Suffering and Teshu’vah

FreePsychArticles#20          SUFFERING AND TESHU’VAH

The process of repentance or teshu’vah contains the element of suffering  as one of the necessary stages in achieving “change of mind or heart.”   I use the word suffering as a universal experience of pain that encompasses physical,emotional or spiritual qualities.  It is an ingredient in remorse, regret and perhaps even longing.   It can be a mild discomfort or extreme agony.  At times it seems senseless or undeserved while other times we believe or are well aware of it’s cause.  Regardless of its variations it is a universal human experience although there is no doubt other life forms experience it in some form as well.

The distinctly human phenomena of suffering is the subject of this article.   Furthermore I would like to discuss suffering and it’s relationship to repentance or Teshu’vah that can be seen as a ubiquitous psycho-spiritual behavior occurring on all levels, anytime one goes through a change of heart or overcomes a behavior recognized as negative.  The three stages of teshuvah are recognition, “remorse,” and resolution by rejection of repeating the behavior are usually thought of occurring in sequential order.   One must first become conscious of a “lacking” before he moves to the following stages.   The essence of this article is a psycho-dynamic shift in this paradigm in which “remorse or suffering” initiates the process of teshuvah.   Since “remorse” implies feeling bad about one’s own behavior, acts or practices the elementary emotion is to “suffer.”

I enter into this article with a hypothesis that suffering, as a ubiquitous human experience is always linked with the possibility of teshuvah.

In the absence of the concept of teshu’vah one is left to deal with suffering in the negative sense.   One lives through life hoping to be comfortable with the knowledge it is virtually inevitable something will eventually happen that causes some form of suffering.   No one has found a way of avoiding it completely as far as I know.    Most people accept the simple fact ownership of a body, a mind and a human heart will occasionally lead to suffering in some way.     When “discomfort” arises initially a natural response is to name or seek the cause.

Sometimes due to the proximity in time, space or association there is an almost automatic conclusion of an external cause.   For example, if one goes into a social environment and suddenly realizes he is uncomfortable there are myriad natural assumptions of its cause,  from an environmental stimuli, the food, music, temperature, crowds, potential threats or any number of perceived problems .   At times one may focus on their own “shortcomings” as if they are “sinking.”   There is extreme variability in experience both in levels of discomfort and the perception of cause throughout one’s life and between different individuals.

Regardless of the personal experience suffering is by and large something to bypass, overcome or hope will pass rather than getting worse.   There are some who feel they “deserve” to suffer and even a few who bring it on themselves in an compulsive repetitious behavior.   In psychiatry we occasionally encounter small minority who actually achieves intense physical pleasure from suffering, in the form of physical pain inflicted on them.  Those who focus or conclude life is merely a material existence made up of a struggle to survive and hopefully prosper find it hard to accept suffering as anything more than a necessary ingredient and an end product of physical existence itself. It would be a large jump from a normal life against common sense to consider suffering has a positive function.   From the perspective of one who understands all things come from Hashem and are internally and essentially good the burden of suffering is relieved.

The avoidance of suffering is the predominant goal of most modern societies.   Over the last several years there has been an explosion of the healing arts.   There is a plethora of new treatment modalities and an increasing expansion of more traditional medical approaches.    Acupuncture, once practiced mainly in the Asian cultures is commonly accepted as an alternative to conventional medicine.    Pain management has become a sub-specialty of medicine that’s become vastly popular.   As a society develops and material prosperity reaches increasing numbers of people, problems of “stress, mental anguish, boredom, the need for entertainment, and personal or self realization” become prominant concerns.   Answers and solutions to human suffering fill the media with offers of medications, meditations, massage, diets, and wide-ranging newly discovered “ancient teachings.”

Minor aches or worries once dismissed as “part of life” are now given the utmost attention or are considered reason to seek help from MD’s, DO’s, PhD’s, social workers, therapists, reflexologists, chiropractors, dieticians, personal trainers, and numerous others.   The use of illegal substances spreads as a remedy of personal suffering throughout the societies of the world.   The more financially stable and educated groups tend to seek ways of avoiding discomfort or normal human suffering with their increased ability to seek outside help.   People from all walks of life flock to mental health providers stupified with the questions, “Why am I suffering?”  “Why must I suffer?”  and seem to believe it’s simply “not supposed to be like this.”   It is not uncommon to see someone suffering ‘because they are suffering…’

I have been privileged to be present at the birth of all my children.    I have watched with incredulity as my wife, who does not have exceptional pain tolerance, go through the pain of childbirth without any appreciable demonstration of the suffering she certainly experienced.   No screaming, moaning or daiphoresis.  I asked her once how she did it?    She answered, “because I know it’s a pain with an reason and purpose and will lead to the reward of a new child being born.”   In other words, something good will come out of it.

In the so-called spiritual school of life, especially Judaism (since I am most familiar with it), suffering is an aspect of spiritual growth and human development.   On the psycho-spiritual level of existance the external world, although important on it’s own merit, is the arena in which a Jew develops internal capacity and improvement of the soul.  This is, indeed, the goal of life:   perfection of the soul as the process of “coming closer to G-d.” Interaction with the world through Torah values and precepts defines his dealings and ultimately his search for G-d in this life.  There is an assumption or belief G-d created and sustains the world, existence and everything.   Indeed there is nothing without meaning or purpose.

Many years ago I heard an astute observation about change and growth.   There are two ways one will go beyond his normal patterns of living:  listening to the advise of wisdom or suffering.   In both cases, one more volitional than the other, it requires some form of discomfort with their current mode of functioning to enter a new path since humans tend to stay with what works and is comfortable.   Only wisdom or, if need be, suffering can initiate one to enter the unknown in the process of change.

To return to the original thesis of this article, there are numerous ways of coping with suffering when it arises.   I have mentioned several above although clearly have not exhausted the subject.    Before I presented the entry into the teshu’vah process in which suffering takes the role of initiator or driving force to change I’d like to mention a simple assumption discussed in prior articles.   The parallel process of beliefs proceeding emotion.   Let’s use a common experience of meeting someone and taking an immediate dislike of the person.   Perhaps it is assumed it is purely an emotional response without any particular “reason” behind this dislike or discomfort.   It may have merit since we can generally chose with whom we want to associate (unless it is a family or in-law).   If we carefully examine ourselves we will find a “belief” lurking in the background that triggers an emotional response.  They may remind us of someone or have some preconceived notion of prejudice that sets this dislike in motion.   Yet, as is often the case, if we give it a chance we may find the person quite likable and our feelings change.  Inevitably this is due to a alteration in our “beliefs” about the person.

This is parallel to the process of the change of heart in tesu’vah where due to the emotional experience of suffering, from whatever cause,  we come to alter or submit to a new way of thinking about ourselves or our behavior.   What was once acceptable and well-tolerated becomes unacceptable.   In the process we move away from our previously held belief or conclusion to reach a greater level of acceptance, or, in the case of the G-dly person move away from our personal point of view to embrace a more spiritual level.   This is the process we call coming close to G-d, from constriction to expansion and from selfishness to selflessness.

To go a step further, all suffering as a universal experience can be viewed as the pathway to teshu’vah.   Suffering itself is a motivating force and although we may be unable to relieve ourselves completely of pain can find new vistas and connections.   The lonely self joins the suffering of humanity in search of a Loving G-d.   We can come to realize that every moment has meaning and purpose in our broadening closeness with and connection to our own greater selves.

Gershon Freedman, M.D.

Posted in Growth, Suffering | Tagged , , | Leave a comment

Diagnosis of Mental Illness


FreePsychArticles#19   What is Mental Illness?

