"They gave me your number for meds, but I don’t want no therapist! Therapists are a bunch of idiots"
"Dr. Freedman, I just want to make sure you’re not a therapist,” he said over the phone.
“Well, I am a therapist,” I responded.
“No, I mean, you’re a doctor, right? They gave me your number for some meds, but I don’t want no therapist! Therapists are a bunch of idiots. I need a doctor, not an idiot.”
“Did you want to schedule a time to meet, Yehudah?”
“I guess, as long as you don’t try to psychoanalyze me.”
I let him know that it wasn’t part of any devious plan, but it did make me wonder what his aversion to therapy might be.
Yehudah came to the office looking like any other bochur from a mainstream Flatbush family learning in yeshivah in Eretz Yisrael.
“So,” he rushed in. “Do you give people Sertraline?”
It was certainly an interesting way to begin our discussion, as most folks who ask for a drug by name are looking for Adderall, Xanax, Percocet, or something else to give them quick relief. But Sertraline was a standard antidepressant often prescribed for depression, anxiety disorders, and OCD. It was generally an effective medication and well-tolerated by patients.
“Yes, I’ve prescribed it before,” I answered.
“Like once? Or do you really know how to prescribe it?” He asked in a snappy tone that might have irked me if I felt he was trying to wrangle a prescription for Vyvanse while faking symptoms of ADHD. “Because if you’re not an expert, then I’m outa here.” He actually started to reach for his coat.
“Yehudah,” I said, “how about sitting back down and telling me what you need help with so I can help you. I’m not going to grill you about your dreams or psychoanalyze you. But you’re the one who made the appointment, remember?”
Yehudah sat back down. “So you’ll give it to me?”
“Depends what you need it for.”
Yehudah proceeded to tell me a pretty standard OCD story, complete with cleanliness obsessions and compulsions. He’d spend up to an hour a day in the shower scrubbing himself to get clean as well as washing his hands raw every time he shook hands with someone or touched a foreign object.
“Sertraline might be a good option for you, Yehudah, as part of the treatment.”
“What do you mean, ‘part of the treatment’? It won’t fix me?”
“Well, it will certainly help to decrease the volume of your symptoms, but it won’t make them go away altogether.”
“Listen just give me the pill and I’ll follow up with you in a month. No way I’m doing therapy.”
I tried to explore further options but he was deadlocked against everything. The more I talked about how cognitive behavioral therapy (CBT) and exposure and relapse prevention (ERP) aren’t the same as the other types of therapy he might be thinking of, the more he backed away.
“Thanks for the script, Dr. Freedman. Maybe you should keep on being a doctor and save the therapy for someone who needs it. I’ll see you in a few weeks.”
I avoided any further confrontation with Yehudah, as it was clear he needed a good therapeutic relationship that wouldn’t be established if I fought him too hard at our first visit. He wasn’t suicidal or homicidal, so there was no need to force the issue and run the risk of him bolting.
Yehudah came back as promised, three weeks later, with a predictable story. “Your medicine didn’t fix my problem.”
“Well, you’re right for a few reasons, Reb Yehudah. First of all, we need to slowly increase the dose over time, as OCD generally requires high-dose antidepressants for the full effect. But as we discussed last time, we also need to address the need for an evidence-based therapy.”
“Listen, Doc, if I wanted to light my money on fire, I’d donate to Bernie Sanders’s election campaign. I’m not into therapy. Let’s just get the dosage right and get me back to normal. My roommates are gonna kick me out of the dirah if I don’t stop showering for an hour a day and using up all the hot water.”
He had a point, but I needed to make myself clear. “Medication and therapy work hand in hand for OCD, Yehudah. People who only use one don’t really have a full recovery. You need both.”
“And you need to mind your own business, Dr. Freedman. I didn’t come for a mussar derashah about therapy — I came to get the right dose, and I’ll see you in a few weeks again to tell you that the medication was enough and that I got cured without the therapy you’re trying to stuff down my throat.”
“And if you see the medication isn’t enough, and you do need therapy like 99 percent of other people with OCD?”
“Then I’ll buy you a sandwich. See you in three weeks,” he snapped as he snatched the prescription and walked out the door.
Four weeks later he walked into my office and handed me a paper bag — with a bagel and cream cheese.
“Okay, I told you I’d get you a sandwich. Now, why doesn’t your medication work? Do we need to increase the dose some more?”
“No, Yehudah, we need to have realistic expectations about psychiatric medication. So many bochurim come into my office after suffering years of anxiety and are broken, miserable people who’ve struggled through dozens of therapists without results, having refused psychiatric intervention. Granted, sometimes they had crummy therapists or didn’t put in the work, but often it’s because therapy just wasn’t enough to control their symptoms. They had unrealistic expectations about the power of therapy and unrealistic fears about the negative side of medication treatment.
“But, Yehudah, you’re the exact opposite. You have unrealistic expectations about the power of medication and unrealistic fears about the negative side of therapy. And you know, psychotherapy is medicine when it’s done right,” I continued. “Do you know that certain therapies cause changes in brain activity that we can actually see on an MRI? This stuff is for real — it’s not just talking about your feelings, which you obviously don’t want to do. What’s your problem with therapy, anyway?”
“Well, I know some guys who just kind of talked to someone forever and never got better.... I mean, who audits those guys to make sure they aren’t a bunch of ganavim?”
“What do you mean ‘you do’?”
“What I mean is that if I refer you for therapy, I make sure things are going in the right direction. If someone isn’t making progress, I talk with the therapist to see where things are getting stuck. If I’m the therapist and things aren’t working out, I send the patient for a second opinion with a colleague so I can know where I’m getting stuck myself.
“Look, Yehudah, medications can help some people some of the time with some of their problems. Therapy can help some people some of the time with some of their problems too. Both of them together do a better job than either alone. No one does well learning without a chavrusa, Yehudah.”
He thought for a moment and then took out a pen. “Nu, so give me the name of a good frum guy to help me out already.”
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 can be found learning Torah in the Old City or hiking the hills outside of Jerusalem. Dr. Freedman can be reached most easily through his website www.drjacoblfreedman.com
(Originally featured in Mishpacha, Issue 801)
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