| Off the Couch |

All Mixed Up

“Of course, he’ll cooperate with you, Dr. Freedman. He’s heard about you and is convinced you’re Eliyahu Hanavi”



The appointment was booked by Mrs. Goldberg for her son Yonasan.

“He’s a very lovely young man,” she told me. “Maybe just a little eccentric.”

“I generally like eccentric folk as they’re more likely to have a good sense of humor and to appreciate my jokes,” I told her.

“Well, actually, he’s a bit more than eccentric,” she continued. “Sometimes people think he’s not connected to reality. I think he’s very lovely, though.”

I was starting to get the feeling I get when an elderly mother sends in her adult son with treatment-resistant schizophrenia for an evaluation that he has no desire to participate in. It’s not the most optimistic feeling.

“Does he want to come in for a consultation, Mrs. Goldberg? I would feel bad to make him schlep out to my office and for you to pay for an appointment if he isn’t interested in the sort of help I’m likely to offer him.”

I’d actually had a measure of success with schizophrenic patients who’d been labeled “treatment resistant,” by using cognitive behavioral therapy (CBT) to enhance coping mechanisms for psychotic and depressive symptoms. And the therapy, combined with certain antipsychotic drugs, can help reduce delusions, depressive symptoms, and the risk of suicide. I hoped I could get him on board.

Mrs. Goldberg, for her part, was very positive. “Of course, he’ll cooperate with you, Dr. Freedman. He’s heard about you and is convinced you’re Eliyahu Hanavi.”

Well, I’d received a few awards in my day, and I even once won a three-point shooting contest, but this was far and away the most humbling bit of praise I’d ever received.

“And as far as payment,” she continued, “he has money from a settlement with a private hospital that illegally drugged him and nearly killed him. We’re happy to pay for a real psychiatrist.”

Yonasan was a thin man in his mid-thirties wearing a pinstripe suit and a bowler hat straight out of the 1920s. I stuck out my hand to introduce myself.

“Mr. Goldberg, it’s a pleasure to meet you. I’m Dr. Freedman.”

He looked at me quizzically for a few moments before wagging his index finger at me and stating what was apparently obvious to at least one of us. “Oh, no, you don’t, Eliyahu. If you think I don’t recognize you, you’re terribly wrong.”

“Actually, I’m Yaakov Freedman,” I said, as I took the frame with my medical school diploma from the wall to show him.

Yonasan waved the diploma aside and told me as a matter of fact, “That’s a good trick, Eliyahu. But I know you when I see you.” And then he offered quite magnanimously, “But if you need to pretend you’re a doctor today, then I’ll let you.”

It’s not easy to do an intake with a delusional patient, but I was warming up to Yonasan — his brain was hijacked by a disease of delusion, but there was a noble soul underneath, striving to navigate a complicated world.

“Can I tell you what’s bothering me, Dr. Eliyahu?” Yonasan said as I offered him a seat. But then he sat down… in the big brown chair with my glasses on the arm and my notepad and pen on the seat. The chair he’d seen me sitting in when he entered.

But Yonasan didn’t seem to mind as he handed me my glasses, notepad, and pen, put his feet up on my ottoman, and proceeded to drink from my coffee cup. I took his gracious cue and sat down in one of the two seats marked for patients. After all, it was certainly unclear to at least half of us who I really was anyway.

“You see, my neighbor is a very bad person, Dr. Eliyahu,” Yonasan began. “In fact, he’s worse than that. He’s a rasha gamur. He’s the wicked King Ahab, a terrible person who wants to lead me astray.”

I wasn’t sure if this person was even real, but I decided to let Yonasan continue. If I was Eliyahu, could Ahab be far behind?

He tried to speak in a collected manner, but couldn’t contain his rant as he let me in on his story: “My neighbor, wicked King Ahab, is this crazy guy who’s always telling me crazy, upsetting things. And before I know it, I’m scared and I can barely function.”

I was already planning out a CBT protocol I thought could help when Yonasan continued, “Do you know how smart cuttlefish are, Dr. Eliyahu? No wonder some people think they’re the source of the lost techeiles. Wicked King Ahab says he read online how they’re the smartest nonmammal or at least one of them, all cephalopods are all smart. Also do you know what they look like? I didn’t, so I went to the aquarium and then I saw them and they look very weird, they look like an ice cream cone except instead of ice cream in your cone there’s a squid-face in your cone. And they change colors when they get angry. The one I was looking at was angry, which was very upsetting. Why do they change colors when they get angry?”

“I think you’re asking good questions, Yonasan,” I said as I tried to slow him down.

“Wicked King Ahab told me that cuttlefish are smart and the lady at the aquarium told me that they use their color changing to show they’re angry. Maybe they were trying to bully me by looking angrily at me. Maybe they wanted me to scoop them out of the tank so they could do their evil deeds by bullying other people.”

Yonasan had worked himself up into a state, and so I decided to try a different track. “Did the lady at the aquarium also tell you that cuttlefish change color when they’re happy? Maybe the cuttlefish at the aquarium liked you and were happy you came to visit! Maybe they don’t want to do anything bad to you? Maybe they just liked spending time with you. Most people don’t really want to hurt you, Yonasan, and I bet the cuttlefish don’t either.”

Yonasan thought about this for a moment. “I guess most people don’t really want to hurt me, like you said. But wicked King Ahab said all sorts of craziness, and then I got crazy too.”

I smiled at Yonasan and told him, “Your neighbor is allowed to be crazy, and we can’t control that, Yonasan. We can only control the way that we respond to King Ahab’s craziness. Maybe cuttlefish are around specifically to teach you this lesson.”

Apparently Yonasan agreed. “I’m going to tell Wicked King Ahab that cuttlefish aren’t politicians or bullies, they’re just happy to visit with me.”

And just like that, Yonasan was out the door, leaving me to mull over a protocol we could try implementing for next time that would help him stabilize. So why was I thinking about wicked King Ahab — Eliyahu’s nemesis — all afternoon instead? When Yonasan returned the following week, I’d get the shock of my life — and learn a powerful lesson about the fine line between delusion and reality.

to be continued…


Identifying details have been changed to protect the privacy of patients, their families, and all other parties.



Jacob L. Freedman is a psychiatrist and business consultant based in Israel. When he’s not busy with his patients, Dr. Freedman, whose new book Off the Couch has just been released in collaboration with Menucha Publishers, can be found learning Torah in the Old City or hiking the hills around Jerusalem. Dr. Freedman can be reached most easily through his website www.drjacoblfreedman.com

(Originally featured in Mishpacha, Issue 869)

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