This is a question that has broad implications.   In fact, this is one of the questions of the ages.   Modern diagnosis is in conflict and controversy.   Yet there is much agreement in ”recognizing” the disability of mental illness.   When psychiatrists work with a mental health team they generally seek a broader consensus.  In teamwork settings diagnostic formulations are usually the result of an interaction between different disciplines.   Never the less, the concept of “Mental Illness” is far from clear and there is both professional and public dissension of this critical issue that effects most of us.

There is a lot of literature lately discussing the validity of psychiatric diagnosis as the DSM V is being developed and prepared.   Most of the nomenclature has only vaguely descriptive names that are, as yet, lacking objectivity.   The best the DSM can do is group symptoms and signs to form a diagnosis.   This system tells us nothing about the actual etiology or cause of the disorder.    In medical disorders the disease is named in accordance with it’s pathophysiology and, when known, its etiology. For example “Chronic Obstructive Pulmonary disease” describes something about the pathophysiologic mechanism of the pulmonary disorder.  It is the increasing difficulty exchanging oxygen and carbon dioxide due to ongoing obstruction of the airways through the loss of elasticity of thoracic structures.   True, in this case there can be numerous reasons it develops but the nature of the disease is universally understood and diagnostic concordance is very high.

Mental illnesses are usually too complex and vary too much from one patient to another to arrive at a clear understanding of what defines the illness.  There is usually an evolution of mental illnesses that can be quite dramatic.   The presentation of the illness in the beginning stages can be different from the more chronic stages.  Meanwhile beyond the confusion about the boundaries of mental health the process of diagnosis and treatment is going on and psychiatry has had mostly partial success in treatment outcome.   Today’s psychoactive medications have a tremendous overlap in therapeutic usage so , for example, the antidepressant Prozac, a selective serotonin re-uptake inhibitor is used to treat depression, anxiety, obsessive compulsive disorder, bipolar disorder, Post-traumatic Stress Disorder plus used as an adjunct to the treatment of schizophrenia, substance dependence and Personality Disorders.

Regarding etiology we are also mostly in the dark.   For most psychiatric disorders there are theoretical causes ranging from genetic, early childhood trauma, other environmental influences, bacterial or viral exposure to parental neglect or substance or chemical use.   Any particular patient diagnosed with schizophrenia could have very different causal factors to another with the same disorder.   The manifestations of the disease can have only limited overlap of symptoms while personality differences can bring about a significant variety of presentations for the same diagnosis.

The designation of ‘mentally ill” has a broad range of effects in a particular persons life.   So deemed mentally ill can make one eligible for government subsidies,  or remove the ability to assume certain employment positions.  It can affect the findings and course of judicial proceedings.   Social standing can be significantly affected if certain diagnoses are made public.   One’s position in the family can be altered once diagnosed with a mental illness or disorder.   It can affect one’s chances of finding a suitable partner or spouse and may stigmatize the individual’s entire family.  Once deemed mentally ill, it may be very difficult to remove even in the event a cure takes place.  Being deemed mentally ill affects those and can bring about a myriad of effects, often quite negative.

As mentioned in other past articles, attitudes toward mental illness vary widely according to groups, cultures, families or individuals.   In the modern utilitarian nations one’s position in the society is greatly effected by economic issues. This varies greatly with more rural or developing cultures.   There is tolerance to more eccentric behaviors and the mentally ill tend to become dealt with in the family.    Likewise local cultural or tribal units may take little notice of people/patients within their group who would be considered mentally ill in the greater society.

The fundamental aspects of mental illness include thought, speech, emotion, and behavior.   How they manifest in a person’s life determines a lot about how the brain is functioning.   This has a lot to do with the difficulty understanding mental health since the bio-molecular processes occurring on a microscopic level are the operational units.  Our understanding of these processes, and how they coincide with behavior is extremely limited.   Even our grasp of the workings of the human mind itself, although much greater than 20 or 50 years ago, remains fairly rudimentary.   I believe an apt metaphor of medical sciences understanding of the brain is a huge dark auditorium filled with thousands of people.   In walks medical science holding up a small candle.   This light gives a slight illumination so a few shadows are highlighted but otherwise the rest of the observers can only see the candle and get a sense of the size of the theater.

The mystery grows when you consider we actually don’t understand the basic physical functions of the brain and it’s appendages.   Seeing or hearing are facilitated through the “special sense organs” called the eyes and the ears.   When a sound vibration reaches the apparatus of the inner ear it converts it from air born to physical vibrations in the hearing organs themselves.   From there they pass through nerve circuits to auditory, memory and numerous other centers within the brain.    The question is:  “what actually becomes conscious of the sound?”   If the person is unconscious or asleep, the activity of sound vibrations moving through space into the ear and the deeper recesses of the brain still occur, but the person is not known to actually hear it.   The question of consciousness also plays an essential role in understanding the connections between bio-molecular brain behavior and our mental health status.   When it comes to consciousness does the brain serve as a transmitter, a receiver or an intermediary of something more subtle than cerebral organ tissue, the nerve circuitries and the bio-molecular chemicals that form the networks of communication within and with the outside world?

I am not a kabbalist nor do I know more than a few rudimentary concepts of kabbalah but I have heard descriptions of spiritual entities that are the constituents of consciousness.   They are the spiritual pathways or emanations called “Sefiros,” and are the basic channels whose source is none other than G-d Himself.    The various transformations from a totally non-physical and infinitely capable G-d to the smallest limited physical particles occurs through these sefiros.   This flow of energy from spiritual to vibratory to physical is seen to become the substance of our souls that animate our physical bodies.   This is the consciousness that forms the link between being to non-being and back again. In some ways this consciousness knows no boundaries.   In mental illness one or more of the sefiros is somehow blocked from it’s nature to flow freely through space and time.   One scenario is some defect in an attribute, such as a sefirah.   Another mentioned by Rabbi Yitzchak Ginsberg in his book,  “Body, Mind and Soul” states “illness and disease derive from a spiritual state of deficiency or emptiness, and since the Hebrew word meaning “sick” (Choleh) has the numerical value of 49, this indicates that the sick person lacks the “fiftieth gate of understanding.”  We can thus conclude that to heal is “to fill” or “to complete” one’s consciousness by reaching the fiftieth gate of understanding…

“The power in the soul to fill all states of spiritual and physical emptiness must derive from a place of consummate “satiation”, a place in the soul where all is present, nothing lacks.   This is the super conscious level known as the “higher crown” (keter elyon), which, upon entering the conscious aspiration to reach this level is the spiritual service of teshuvah or repentance.  This ties in with article #18 on Psychiatry and Repentance.

Each of the organs of the body corresponds to a sefirah, a number,  a letter or part and a spiritual color.   It would take volumes to even begin to explain the system of kabbalah but it is enough for the purposes of this article to point at spiritual consciousness as a requirement to understand mental health.   Consciousness and dealing with any obstacle to its fulfillment plays a pivotal role in achieving mental health or “balance.”  Therefore repentance defined in the broad sense is the unifying central factor in achieving mental health.

Conventional psychiatry, lacking any consistent or operational tools to integrate spiritual elements into clinical practice will never achieve full understanding of mental health.   As it develops as a science, it may learn more about the “small world” of molecules and neurotransmitters yet the actual connection between brain and behavior will continue to elude it.

Gershon Freedman, M.D.

Posted in Chassidus and Mental Health, Diagnosis | Leave a comment


FreePsychArticles#17            Inclinations

Everyone has inclinations.   In Chassidut two broad categories are discussed:  The good inclination (yetzer tov) and the evil inclination (yetzer hara).   Within the yetzer hara is an array of ‘sub-sections’ called “tie-vahs” or personal desires.    They are too numerous to mention but include arrogance, money, foods, fast cars and beautiful women to mention a few.   For the purposes of this article I’ll limit the discussion to good and evil inclinations.

