Advise for Bipolar Child


To Whom It May Concern:

You didn’t ask or inquire or request my advise.    I’m almost sure you don’t really want to know what I’m going to say.   But since you’re reading it someone who cares about you must have advised you to read it.    You might not recognize it but in one way or another this letter is about you or someone who wants to be closer to you and wants to see you happier.

This letter is is directed to those people who are struggling with the problems of bipolar disorder and the use of psychiatric medications.    You have decided your child can be treated for this disorder without the use of conventional drugs.   “Drugs.”  Sounds terrible and I don’t blame you.   You have heard so many horror stories about psych meds you really believe you’re protecting your child from something dreadful.   Maybe he or she has been given these drugs and got worse or sick from them…and when they were stopped improved?   It could have been someone close who took the meds and deteriorated or had terrible side effects?   There’s plenty of literature written or media coverage by groups with extremely convincing arguments against psych drugs and you have no reason not to believe them.   Why trust psychiatrists, the pill pushers?   They “probably cause brain damage.”   They change the person so much you can hardly recognize them.   There must be a better way like naturopathic or vitamins or special diets.   Maybe biofeedback or hypnosis?  They’re at least not so “invasive.”  There’s got to be a better way and you’re going to try to find it.

Well, maybe you’re right!   Certainly your intentions are right and your desire to save your child of needless suffering.   It’s not irrational to see things like that and if you’ve got others on your side it’s easy to be convinced you’re right.   If your child agrees or asks for your help to stay off the doctor’s drugs there’s even more reason to keep up the fight.  And a fight it is.   You’ve had to argue with all sorts of people and conclude that “perhaps they’re not on your side?”   You’ve become stronger in your position rather than to give in because you really believe you are right.    You have plenty of excellent arguments and “proofs” to show your decision to refuse the drugs is right.   Anyone who opposes you has some hidden agenda or just doesn’t”t know what you know.

If most of the above is true for you I must tell you  few things.   If you really want to help you child please read on.  You have nothing to lose except conflict and frustration while gaining clarity.

The first thing I want to tell you is this, “if your child has a diagnosis of Bipolar I that has led to arrests and/or hospitalization and if this diagnosis is correct” you are exactly who needs to know the following information.    The second thing you must know is you can’t help your child by preventing the use of meds.    In fact you can’t hep him by going against conventional psychiatry if the major consensus is that meds are needed.    The third thing is you can do irreparable harm to your child by striking out on your own against the advise of two or more psychiatrists or clinical experts.   It’s true, occasionally you find a doctor who is simply wrong.   Wrong in the diagnosis and the treatment.   Perhaps that’s why you’ve taken the position you now hold?   But if several clinicians in different locations and at different times have told you medications are necessary, believe them.

There’s more you must take into consideration.    Your child’s condition can be helped through numerous approaches in addition to the medications.    Perhaps some of these can reduce the need for medications.    In fact let’s be very clear,  medications are only the beginning of the road to recovery.    Bipolar Disorder clouds judgment especially when untreated and requires a lot of education and training for the afflicted person to improve his judgment.   Medications and “psycho-education” are the main tools for recovery.

It may take some time to find the doctor who can hep your child.   But, before you can do that you have to be ready to move over to the doctors side and relinquish control of your child’s treatment.    While you are in control of the care you will suffer greatly and unnecessarily.   You may see brief improvements but a slowly deteriorating course will occur over years as long as you are at odds with the doctors.   If you want to help, both yourself and your child, relieve yourself of a false responsibility.    You aren’t prepared to provide the kind of help you really want to.   Even if you yourself are a psychiatrist.

