I cut straight to the chase. “So, you’re pretty much high all day, tzaddik?”

Levi Yitzhak was a bochur who was slowly killing himself,

yet he wasn’t particularly interested in what I was offering to help extricate him from the pit he’d crawled into.

He’d had a tough childhood, having started out life with the challenge of a mother who was hospitalized with a postpartum manic episode shortly after his birth. Her subsequent diagnosis of bipolar disorder and his father’s exodus from the family didn’t make his toddler years any easier.

From the age of five, Levi Yitzhak had been raised by a loving aunt and uncle whose own children had already grown up and married. Uncle Boruch and Aunt Frumy cared for her sister’s son like their own, but no amount of varmkeit could keep Levi Yitzhak from rebelling. By the age of 17, he’d been kicked out of a number of institutions and finally landed in an open-style yeshivah, bringing along his significant substance-abuse problem.

This time, Aunt Frumy gave him an ultimatum: Stop the drugs or you’re going to rehab. This apparently scared him a bit, but not enough. Levi Yitzhak was willing to give up painkillers, Xanax, and psychedelic mushrooms, but he remained a heavy marijuana user. On her end, Aunt Frumy felt like she had to pick her battles, and theirs ended with an uneasy truce: Go to an expert therapist and we’ll shelve the rehab discussion for the time being. Levi Yitzhak agreed, and an askan put him in touch with a substance-abuse clinician.

Levi Yitzhak actually liked Dr. Alvarez, and felt like it was “a good fit” — probably because Dr. Alvarez didn’t push him too much, and because Dr. Alvarez had clients in the Orthodox Jewish world. Aunt Frumy was impressed with his credentials, which included a doctorate in psychology from Yale and a faculty position at Columbia as an addictions researcher.

Two years of daily marijuana use later, Levi Yitzhak left his open yeshivah for a yeshivah in Jerusalem, which I’d been affiliated with as a mental health counselor in the past. And while his new home offered three sedorim in the beis medrash each day, this was a bochur who was constantly far too stoned to appreciate anything his rebbeim had to offer.

After a few months, I received a phone call from his mashgiach, Rav Kuper, telling me they’d made him an ultimatum: Go to meet Dr. Freedman or go home.

“All this kid does is smoke marijuana all day,” Rav Kuper told me. “He clearly needs treatment, but every time we bring it up, he has the same excuse: ‘I’m in treatment.’ Apparently he’s covered and has someone back home named Dr. Alvarez who’s on his case, but between you and me, it isn’t working.”

“He’s still in treatment with a therapist in the US even now that he’s here in Eretz Yisrael?” I asked, frankly surprised. Providing ongoing care for a patient in a different country is generally discouraged, if not illegal.

“Well, they talk almost every week” Rav Kuper responded. “I can’t see how it’s helping him though. This kid hasn’t woken up before noon a single day since the zeman started.”

Levi Yitzhak showed up 30 minutes late for his first appointment and offered a very half-hearted apology — which I refused to accept given that his eyes were bright red, he was still wearing his training pants/pajamas, and he reeked of marijuana.

I cut straight to the chase. “So, you’re pretty much high all day, tzaddik?”

Levi Yitzhak giggled in admission and sat down in my chair, opened a bag of Doritos and began eating — without a brachah.

“You wake and bake, Habibi?” I asked him, kicking in an idiom I’d picked up, referring to daily marijuana use from the moment one gets up in the morning. “You have a pipe next to your bed instead of a negel vasser, yeah?”

Levi Yitzhak couldn’t stop laughing and I told him I would be back in a moment as I left him high as a kite to enjoy his snack.

It wasn’t the first time a patient had come to my office stoned, but I didn’t need to waste the next half hour with a kid who was incapable of productive work at this point.

As he sat in my office enjoying the nacho-flavored chips, I called his mashgiach to let him know my thoughts.

“Kevod Harav…” I said by way of introduction as he picked up the phone.

“I’m glad you’re on the case, Dr. Freedman,” he said, cutting me off.

“I may be on the case, but I gotta tell you, he’s not here on this planet,” I told him bluntly. “He’s high as an astronaut and it’s barely after Minchah Gedolah. If his drug of choice was alcohol, this kid would need a liver transplant by now.”

“It’s a big problem, Reb Yaakov,” Rav Kuper agreed. “Nu? What do we do?”

“First of all, he needs to get serious about treatment,” I offered.

“Did he tell you anything about this fellow Alvarez? Do you know anything about him, at least to see if he’s a decent therapist?”

I didn’t, but I had more than enough information to suggest that he was no longer a good fit based on the mental state of the bochur who ended up in my office.

I encouraged Rav Kuper to come pick up his bochur, as Levi Yitzhak was clearly impaired and I didn’t want anything to happen to him on the way back to his dorm.

I hung up and walked back into my office, where Levi Yitzhak was licking the crumbs off of his fingers and had thrown the empty Doritos bag on my floor.

“I’m happy to help you, tzaddik, but you need to be present for a discussion if you want it to go anywhere,” I told him as I picked up the empty bag and threw it in my trash.

“I am present,” he said, laughing again. “Where am I if not here?”

“I mean ‘mentally present,’ Levi Yitzhak. We can’t make any progress unless you’re sober, at least for the hour when we meet tomorrow.”

“Hey, but I already have a therapist. Why am I coming back here anyway?”

“Alvarez is fired, Levi Yitzhak,” I said bluntly.

“But he’s a great therapist! He doesn’t push me and doesn’t care if I’m high.”

He began laughing hysterically again, just as his mashgiach walked into the room.

“This guy is hilarious, Rav Kuper.” Levi Yitzhak giggled. “He thinks he can fire my therapist.”

Rav Kuper slapped the bochur on the back in a firm but loving manner and told him, “He doesn’t have to, because I’ve already spoken with your Aunt Frumy.”

Levi Yitzhak started sobering up quickly. He didn’t like where this one was going.

“Levi Yitzhak,” continued Rav Kuper, “your aunt and I both agree that Alvarez is fired, whether or not you continue with Dr. Freedman. She can’t imagine paying another dime to a guy who watches you smoke all day long and yet calls his work ‘a success.’ ”

Levi Yitzhak was done laughing.

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 855)