These “yetzers” are active within every individual all the time. That is to say every decision or choice made comes under the influence of these inclinations.  The yetzers are the fundamental life drives. There are similar dynamics described in other systems besides chassidic Judaism such as Alcoholics Anonymous and Native American cultures.   The latter refers to two dogs, one white and one black, within that are constantly battling for dominance.   Which one wins at any given time depends on who’s being fed.    The white dog, representing good, presumably wins when he’s fed while the reverse is also true.

This is similarly described in Jewish tradition with further aspects.   The issues of “good and evil” are higly charged in conventional society, since they are often considered relative to a given situation or culture.   Without tackling the whole issue of “moral relativism” and secular society I will proceed by sidestepping it entirely.   Suffice it to say, good is good but evil is not necessarily  negative in this context.

The nature of the yetzer hara is physicality, natural and earthly, while the yetzer tov is “spiritual, transcendent and G-dly.”   These distinctions are very important and deserve volumes to even attempt to explain them properly so I apologize in advance on the brevity of these remarks, but I will try to provide a basic conceptual framework for purposes of relating them to psychiatry and the individual’s life.

The yetzer hara, being the instrument of the physical body, strives  for the satisfaction of physical desires only limited by  bodily capacity.  So, while supplying the ‘inclination’ to eat or drink will seek fulfillment without prudence or concern for health or dietary restraint.  The same is true for all the bodily pleasures.   Without it we might just well starve or become extinct so it certainly has it’s purpose and function.

The yetzer tov, on the other hand, is a kind of executive function to guide and channel the yetzer hara in a sustained and constructive fashion.    It is the operational force to curb appetites and focus more primary drives.

The operational questions here are:  “How do you live your life and make decisions with the good inclination?” &  “When a decision arises how do you decide which way to go?”

A general guide for behavior and decision making for one wishing to free oneself from deterministic material influences is fairly simple. This is to say simple, not necessarily easy. When one realizes there is a decision to be made, based on one’s ability to exercise free will through thought or action, there are basic options. Let’s use the simple decision to get out of bed in the morning.  Ultimately everyone must grapple with this decision although most of the time it is automatic and requires no choice. But, when we break from our routine or have slipped into emotional distress we may feel conflict about leaving our bed and starting our day. The comfort, safety and security of the bed beckons us to remain in the most persuasive way. Facing the day seems an inordinate burden, a daunting task or perilous challenge. Many will say, “I just couldn’t get out of bed.” If one has power of physical movement and basic muscular control this statement is simply untrue. Yet here is an example of the struggle of the yetzers in the nutshell.

The yetzer hara, clever and persuasive as it is, wants the physical comfort above all else and automatically disregards the necessities and responsibilities of the day thereby eliminating the potential for fulfillment and growth.    In other words, the yetzer hara characteristically presents itself as the easy, automatic desire. We experience this as our immediate wish, yet with brief contemplation know we will ultimately feel worse for having followed its path.
On the other hand, the yetzer tov presents itself to us as the choice we would prefer to avoid because it seems more difficult while with an honest appraisal must admit we will feel better once we venture forward toward its basic goals.   The nature of the inclination gives us an indicator and helps us to consciously direct ourselves toward lasting self-fulfillment.

If we come to a point of conscious decision we should try and simplify it.   Even though most of life’s decisions seem often complicated they can be broken down into two possibilities: the easy way and the hard way.   The advise of the sages is simple: “Take the hard way.”  In other words, do that thing you know will benefit you in the long run although it seems to require greater effort.   Sometimes yielding to urges feels right.  You may feel you have no control and get definite immediate pleasure out of giving in to an inclination.  Know if you do so you are handing over your life force to the evil inclination and strengthening it’s grasp on your destiny.

How does this work?   Why should giving in to desires or inclinations make any difference?   We shouldn’t assume the goal is to behave like a robot or automaton without emotions, desires or passions.   There is plenty of room for feeling.   In fact it is inevitable and human.   The idea is generally that mental health is a function of a balanced and conscious approach to living.   There are times emotions are the deciding factor in the moment.   We’ve all been swept away with love and affection, inspired by music or beauty, tickled with joy or humor or slipped into melancholy.   Taking charge of day to day and moment to moment decisions is the basis of ‘free will.”   This is the tool G-d gave us to navigate through all of life’s challenges.   While emotions plays an important role in living a full life they should not be the ultimate guide.   When we take a dog for a walk we take control of the leash to avoid being led into stream or into the street.  Allowing our emotions to control our decisions is like putting the dog collar around our own neck and giving the leash to the dog to lead us where it will.

There are some other aspects of the “yetzers” that can further deepen our understanding of mental health and self-mastery.  In forming opinions and coming to conclusions we find the yetzer hora and yetzer tov at work.  It is important to recognize which is operating at any given time.   This is especially true in the social sphere and relationships because often discord comes about as a result of our opinions and beliefs.   Since no one is perfect the conclusions we arrive at can be based on false or partially true beliefs.   Admittedly this is a little less obvious than the prior discussion on emotional urges.

To expand on the earlier explanations of the yetzer hora let’s consider the idea of physicality.    Opposed to the spiritual world, the physical or material world is essentiallly limited.   To take this to the extreme it’s all about limitation.   The physical body experiences a limited existence animated and alive.   All of human and material life is limited by boundaries of time and space.   As soon as we are born we begin heading toward the grave.   The most limiting aspect of the body is the cessation of life and being placed in a coffin in the ground.   As powerful and vital as it seems, this is the projectory of the of life force we call the yetzer hora.   So while the yetzer hora moves toward separation, the yetzer tov drives toward connectivity and interconnectivity.   It is fluid and flowing without regard for division or completion.    When we reach inflexible judgements or conclusions we are operating under the influence of the yetzer hora.   These rigid positions or attitudes are the hallmark of impaired mental health.   The ability to yield or compromise, to seek positive and mutually satisfying commitments that can adjust to change or stress highlight the yetzer tov in action.

This brief article on the concept of the yetzers hora and tov barely scatches the surface of an infinitly profound dynamic where Chassidic Judaism and practical mental health principles seems to naturally merge in the fascinating river of life.

Gershon Freedman, M.D.

Posted in Chassidus and Mental Health, Faith and Mental Health, Growth, Uncategorized | Leave a comment

Freedom Through Action

FreePsychArticles#16   THE FOUR WORLDS: 

Rabbi Yitzchak Ginsberg spoke once on Parshas Beshalach, when B’nai Yisroel arrives at the Yom Sof (Reed Sea) and sees the Egyptian chariots in pursuit while the escape route is blocked by a great sea.   The Midrash relates the people separated into four camps that corresponded to the four worlds of Kabbalistic literature.

1. Those who lamented the venture and wanted to return to the life of slavery.  This is the world of Asiyah, where Evil appears to have greater strength than good.                                                                                                                           2. 2. Those who wanted to enter into battle with the Mitzris (Egyptians).  This is the world of Y’tzirah, where good and evil seem to have equal strength.

3. Those who wanted to go off into the desert and prayer for help from Hashem.  The world of Bri’ah.  Although one turns away from evil, there remains a recognition of the power of evil.

4. The last group, symbolizing Atzilut simply performed Hashem’s will by entering the Yam Sof as it split before them.  This is the highest world, where evil simply ceases to exist.   They simply moved forward in Emunah Shaleimah (Complete Faith),   They were the rishonim (leaders) followed by all the remaining “worlds” who fell into place in a state of Bitol as they made this monumental passage.

The aspects of each of the four worlds are concerned with the basic positions of faith in general and our relationship to Hashem.    On the level of pshat. the obvious or simple level it refers to the transition from conflict with man to unity with G-d.   As our trust in G-d grows,  our fear of man diminishes .