The successful treatment at this stage of history is with the careful and judicious use of medications and appropriate guidance.    In my experience over the last 25 years with thousands of patients with Bipolar Disorder I have seen a large number of families like yours who are trying to protect their child by running interference to the doctor’s advise.  That’s why I am writing this letter now, since a case of this kind has presented itself to me very recently.   I wish what I am saying was not so.   I have great pleasure removing or lowering medication doses or telling someone they don’t need them.  I wish there were better ways but at this time, in 2011, there are none.   I pray to the Kodesh Barchu improved, non-medical treatments will soon become available, but meanwhile we are left with the difficult problem of finding the right combination of medications.

I believe there are two requisites for successful treatment with medications: they must be comfortable and effective.  Often they both come gradually according to the length of time the person has shown symptoms of the disorder without taking the proper medications.   The longer the treatment is delayed, the longer it takes to find the right treatment.

The first requisite is comfort.   This is often the determining factor in holding off the meds.   This is what you need to know about medications.   ALL medications have side effects, both psychiatric and non-psychiatric.   The idea is to reduce those side affects as much as possible.   Very often, once one starts seeing benefit and good results with them finds the side effects are minor and comparatively unimportant.   Most side effects are uncomfortable and scary but not harmful.   There are ways to reduce them by starting at low doses and going slow.   Medications in psychiatry are the most interchangeable chemicals of all medicine.    The art of psychiatry to a large degree is with what is called medication adjustment or management.   Once the correct diagnosis is reached the phase of treatment the dominates the work of the psychiatrist is “Medication Management.” The comfort of the patient is the good doctors first major concern.

Effective medication treatment means symptoms of unstable moods, irritability, agitation, grandiosity or euphoria or depression or a mixture of these are reduced.   Any auditory hallucinations or paranoid ideas should be at a minimum or completely absent. The person should be able to function at a higher level then before the medications were started for longer periods of time.   This can be a long and difficult process but at least recovery will be possible.   I treated a bright 19 year old bipolar girl who came to me after a single encounter with a psychiatric hospitalization.   She was resistant to treatment but gradually began following my advise throughout one year before she had reached a degree of recovery enabling her to begin college and move forward with her life.   Others had such chronic conditions improvements were extremely limited.   As I mentioned the longer they go without medications the more difficult they are to achieve success.

Another thing well known to the field of psychiatry is each time the person stops the medication, the more difficult achieving the same level of function or better.   Most of the time they require increased doses of the medications and/or addition of other medications.   This is well documented across all psychiatric literature in Bipolar Disorder.

I speak directly from my heart and soul imploring you to give it a try.   Every day you resist worsens your child’s chances of recovery.

Gershon Freedman, M.D.

Posted in Advice on psychiatry, Medications, Mental Health advice | Leave a comment

A Need for Vigilance

FreePsychArticles#22      OUT OF THE CLEAR BLUE SKY?

