing the same.
(The Psychiatrist closed his private practice and is working for the University of Oregon)
So, that never occurred to me.
Yes, of course I thought about you, and maybe I also just missed talking with you?
Thanks again,
KAT
Some people just always leave a special place in my heart, and that never goes away, no matter if over the Internet’s ‘real life’, or in ‘real life’ not over the Internet. They are all real.
One of them is Andy Schmookler, and another Hester Hill Schnipper at ‘Beth Israel Diaconess Medical Center’ in your area, and her husband is an oncologist there whom you may have heard off.
Hester and I did a lot of work together with a great online breast cancer support group.
And then there is you….
Thought you may like this. Kat
Hi, Katrin–Thanks for directing me to your very compelling story, “Ordinary Heroes.” It stirs up many emotions and reactions for me, both personal and professional. On a personal level, I confess that had I been in that store under those circumstances, I might have bounded for the nearest exit! No doubt, there were reasons you decided against that course of action, and I respect the judgment you made.
On a professional level, the experience you recount teaches a number of valuable lessons, in my view: first, we live in a very violent country, in which many individuals with severe behavioral problems, psychosis, substance use disorders, etc., do not have access to good health care–or, if they do, may not enter or remain in treatment. Our health care system–including our mental health care system–is badly broken, as a certain President keeps reminding us!
Second, there are indeed “quiet heroes” among us, who seldom get their due in the “If it bleeds, it leads” popular news media. The cashier who stayed calm and steady brings to mind the adage from Proverbs 15:1–”A gentle answer turns away rage, but a harsh word stirs up anger.” Oh, if only our contentious and cranky country could adopt that philosophy!
Finally, your ability to experience some empathy under such frightening conditions is truly remarkable! As clinicians and therapists, we are of course trained to “listen with the third ear” and find a scintilla of empathy, even when dealing with very difficult and sometimes even abusive patients/clients. But it is much harder, in some ways, to feel empathy in the middle of the kind of situation you describe. I suspect that, in your role as nurse, you are also able to enter into your patients’ world with empathy and understanding–just what I had in mind by “Getting under the table” with somebody! —Best wishes, Ron Pies MD
Thank you so much for your response, Dr. Pies. It never occurred to me that I had a choice about leaving the store. I thought I was in a ‘hold-up’, literally. So, this is the first time now I am even subjected to the idea that I could have left? Interesting! Thanks again. KAT
PS: I must confess that I have advanced training in group psychotherapy and psychodrama , on top of a MA in Counseling Psychology. So, I am not that remarkable. Sorry, I never mentioned this before. Katrin
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