This remarkable kabbalistic analysis gives us a practical model for understanding human relations and conflict resolution.   In it we see four basic tendencies of normal human response to disagreement, threat and confrontation.   As “spiritual worlds” they represent four states of being all co-existent all the time.   With the facility of free will exercised through our innate ability to ‘alter our belief’ of any given situation we can consciously decide what world we choose to inhabit.   Armed with faith in G-d’s Ultimate Goodness presented to us at every moment through the infinite manifestations of daily life we can choose to climb the ladder toward personal freedom.

Let me remind you the people, B’nai Yisroel, found themselves in an impossible situation.   An overpowering army of Pharoah’s elite chariot force raced toward them with their backs to the sea.   This was the proverbial “caught between a rock and a hard place.”  As dramatic as it sounds,  we have all experienced moments we saw no way out except to react instinctually.   In biologic terms, the tendency is “fight or flight” mode where our autonomic nervous system  takes over.    This shows us the limitations of pure biologic response.   In our Bible story we see the more nuanced ‘four types of response.’

Sometimes we encounter problematic people or events that seem to be happening “all over again” as if we already know how we’re going to respond.   When we feel we have no control our responses are usually poor and ineffective.   We leave the situation feeling we fell victim to “it” again.   There seemed to be no real choice except to surrender, fight or run away.   Since we have ear-marked the situation as beyond our control our behavior will follow suit and we will continue to be locked in an eternal struggle.

One of the hallmarks of mental illness is mental inflexability.   The way toward mental health is countering our preconcieved beliefs.  Entertain the possibility within our “iron-clad” conclusions are other options.    Often crisis situations, no matter how small, seem too unmaneagable or too fast to shift our appraoch from the usual reaction.   Yet, with a little effort to delay our response we can make a significant adjustment in our thinking.   Let’s look at the four worlds again as springboards of change:

1.  Asiyah:   This is the position farthest from faith.   The world has put us in a position of powerlessness.   We might as well give-up.  and return to our old ways.   Once we recognize this state of mind we are already on our way out of it.   To see things like this is the farthest from reality since evil cannot sustain itself.   As we ourselves fuel the bad with our attention,  so can we choose to ignore it anytime and focus on our immediate tasks.

2. Y’tzirah:  We can fight and beat whatever opposes us.  This is the beginning of faith, but it is based on our strength, or a fantasy we can overpower evil.   We recognize evil has power and reality.   This is a split faith:  our ability can win opposes the inverted faith that evil has it’s own strength and ability to conquer us.   We can fight but winning is an illusion.   As we tense up our muscles to prepare for the fight we puff up the enemy as well.   Our solution is to relax our muscles and return to our higher path.

3.  Beriah: This is a further strengthening in our faith.   With enough hope, prayer, desire or time evil will somehow lose it’s power over us.   We still totter on partial faith that Good dominates evil which we continue to recognize.   We can continue to increase our faith and prayer.   Eventually we resume our humble work of those things we must do.

4. Atzilut: Psychologically and spiritually this is the highest achievement.    In a way this is the easiest and it is certainly the least painful.   On one level we continue to be aware of evil since our physical existence finds it everywhere.   None the less, we move forward in our daily life fulfilling what we must do.   We attach ourselves to the path of goodness regardless of familiar things trying to distract us.

In this article I’ve equated goodness with health and evil with disease.    This is a gross oversimplification and misleading since to understand it as intended I would have to further amplify and define these terms.   We must learn how they correspond to spiritual and psychological concepts.   For the current article suffice it to say it is good to be healthy while one’s thinking and behavior can avoid evil if you work on it.

In article #17 I will try to grapple with some basic chassidic concepts about the nature of good and evil.

Gershon Freedman, M.D.

Posted in Mental Health advice | Leave a comment

Azamra: Seeing the Good

FreePsychArticles#15             AZAMRA: Seeing The Good

Rebbe Nachman of Breslav taught:

“Know! One must judge every person favorably.  Even if someone is a complete sinner, one must seek to discover within him some good point which redeems him from being totally wicked.   Through finding some modicum of good in a person and judging him favorably, one actually confers merit upon that person and can bring him to repentance.”

Seeing the good, Azamra,  is a central teaching with unlimited  applications.   This is especially true in the field of psychiatry and mental health.    Intrinsic to this is our ability to alter our beliefs about any given situation and see the good in our patients.

In his treatise Azamra that discusses the above quote, Rebbe Nachman made reference to sadness and depression.    If we find ourselves depressed, feeling down or self-critical he implores us to ‘do more’ by becoming more active in our outward life.     We have power and control over our feelings by consciously applying this principle to ourselves.   When dealing with others we are able to turn a negative moment around whenever we take the initiative to alter our own beliefs.   The same is true when dealing with our own suffering. In depression the Rebbe implores us to search for the good within while increase our connections with the outside world.   He explains the sadness often comes from feeling we’re not good enough or aren’t doing enough.   Pick any good act (mitzvah) we’ve performed and search for its motivation.   Perhaps we will arrive at something disturbing.   We were showing off or trying to prove something and now see it was performed out of arrogance.   Keep looking and penetrate deeper.  We will inevitably discover a core of decency and goodness.   This is a true connection with G-d and His Holy Torah.   This can relieve the pangs of suffering and desperation as we discover our connection to the glowing sparks of Goodness.

The field of psychiatry tends to amplify the need and utility of Azamra.   In my work I tend to meet with people in the extreme moments of their lives.   It should be no surprise those having the most difficulty living and adjusting to the social environment around them find themselves seeking help from psychiatrists.   As is often the case mental health patients get marginalized from the average groups in society.   When this occurs,  with the reduction of social involvement, symptoms or character traits can become more pronounced.    Becoming stigmatized can further reinforce patterns of behavior away from social norms.    Normal reactions of defense can backfire and further isolate mental health patients.  In fact, psychiatrists were called “alienists” prior to the last 100-200 years, since it was their job to separate or isolate many patients.

The Oxford English Dictionary defines “alienation” as in this sense as “mental alienation; withdrawal, loss, or derangement of mental faculties; insanity.” The insane were thought estranged (alienated) from their normal faculties. The root of “alienist” is the Latin “alienare,” to make strange. The word “alienist” came across the Channel to England from France where “aliene” meant insane and an “alieniste” was one who cared for the mentally ill: a psychiatrist.

Many of the people I meet for consultation, especially at the beginning are difficult and challenging.   Certainly this is not always the case and may even be a minority, but when I do encounter this I am called to execise Azamra.   Also during the course of treatment patients will present painful aspects of themselves requiring balanced and fair attention.    I have found one of the most valuable “tools” in treating patients and returning them to function is “Azamra.”    To search and discover “chinks of light” in the field of difficult, aggressive or unhappy people serves as the foundation of helping and forming constructive therapeutic relationships.    If I am able to find positive traits and respond to them eventually the patient comes to identify them within himself. Often this process brings about a marked change in how one sees himself.

Positive traits and behaviors can be found even in the most disturbed patients.   Sometimes it is difficult and requires actively searching since these good qualities are hidden or forgotten.   The patient  may be unaware of their own goodness or deny it.   Some patients excel in expressing negative or bad traits and have developed what Dr. Low calls the “passion of self-distrust.”   Yet the discovery or recognition of some innate goodness is like finding a lost object.   It can serve as a focus to begin anew, and an organizing principle for rehabilitation.

Azamra operates in all areas of human relations.    It is simple but not always easy to apply.   This is especially true when one feels attacked or threatened.    The natural tendency is to become defensive or to counterattack.   It may be necessary to take defensive maneuvers and avoid going head to head with conflicts as they are presented by others, or even oneself.   This is particularly difficult the so-called “truth” of one’s position seems so self-evident and indisputable.   And yet, often we can win the battle while losing the war.   Our own truth or the truth of the patient can be self-destructive in spite of it’s apparent validity.

