Without a Prescription

Two parables and a line from a song cast light down a path that diverged from conventional psychiatry. One parable came from a man named Chacku Mathai. The song lyric was spoken by a neuroscientist, a colleague of Nestler’s at Mount Sinai and research director with the U.S. Department of Veterans Affairs. The other parable served as a statement of principle for a psychiatrist who had turned away from a traditional and esteemed career:

Once, there was a prince who went crazy. He believed he was a turkey. He took off his clothes and crawled under a table and refused to eat anything except to peck at bones and bits of bread, which were left for him on the floor. The king and queen were distraught. They called for the royal physicians, but one after another failed to carry out a cure. The prince remained a turkey, naked and pecking.

Then a sage arrived to offer his services. He undressed and sat beneath the table, nibbling.

“Who are you?” asked the prince. “What are you doing here?”

“And you?” asked the sage. “What are you doing here?” “I am a turkey,” said the prince.

“I, too, am a turkey,” said the sage.

They spent time together like this, getting to know each other, until one day, the sage asked the king’s servants to bring him some shirts. “Is there any reason why a turkey cannot wear a shirt?” the sage asked the prince. Each put on a garment. The sage signaled the servants for pairs of pants and asked, “Is there any reason a turkey cannot wear pants?” The same transpired with socks and shoes, and soon they both were completely dressed.

Next, the sage requested regular food and, when this was brought, asked of the prince, “Is there any reason why a turkey cannot eat good food? I think one can eat what one wishes and still be a turkey.”

They feasted together, and sometime later, the sage inquired, “Is there any reason why a turkey must sit under the table? Surely a turkey may sit at the table, with his place nicely set.”

And in this way, the prince was fully cured.

Pesach Lichtenberg, who found professional wisdom in this rabbinic tale, had grown up and gone to medical school in Brooklyn and the Bronx, then moved to Israel and finished his training as a psychiatrist in the early ’90s. He’d been swept up in the psychopharmacology of the time, and once, as he made rounds with a senior colleague, he had listened to a patient speaking, he told me, “about God and demons and the messiah and so forth. I was fascinated. I’ve always had the problem of being intrigued. I was getting lost in his descriptions. But as we walked away from this person, the senior psychiatrist said, ‘That’s not him. That’s his dopamine talking.’ It struck me as such a wonderful insight.” Lichtenberg laughed almost bitterly behind his cropped goatee. “Today I’m ashamed that I could think this way.”

Lichtenberg was wry and slender; it wasn’t hard to imagine him folding himself up beneath a table with a patient. But for the majority of his career, that’s not at all what he did. He presided over a psychiatric ward at a Jerusalem hospital. We visited his former workplace not long ago. The hospital at first approved and then rejected his request to show me around the ward, but we did descend within the building to a semi-underground level, where we walked a series of long, utterly undecorated corridors that led to the locked doors. While he chatted with the current director, I looked through a window at the bunker-like area where patients received their outdoor time. Two men occupied a pair of concrete benches. One sat hunched and torpid, the other lay on the concrete in a fetal position.

For over twenty-five years, Lichtenberg kept men like these sodden with medication. “Half the dose was to calm the patient,” he said, “and the rest was to assuage the anxiety of the staff.” But even so, staff felt his dosing was insufficient. “I discovered later that the legendary head nurse of the ward, a survivor of Auschwitz, thought I was being too gentle and would take matters into his own hands. He would supplement. The head nurse of the whole hospital finally led me to understand: he’s been giving injections behind your back, because you don’t know how to treat your own patients.”

As Lichtenberg grew thoroughly disillusioned, in the mid-2000s, a new patient was brought to the ward in a state of acute psychosis. Avremi—Abraham in English—was in his twenties, a devout student of kabala, an ancient form of Jewish mysticism. Weeks earlier, Avremi had purchased the thirty-seven fruits that symbolize the kabala’s four worlds, culminating in the seven pure fruits that are most divine. Building a meal around these, he celebrated a sacred holiday with kabalistic friends, and that night and over the next days he began to feel, he recalled when I met with him, “that my legs were a little bit less on the floor. Everything was in the hands of God except belief. And maybe even belief. Only one rope held me to the ground. And then that rope was cut. Everything was God; it was like I entered a quiet light.”

