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.
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”.