For this reason the Torah consistently refers to truth, or EMES, in the same breath as kindness or CHESED.   Chesed v’Emes points to another level of truth.   In fact, in human life and existence you can’t have one without the other.   If there is a truth about something, as indisputable as it may be, without lovingkindness it ceases to be truth.  If one comes to certain “true” conclusions or opinions based on truth that are used to inflict harm on one, “truth” loses it’s meaning.

This enables us to see through all the “truths” we encounter baring witness to negative, harsh and sometimes cruel qualities to find a spark of goodness in oneself or others.   In this sense Goodness equals the Ultimate Truth.

Can we really tap into G-d’s Kindness by simply seeing the good in ourselves or others?    Of course.   The coarse realities of  destructive people will always attempt to take center stage.  This is the way of evil.   It always tries to trick us into believing its as real as goodness.    Without our attention it has no strength or capacity to do anything.    We are not convinced.    Azamra!

Gershon Freedman, M.D.

Posted in Faith and Mental Health | Leave a comment


FreePsychArticles#14  The Pinball Machine: Dealing with Limitations

In the year of my birth, 1947, the pinball machine arcade game underwent a developmental change.   Humpty Dumpty was the first pinball game to add player-controlled flippers to keep the ball in play longer and added a skill factor to the game.   Since then many new devices have been added such as electronic gaming, digital displays, fancy sound effects, speech and other computerized features.   Essentially the game has a limited number of player-controlled devices set into a multiplicity of background reward-stimuli.

From personal experience or movie scenes most people are familiar with the lights, bells, scorekeeping and body movements used to “tilt” the game tables in arcades.   By the end of the 20th century pinball had seen it’s peak in popularity and remains as a vintage symbol of the mid to late 1900’s.

What does pinball have to do with psychiatry, mental health and basic living skills?   As a model it can be used to bring out a simple but often ignored aspect of optimal human functioning.   Just as the pinball machine seems to give the impression one has control over the table as skill develops there is simply more outside the player’s control than in. In fact the majority of the game is spectator-limited.   There is the tilt factor.   One can get carried away with the goal of keeping the ball on the playing field to gather more points by tilting or lifting the table corners forcefully but can actually backfire as the tilt alarm is triggered.   The urge to tilt the machine is essentially futile.

So, in the midst of all the excitement of the game, with all it’s dazzling lights, colors, bells and whistles one really has very little control over the path of the ball once it is launched into the game except the button controlled stationary flippers.   There may be two or more placed around the pinball game field only effective once the ball rolls into their proximity.   At that moment the player suddenly yet briefly has limited operational control.  In fact, as skill develops the effectiveness of the flippers expands.   If target scores are achieved higher levels of play or free games are won.

Without the stimulating array of sights and sounds on the gaming table flipper control would seem dull and unrewarding.   Over involvement in them distracts and compromises one’s prowess with the flipper dynamic.

So is true in the game of life.   It is full of “bells and whistles” that draw us in.   In the difficult times of life everyone experiences times of feeling overwhelmed.   With bewilderment comes the feeling you’re exerting effort and energy with a lack of  equal reward or benefit.   It is a common and all too human.   Often we make plans that don’t go well.   We feel and see opportunities and expect a result yet something else occurs.   We get caught up in all the activity of the family or friends or our own desires.  Relationships become complicated and we don’t take the cues or say the right things.   Frustration can lead us to all sorts of mental turmoil.    Sometimes we ruminate over all the difficult or painful memories to the point we can barely move.   Other times we make impulsive or desperate attempts to right a situation to find it has only made matters worse.     So often we observe the theater of life events as passive viewers.    As ‘psychological beings’ we imagine we have an active role in much of this theater while mostly our roles in the drama or comedy are limited.

These are all aspects of the spectator phase of life where no matter how hard we try can, at best, set off the “tilt alarm” by pushing too hard.   In the process we miss the true opportunities to be effective.    In pinball terminology we forget our true strength to influence the game with “flipper action.”   It is amazing how much difference the game can turn out utilizing the flippers, with relatively little effort,  as they were intended.

How do we know we’re using the flippers and not just caught up the in all the excitement? In our modern world, where much of life is involved in hearing, seeing and feeling, how do we enter the game and influence those things around (and within) us?    What are our only effective tools to “score” on the table of life?

According to Dr. Abraham Low, a great early proponent of ‘Cognitive-Behavior Therapy’ our sphere of action, is through our ability to alter our beliefs and control our muscles.   Since we actually have no control over our temperament, genetic makeup or emotions our most vital strength is altering how we see things.   We can indirectly effect how we feel about something by what we believe.   This is the oversimplified adage often quoted:  “Just think positive.”   Most people get little benefit from this cliche’ and many simply don’t believe it.   They think things just happen, beyond our control, and fail to recognize the part their own beliefs plays in their lives.   Often they don’t recognize having beliefs or pre-determined conclusions since they are already solidified into their personal patterns and attitudes.    Yet, with an honest appraisal beliefs have the power to transform most, if not all the experiences of life.

There is a documentary about two Vietnam prisoners of war who spent several months chained to the same wall.   One man, the author of the story, was quiet and contemplative.   His fellow prisoner, an officer, talked all the time.   He was very knowledgeable of military strategy, geography and several other fields of no particular interest to the author who found him increasingly annoying and numerous arguments or disagreements occurred.   The specter of being held prisoner, unable to escape or find privacy was only worsened by the overbearing insistence of the officer.    The author became increasingly desperate and discouraged.   The intellectual competition was unbearable.   After several weeks he woke up realizing he could continue along this path no longer.   Unable to do anything else he decided he would stop fighting with the officer and become his student.   He altered his belief that he was intellectually equal and therefore deserved equal time and equal consideration of his ideas and chose to subordinate himself to his fellow.   From that moment on the two developed a highly mutually rewarding experience described by the author as one of the most enriching times of his life.   He learned about things far more interesting than he’d ever have imagined.   Even though the situation had not changed in any outward way,  he came to think of his fellow prisoner in a totally different light.  Instead of seeing him as his tormentor, he became an inspiration and asset in his struggle to survive.  After they were freed he was moved to write about his detainment and incredible transition.   Just one shift in his beliefs opened up a broad horizon of possibilities.

This example shows just one simple and dramatic result of using one’s functional ability to alter a belief and transform a situation.    In addition, since the ability to utilize control over his muscles appeared severely limited the changing of his belief produced unimaginable benefit.

Looking closer we find the most important functional control over his muscles was indeed utilized.   The muscles of the speech apparatus originate in the thought.  This specific ability to control muscles is frequently lost, overlooked or underutilized yet occupies one of the most important aspects of human interaction: Speech.   With his decision to become a student came a whole set of new thoughts expressed through his speech or silence.

Once we consciously focus on these two essential functions , our ability to alter our lives becomes tangibly better.   In Jewish thought it is called “Derech Eretz” or the “way of the land.”   It refers to many approaches but basically to common sense or the middle path.   Further, it refers to “common decency,”  as when the Torah instructs us to greet others before they greet us.   The main issue here is how we relate to ourselves, others and to our society at large.  Giving the benefit of the doubt, judging favorably and ultimately the basis of the Torah according to Hillel, “Don’t do to others what you don’t want them to do to you” are all examples of beliefs under the control of our “flippers.”

Effectiveness in living with good mental health is within the grasp of everyone.   In fact, it is simpler and more available than what many think.   To approach the pinball table with attention to the player-controlled flippers and your eye on the ball is the essential task.

If you enjoyed this article please share it with others.   Your comments are appreciated.

Gershon Freedman, M.D.