His new wife, Yisca, the daughter of Yemeni immigrants to Israel, was not pleased. She and her family were at least as devout as Avremi—but this was scary. “Things started to go more and more,” he said. He had meetings with a prophet from the Bible and with Nebuchadnezzar, the Babylonian king who had destroyed Solomon’s temple in the sixth century B.C.E. He consulted a revered living rabbi, asking whether, as he suspected, he had been chosen for a pre-messianic purpose. “The rabbi closed his eyes; he was thinking. And then he told me that it was not so. I was very disappointed; I had felt I was on top of the world; but I accepted what he said at that moment.” Avremi contemplated, though, what another rabbi had taught him, “that if one person, just one person, wants the messiah to come, he will come. So I thought, I may not want more than anyone else on the planet, but I want to want in this way, and I will pray from this position—like from a sanctuary of the heart—the position of wanting to want.”

He told his wife he was going to Jerusalem’s Old City, to the kotel, the two-thousand-year-old wall that touches the remnants of the second Jewish temple, built by Solomon’s descendants. Because of this proximity, the wall is the holiest place of prayer in all of Judaism. Avremi went, dressed in white. He also carried a flowing white tunic. This was for the messiah to wear, when he appeared.

Avremi prayed at the wall of rough limestone blocks. It was a bright, warm day, and the plaza in front of the kotel was filled with all manner of ultra-Orthodox worshippers in their long black or embroidered coats, the socks that distinguish their sects, their fedoras and fur hats, alongside non-Orthodox visitors who nevertheless were moved to press their lips to the stone and to write words of prayer on scraps of paper and slide the folded scraps into the wall’s cracks and crevices. Avremi prayed and prayed. He joined a group of Orthodox children and prayed with them, because the prayers of children would assist in his mission. The messiah did not materialize. He thought about the determination of Joshua, the biblical warrior, as he led the Israelites in their attempt to conquer the promised land, and he lowered himself to the stone floor at the foot of the wall. He would not give up. With his white prayer shawl draped over his head, he rocked back and forth in time with his incantations, a white mound of extraordinary devotion even by the standards of the ardent believers surrounding him. He sat on and on, prayed on and on, hour after hour after hour, and then—vaguely he knew this was happening—he was being lifted into an ambulance.

He was put in an isolation room, diagnosed as psychotic and perhaps afflicted with catatonia, a disorder marked by stupor and immobility that can accompany schizophrenia. He was about to be treated with an antipsychotic and a benzodiazepine. By that point, it was morning, and Lichtenberg arrived at work. He had Avremi brought into a meeting of staff and psychiatrists-in-training. “I felt like a mouse,” Avremi said. “Or a rabbit. Or a rat. Like, Let’s see this psychotic person, let’s see his sickness. But at the same time, I felt that one of them had a good voice, that he had empathy, that he honored me. I felt, because of this, my eyes start to get a little bit wet. Before that, I was in so much stress and in euphoria, both, I wasn’t feeling anything, I was numb, I was thinking I will give my life if I must to bring the messiah. But the empathy in his voice made me start to feel my feelings.”

Lichtenberg, a religious skeptic who had been raised in one of Brooklyn’s Orthodox communities, arranged for a family rabbi of Avremi’s to come to the ward. The rabbi conducted a ritual releasing Avremi from his vow to bring the messiah, and Lichtenberg took part, a kind of enactment of the turkey prince parable. He sent Avremi home without pills, without a prescription, without even recommending that he consider medication.

A decade later, Avremi reappeared in Lichtenberg’s life. He was studying to be a psychologist. At the same hospital and on the same ward where they’d first met, Avremi began to work with patients under Licthenberg’s supervision, and then to help Lichtenberg plan and eventually open a set of homes—known as Soteria Houses—with a transformative approach to the treatment of those who mainstream psychiatry calls psychotic, those who experience alternate realities.

Lichtenberg’s Soteria Houses, which have won the support of the Israeli government and the country’s public insurance system, are magical places. The main treatment philosophy comes down to two words, “being with,” and is carried out, above all, by melavim, companions—paid, full-time interns whose ameliorative mission is simply to be engaged, empathetic, deeply curious, and undoubting, to leave residents, who stay for up to 12 weeks, feeling less alien, less alone in their subjective worlds. Clinicians play a role that is secondary in importance; secondary, too, is medication, which is mostly avoided unless residents arrive already on drug regimens.

In 2016, Avremi became the first director of one of the houses, a rambling home just outside Jerusalem’s Old City. Today, he is nearing a Ph.D. in psychology, publishing papers, and conducting the first study comparing the efficacy of Soteria care to that of traditional—mainly medical—treatment on psychiatric hospital wards.