Posted in Mental Health advice | Leave a comment

Ecology of Mental Health, Part II

FreePsychArticles#13           The Ecology of Psychiatry, Part II: Arousal and Diagnosis

Accurate diagnosis is the basis for all clinical intervention in mental health.   There are known short-comings in the current model of psychiatric diagnosis, which may be effecting the successful treatment of an untold number of patients.   Mental health professionals are a worthy and dedicated bunch of people, doing a difficult job.  In spite of the limitations there are numerous emerging approaches with potential to enhance diagnosis and treatment.   Unable to start back at ‘square one,’ the emphasis is moving beyond  conventional diagnostic structures to conceptualize more fundamental ground states underlying all illness.    In the current article I will focus on the current disconnect of conventional diagnostic criteria with these foundational ground states.   This is especially true for the DSM IV used in all spheres of psychiatry today.

There has been a lot of controversy in the development of the Diagnostic and Statistical Manual, fifth edition (DSM-V) currently underway.   Dr. Al Francis, a lead editor in the development of the DSM IV has come out with serious criticism of the proposed manual, pointing out its shortcomings.   He says, “there is no definition of a mental disorder…I mean you just can’t define it.”   He has, in fact, launched a “bitter and protracted battle with the people, some of them his friends, who are creating the next edition of the DSM in a very public way, to include the general public.”  (From Wired, Jan. 2011 edition).

In “Ecology & Psychiatry, Part I”, I began working on ways to describe the phenomenon of “arousal”as basic and more fundamental than diagnostic categories.   The state of arousal is an innate aspect of living organisms.  The more differentiated the organism, the more the individualized the state of arousal can be.    I speak in macro-cosmic terms since there may well be great variations from say, one insect to another.   But those theoretical variations, although outside the sphere of relevance to psychiatric inquiry, do fall in sync with the overall picture of paced pulsing levels of energy expressed through the arousal of given individuals.

I learned the basics of the DSM III in the early days of my psychiatric training.  As time passed I discovered most patients did not fit into the diagnostic criteria.    There are often ‘spill-over’ of symptoms and signs beyond diagnostic boundaries.  Often, to be usefully accurate, it required more than one diagnosis to encompass all of the findings.   Often dramatic arousal states found non-expression or non-inclusion in DSM diagnoses.  The DSM IV purposely avoids underlying cause of disease expression.  If the DSM is used with these limitations in mind, it’s not a bad system for organizing symptom-cluster states.   Since psychoactive medications of today are used across diagnostic categories boundaries one does wonder what function the manual actually serves?

In clinical work hyper-arousal is a fairly consistent finding in Bipolar Spectrum Disorders in which “distinct periods of elevated, expansive or irritable mood”  are necessary.   These mood variations must be accompanied by inflated self-esteem or grandiosity, decreased need for sleep, pressure of speech, flight of ideas, distractibility, increased involvement in activities, psychomotor agitation, and excessive involvement in pleasurable activities lasting at least a week.”

It’s not a stretch to consider a “furnace of arousal” as the energy source for these symptoms.  Ostensibly, once successfully treated the mood returns to “normal.”   In my experience the overt and prominent symptoms do diminish in amplitude but frequently underlying hyper-arousal remains.  The 8-Signature Array, a diagnostic test, shows expansiveness, accelerating enlargement of signatures and increased pattern size in bipolar patients long after the manic state has been treated.  When someone, in the absence of available history, presents with presumptive depression it is often difficult to diagnosis bipolarity.   They may have no recollection of the prominent signs and symptoms with episodic high-energy states, lack of need for sleep and increased gregariousness they see as “normal.”   Yet they present with many depressive parameters like sad mood, lack of interest or drive, sleep problems and negativity.   The 8 Signature Array handwriting test most often reveals acceleration in speed, size and other telltale signs of underlying hyper-arousal.   This finding is not consistent with a true “uni-polar depression” where there would be slowing and reduced surface area.   On further questioning the bipolar depressed patients would endorse report symptoms of agitation, difficulty concentrating, racing thoughts and irritability.   The assumption is the hyper-aroused state drives one to “expand” neuro-vegetative energy in areas under the least conscious control or less integrated channels of development.   (This also alludes to the idea of energy flow and utilization).

Hyper-arousal can be found in non-bipolar patients, who are often misdiagnosed as Bipolar.  This is certainly true in some of the personality or character Disorders.    They can have positive findings in moodiness, irritability, highs and lows, racing thoughts and anxiety without the clearly demarcated periods of mania, hypomania or depression.   In fact I’ve come to think about the personality mood disorders as multi-polar rather than “bi-polar.” Their mood changes tend to orbit around interpersonal issues rather than the mood states themselves.    The issue in this case is clearly hyper-arousal driving dysfunctional emotional response or acting out, in ways particular to the individual’s psychopathology.

A third example of hyper-arousal at the heart of a diagnostic entity is Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD).   People with this diagnosis often present diagnostic confusion sometime during their lives once they enter the clinical environment.   There may be crossover symptoms and signs although far less dramatic than chronologically mutable mood states of bipolar disorder.   Whether they are diagnosed bipolar, mood disorder, conduct disorder or ADHD is more a result of convention or vogue.  Their handwriting can be fast and expansive to reflect hyper-arousal as are their subjective reports.   Non-stimulant medication can reduce some of their arousal while doing little for the attentional deficits.

Finally,  patients new to the mental health system have frequently been functional throughout their previous lives.  Once hit by one or a series of interruptions in life they may develop overwhelming symptoms.   Middle age job-loss, divorce or other major stressors may have a domino effect on other areas of life.  The energy or arousal level that was once normal and functional converts into symptoms difficult to contain.  Their innate level of hyper-arousal has not suddenly appeared in the form of a psychiatric diagnosis, rather it has shifted course.  The “energy channels” developed over years are suddenly blocked.   The “arousal energy” once directed outward turns back on itself.   This results in a kind of “building up steam” paradigm manifesting in numerous ways.

Clearly this “Arousal Hypothesis” lacks scientific rigor and peer review.   Other than the 8-Signature Array and clinical impression it is not quantifiable nor does it conform to formal methodological research standards.   I have attempted here to describe commonalities of nature that crossing  conventional diagnostic definition,which I’ve encountered over the course of 24 years of clinical practice.

In Parshas Tazria, in the Book of Exodus, there is a description of a kind of malady called “tzaras.”   In English translations it is frequently called “leprosy” and confused with the medical condition of the same name.   Correctly, it is actually a spiritual condition brought about through certain transgressions of Torah Law that manifest in stages, first of which is a coloration on the face or beard.   If “untreated” it progresses to the clothing and finally to the stones of one’s house.   In contrast to our current medical model, a physician is not brought in for diagnosis and treatment.    Rather, it is the Cohen, or priest who performs these tasks.   He alone can properly pronounce the diagnosis and the formal practices required to bring about a cure.  The diagnosis and the underlying cause are the same.   The adjustment in the “patient’s behavior” brings about the cessation of the symptoms.   In our modern life we’ve placed layer upon layer of “stuff” between ourselves and our own Spiritual connection with G-d and Essence.   Science has been unable to “prove” or disprove the existence of this immeasurable G-dly Effervescence that pervades all existence.   In the Torah all disease is spiritual in nature and cure.

How does this relate to us and modern maladies?    How do values and behavior effect our mental health?    How can we incorporate these into treatment approaches for more relevant, holistic solutions?    Finally, can a conscious eye to underlying arousal states enhance diagnostic accuracy by forming a bridge beyond symptom clusters to less differentiated emotional energy experience?

These are some of the questions I will try to address in future articles.

Gershon Freedman, M.D.

Posted in Mental Health advice | Leave a comment

The Model of Kosher

FreePsychArticles#12  Kosher and Not Kosher

Jewish (kosher) dietary laws have always been a source of curiosity for Jews and non-Jews alike.    Why can’t they eat pork?    Who understands why they can’t eat milk and meat together?   The esoteric nature of these laws the topic will generally spark all sorts of questions.

Though it seems these laws are exclusively about ancient Biblical eating practices, religious Jews continue to practice them to this day.   Many wonder whether they’re really outmoded and irrelevant in this day of high standards of food quality.  Pork used to cause trichinosis but that’s no longer a worry.   And what about all those great restaurants religious Jews can’t go?

To add to the basic laws of pork, shellfish and the milk with meat prohibition is the requirement to use separate sets of dishes for meat, milk and Passover. Some Jews will only eat meat slaughtered by a ‘shochet’ they personally know.  There is increasing stringency for dairy products, and wheat harvested before or after the new year.

As a natural outgrowth of my own religious Jewish practice and learning coupled with my work in public psychiatry I often think about what possible application Torah precepts might have?   Part of the mandate for Jews is to teach the ethical principles whenever appropriate.  The principles of theTorah, as brought down from Mount Sinai, express universal values and lessons.  The specific details of Kashrut (dietary laws) are really only applicable to the Jewish people, so I wondered what relevance could they have to non-Jews?

Well, the idea of prohibited foods expands and informs anything prohibited as well.   Certainly the kosher laws are about what one puts into his mouth and eats.  This limited focus is deceiving since there are other issues involved besides to intricacies of keeping a kosher diet.


Anyone who is dealing with a habit, or addiction, can benefit with this Jewish approach to food.   In spite of the fact non-Jews are totally exempt from the Torah Kosher Laws, they can take something away from them anyway.   I have personally seen the following occurrence:  During a social event a 6 year old boy child was given a piece of wrapped candy by one of the guests.   The bot took the candy to his mother to ask, “Mommy, can I eat this?”   The mother looked briefly at it and said, “No, it’s not kosher. “   The child, not missing a beat immediately threw the candy in the trash.  No fuss or bother.

This is not a trick report nor is it uncommon.   He never returned later to fetch it out.   The child simply understood some things were for eating and some were not.  Once mother informed him it was of the latter category it became unthinkable to eat.  For us who keep kosher, non-kosher food is simply outside our universe of experience.    There are no second thoughts or other considerations except in extraordinary, life or death situations.  And this applies to Jews regardless of their level of sophistication or understanding.   There are no gray areas once the food is determined unfit (not kosher).   It applies to newly religious Jews (called Balei Tzuvah) as well, so one who ate non-kosher food his whole life ceases once he has ‘returned to the (Torah) law.’  Further, this practice of restraint can actually give one the feeling of strength and satisfaction.


In the absence of a religious ideology can these ideas be applied to anyone?    I frequently meet people wishing to be free of their habits or addictions.    Most of these people have suffered extensively from the dependence on alcohol or illegal substances and want to stop but have little equipment to maintain their sobriety.   When the urge or craving returns they have little to over come the powerful emotional desire to take these destructive substances.

In my practice in California and Israel, the overwhelming majority of the patients I encounter maintain some belief in G-d and it would not be a great leap to see relevance in the heavenly decree to exercise restraint, as do the Jewish people in their practice of the laws of Kashrut.   Emotions or craving can be tempered by how they are viewed.   The beliefs alter the emotion and can mitigate its influence.   We learn the Jew can learn to easily resist any temptation to eat non-kosher food by the simple decision it is “not for me.”

These same concepts can be applied to weight-loss or health diets.   Upon entering into the diet, one makes a conscious decision of what foods are “inedible.”   There’s plenty more to be said about discipline and will-power yet the major focus in the approach to altering behaviors is to change one’s thinking about the behavior.   The Kosher Concept is one more model in the tool chest of abstinence.   Since changing one’s temperament or emotions is basically outside the realm of conscious control, we have to focus on the things within our control.

The fundamental realities able to change under our conscious direction are thought and our muscles.   It is in the exercise of control over our beliefs and behavior that we will reach the highest levels of function and mental health.

Gershon Freedman, M.D.

Posted in Addictions | Leave a comment

Ecology of Mental Health, Part I

FreePsychArticles #11   The Ecology of Psychiatry

What’s all the fuss?!   Everyone’s talking about “saving the planet, saving energy, balancing ecosystems and global warming.” It seems to be the consensus of many the planet is in trouble. What do all these concerns have to do with us? With our personal daily lives? I believe psychiatry has a lot to say about our lives and our “internal ecology.”

Here’s what Wikipedia says about Ecology: ”Ecology (from Greek: “house”; “study of”) is the scientific study of the relation of living organisms to each other and their surroundings.”

I think there’s a parallel process within the individual. Concepts like preservation of energy and resources are easily applied to the individual. ”Life processes and adaptation,” both studied by ecologists, relate to the individual’s internal processes and adaptation. “The movement of materials and energy through living communities” in ecology finds a parallel in both the molecular biology of psychopharmacology and the redirection of temperament and emotions.

Just as the earth has a limited amount of energy available at any given time, human beings can think about their own energy system. There is much value in raising the question of how one utilizes his own energy with the most efficiency. Some people have excesses of emotional energy while others seem to have too little. Another way to think about emotional energy is the “level of arousal.” Arousal can be described or related to the idle of an automobile. The idle of a car is set to balance the running of the motor fast enough that it won’t die while slow enough to utilize fuel most efficiently. When the level of arousal is increased or hyperaroused, it is very difficult for an individual to reset it alone.    Another analogy is climate, that as a rule remains fairly consistent in geographical regions, with shifting changes in the weather being variable.

In my work in psychiatry I use a diagnositic handwriting test called the “Eight Signature Array” to measure the overall level of arousal. (This test was developed by Thomas Kappeler, M.D., a neuropsychiatrist.) For the rest of this article I will refer to “arousal” as the working concept in the management of the “internal ecology.” But first, let me explain as little about the “Eight Signature Array (ESA).” One model is the EKG (electrocardiograph) machine that records the electrical impulses traveling through the heart muscle as it contracts, and prints a graph. The ESA uses the person’s own handwriting of his signature eight times in a column down a blank page to record information of his level of arousal. These eight signatures are timed and, with some simple calculations, converted into letters per second. Also, by measuring the boundaries of the signature “graph” one can calculate square centimeters per second. Both these measurements are compared to the rates of the normal population and the individual’s own average rates. From this it can be determined the basic level of arousal, by speed and area covered, for the person.

There are many things one can learn about a patient from this test, but for purposes of the present article I will focus on arousal and how to use it as way to utilize own’s own energies most efficiently.

One striking thing I’ve found is arousal does not necessarily correspond to a specific diagnostic category. Depressed people can be hypo-aroused or hyper-aroused. The same holds true for anxiety or schizophrenia. To some extent it is even true of Bipolar Disorder. Arousal levels do remain fairly constant in the same individual over time. Medication treatment can alter the level of arousal significantly, especially in acutely agitated patients. Cetainly stress in the person’s life can also effect arousal.

The question is, how does arousal work and how can it be ‘utilized’ most efficiently? First we must look at how the indiviual handles his own level of arousal. Most often, in my practice, patients will come for help in their mental health following a significant disruption in their life. They’ve lost their job, their home, or suffered some kind of loss. They find themselves lacking the usual pathways to fulfillment. It could also be a physical or medical problem curtailing their activities. In all these situations the flow of energy from inside to outside or vice versa has been effected. The internal ecology is upset and the normal flow has been altered. When one is actively pursueing his goals and fulfilling his needs the level of arousal, as a kind of energy source, finds connection with the appropriate conduits. When these conduits are blocked or altered, a damming of energy can be turned back on it’s source. The level of arousal, once consistant with one’s ability to direct and utilize, becomes a source of discomfort, or worse.

The interruption in normal internal ecological status can lead to increased levels of anxiety, irritabilty, depression or even physical problems. Each of these manifests in accordance with the person’s own particular nature. If there are genetic or constitutional tendencies, that is where the disturbance will take place. An simple example is the fellow who injures his back and subsequently heals. Later, when straining beyond his strength feels a recurrence of the original injury. When one has a disposition toward a psychological disorder, one that has been tolerable, becomes manifest again.

Part of the approach is to evaluate the basic level of arousal and how it manifests in the individual. In cases where the person is incapable of “redirecting” the arousal to fruitful or constructive activities because it is overwhelming medications may benefit. The goal is to reduce the arousal to a manageable level. This is, in fact consistant with the general use of medications in psychiatry as I see it.

With the use of the “Eight-signature array test,” the mental status examination and other objective observations the level of arousal can be monitored.  Often the patient’s overwhelming sense of lost control can be reduced by this simple formulation. While not removing the responsibility for future temperance and descretion, does reduce some of the “passion for self-distrust,” as Dr. Low would say.    Rather than focus on the behavioral manifestations of “too much or too little” we start with a relevant personal yet neutral cause underlying the behaviors.    Thus, cognitive-behavioral therapy, for example, places things in the context of the person’s temperament, that he has no control over, and in touch with the actual aspects he does.   In conjunction with this we focus on thoughts, speech and action as most accessible to conscious control.   In other words, utilize the energy in areas one can affect like control of the muscles and thoughts while avoiding the trap of taking responsibility for things beyond one’s control.

The use of this formulation can bring a clear focus of a patient’s dilemna, limit the spectrum of impossible interventions, and define the individual’s goals for recovery into a more manageable program.

As we know, the balance of external ecology is a daunting task with numerous variables. It is an ongoing process of education, scientific inquiry and political exercise. The closer one can get to the source, the more able to understand and effect the multitude of manifestations.

The “Arousal Paradigm” briefly delineated in this article finds no place in the current (DSM IVR) Diagnositc & Statistical Manual, Fourth edition revised of the (ICD) International Classification of Diseases.   In future articles I hope to discuss and expand on this theme.   It is a part of a much larger schemata that goes beyond conventional diagnostic formulations in an effort to link with the ancient traditions of consciousness and religious thought.

In the Jewish Torah, G-d bestows a structure upon B’nai Yisroel in preparation for the great task of bringing mankind closer to Him.   The job is the enhancement and fulfillment of inter-connectivity, on all levels of existence.   But, in order to achieve this, appropriate channels must be established to contain this powerful Life Force.   The essential issue is containment, and re-direction, of the Inner Light of Creation in a life sustaining way.   Within the limitations of each human being, and within the confines of one’s specific discipline, is this challenge.   In psychiatry the recognition of arousal is a tool to achieve enhanced connectivity and healthy, efficient use of the energy or life force within.

If you found this article interesting, please forward it to others.  I welcome any comments you may have.

Gershon Freedman, M.D.

Posted in Mental Health advice | Leave a comment

Medications and Mental Health

FreePsychArticles#10  Once Medications Do Their Job

In the clinical practice of psychiatry there are basic phases that occur throughout treatment.   In the beginning of treatment these steps are initiated with a one, two, three sequence but as the process moves forward, these steps are revisited.

The first phase is the clinical evaluation in the initial consultation.   The emphasis is collecting relevant information about the past (history) and the present condition of the patient.     We look in the history for any clues that could be contributing to the formation of the patients current status.   These are the genetic or family traits, called the bio (biology) and any physical factors such as illnesses or physical trauma effecting the patients development.  Since it is often impossible to learn all there in the initial meetings we may return to this in the future to help explain new findings as they appear in the course of treatment.

The next phase is learning about the patients current condition.  This is referred to as the “mental status examination” and functional evaluation.    While observing the patients responses, questions are directed toward evaluation of thought, speech, behavior and emotion.    Included in this are symptoms and complaints or concerns expressed by the patient or collaterals (other’s involved in the patient’s life).   We also inquire into how the patient behaves and manages their life experiences.

From information gleaned from the first two phases we can begin to speculate and conceptualize diagnostic ideas.   This leads to decisions in treatment approaches including the use of medications, advise on activity, and other positive plans and suggestions.   Everything should be directed toward the improvement of basic health and vitality in harmony with the person’s world.

A major emphasis in modern psychiatry is the alteration of the microbiological behavior of the central nervous system.   This is the search for chemical balance or ‘enhanced connectivity of neuronal circuits.’   Counter to most peoples impressions, the conventional understanding of how the brain functions is extraordinarily limited!   This is especially true when it comes to designing and prescribing medications.   Nevertheless, the focus of most biological psychiatry is the ‘synapse’ where nerve cells connect with each other and the enhanced flow of neuronal circuits    This is, indeed, the main function of psychotropic medications.

Psychiatric symptoms tend to be excessive or distorted experiences that all people have at one time or another in their lives.    As I have mentioned in previous articles, the target of medications is the symptoms that grab on and tend to hold on or overwhelm the patient and reduce the ability to function normally.

But what happens once medications seem to do their job?   Sleep and appetite become regulated,  the mood stabilizes, depression lifts, anxiety or panic subsides, and the noisy or overactive mind quiets.  In many cases, the patient has fallen into different negative habits long before they came to the psychiatrist for treatment.    Maladaptive patterns of thought and behavior have become routine and often, become more conscious once the major symptoms have improved.   These people may feel better overall but the road to rehabilitation opens up in front of them with numerous obstacles along the way.

In some, after years of deterioration in function, they find their station in life is much lower than they could have expected to realize.   They have lost jobs, left school, lost family ties and are often financially struggling.    They have suffered under the stigma of mental illness and find themselves isolated with very few resources.   The medications may have reduced their symptoms and that is a good thing,  but to varying degrees they are at risk of relapse if they are ill equipped to revise or improve their outlook  and ability to function.

This is where psycho-therapeutic or psycho-educational interventions become the focus of the treatment.   Medication management is a parallel process that fades in and out of the overall clinical work as needed, to “tune up” the biological tools being used.   A new attention is given to the actual way the patient thinks and interacts with the world around him.

I have found the concept in connectivity or interconnectivity of neurons on the microbiological level a sound basis for all levels of the patient’s life and rehabilitation. Clinical studies have found certain non-medical activities, such as psychotherapy or exercise actually alter brain chemical balance.   Therefore, effective treatment must include helping the patient “get in touch with himself” on a personal level.    Further elements include improving relationships among family members, relating to friends, acquaintances and the public.   For those inclined, it would extend to the connection with soul, faith and G-d.    Connectivity can be enhanced on one level and improve the connectivity on all the other levels.   If the individual is viewed as part of a greater macrocosm, more harmony has a ripple effect both outward and inward.

With psychiatric and nervous disorders,  once medications provide the basic improvement of brain function through enhanced connectivity, there is still a lot to do.   The patient is well on the way or path toward rehabilitation by having participated in the initial steps of healing.   Now one must assume control and direction of self care through other activities to reinforce connectivity where able.   This is more than beneficial,  it’s an integral part of the rehabilitation.   The “other” activities are almost unlimited.  They include physical exercise, regulation of basic patterns of sleep and eating,  ongoing psycho-education, and creative pursuits.   Attention to integrating the parts of one’s life that have become unconnected with each other is another goal.   “Mending fences, patching up things, and sewing up deals” all echo this age old wisdom.   In the spiritual realm, connectivity can be represented by the Star of David, the upper triangle comes down to merge with the ascending lower triangle, as man reaches toward G-d and the Holy One reciprocates in kind.

This is the beginning and the middle, but by no means the end.  There’s a great deal more to be said about connectivity.

If you enjoyed this article, please share it with others.

Gershon Freedman, MD

Posted in Medications | Leave a comment