Recent events over the last month have shocked the world…again.   Innocents were brutally murdered in Borough Park, Norway and Beersheva by different men for different reasons.   We are horrified and bewildered.   First an eight year old Hasidic boy was killed and mutilated by a single Jewish male living in a building owned by his father and uncle in Brooklyn.   Next Norway is shocked by a carefully planned pair of acts of murder and mayheim via home manufactured bombs and firearms.    Then, last Friday Rabbi Elazar Abuchatzeira was stabbed while receiving visitors and subsequently died of his knife wounds on the way to the hospital. Suffice it to say, on the surface all three of these murderers were worlds apart in “purpose, geography, and methodology.”   A hardware store clerk in Brooklyn, New York, a young misguided defender of Christian Europe from Oslo, Norway and an Chassidic Jewish misfit living near Beersheba, Israel.    And yet, from a common perspective all these acts can be reduced to a common denominator: driven and accomplished Evil.    I believe there is no clearer definition of “evil” than the murder of innocents. We’ve all heard, read or somehow witnessed hundreds, if not thousands of atrocious acts like the three above.   The stories intrigue us and to varying degrees we suffer from all of them.   There is a constant bombardment of fictional accounts of real or imagined escapades of violence and murder in the media.   Viewing them is considered “pure entertainment” and has brought about a diminished collective sensitivity.  The initial moments of discovery of such real life events produces a stinging effect to all but the most hardened spectators.   But the sting is short-lived until it fades away into the realm of the impersonal.    Meanwhile those most directly involved in the trauma  suffer with descriptions of “shock, disbelief and horror.” In the religious sphere of life there are no meaningless acts.   The Chassidic concept of ‘effervescence’ is how G-d’s life force drives and pulsates through everything.  Creation and Existence saturated with His Holy Consciousness.    When it comes to the unspeakable cruelties of life religious and secular alike must cope in their own ways.   For the devout G-d is All Goodness beyond any earthly understanding.  In spite of our experience through our senses emunah connects us to G-d’s Creation.   This Goodness is fundamental to Everything. How can we speak of Goodness and Evil in the same breath?   How can we be repulsed and bewildered while knowing it’s all for the best?   The answer is  of course, we can’t.   Or are we not complex enough beings to contain these extremes?   If it was truly beyond our capacity we would have to conclude This G-d wants to torment us.   There are many who either dismiss His existence or conclude the latter.   Looking at the separate pieces of existence as they parade through our lives can appear a cruel reality. This is where Father Abraham enters the stage of history having seen the Unity of all things.   Did he only experience the Bliss of Heaven?   There was no shortage of horror in his life.    His knowledge endures through his spiritual descendents to this day.  But while he survived the tests alone,  we have each other and with that we are girded  for the challenge. In fact, in spite all the rhetoric, descension and hysteria we already know what we must do.   None of these three acts came “out of the clear blue sky.”   Freud and his cronies made this all too clear and called it Psychic determinism.  Must we be psychiatric giants to see the the precipitants and prodromal behavior?    Must we pensively analyze for years to unravel the mystery of our childhood?   Our own natural abilities to “see whats in front of us” have become stagnant and submerged.   Perhaps because we feel alone and afraid of how evil man can be?   But this is a luxury we can no longer afford. I am unable to verify the myriad details these “men” presented prior to the ghastly acts.   The specific veracity assumably required in a courtroom is not mandatory in the shared judgement of the real witnesses.   Mishnaic Law demands three adequate witnesses and they certainly don’t all need PhDs. Eight-year-old Leiby Kletzky was killed by Levi Aron, 35. However, now it has emerged that one of Aron’s neighbors has accused him of previously trying to  kidnap her young son.  Neighbor Zisa Berkowitz told the New York Post that she already spoke to the police to report an incident, which took place sometime in the past two years.  In another alleged incident, Aron also stalked an 11-year-old boy in Borough Park in Brooklyn. He is said to have been following the young boy in his car, “creeped-out” children and had been seen glaring at school yards.   Yet his ex-wife, Debbie Kivel, 34, who lived with him in Tennessee, does point out that Aron had no previous criminal record, save a citation for public urination.   Kivel meanwhile told the Post she was “shocked” at his arrest. “He loved children. He loved kids. My kids are now 13 and 10, but when we were married they were younger — and he loved them.” In Norway our brilliant, self-righteous, self-proclaimed reactionary to the Islamization of Europe Anders Breivik published a 1,518 Page Manifesto and explained how he built his bomb.   He carefully prepared his heinous acts of bombing and gunning down innocents years in advance certainly not in a vacuum .    Regardless of some Norwegian press reports he was an anonymous “lone-wolf,”  red flags were flying all over the place.   Indications are he had numerous moral and financial supporters who have now headed for cover. Murderer Asher Dahan’s neighbours of the Haredi town El’ad claim that he has been an important community member delivering great Shiurim (sermons).    He went to see Rabbi Elazar several times in order to get advice in relationship matters. Neighbours claim that, lately, Dahan started threatening important community members. Also he is said to be mentally disturbed, on medication.  (likely he has a compliance problem as well).   It has also been pointed out that Asher Dahan is a Ba’al Teshuva (returned to Torah later in life).   It said that he tried killing the Rav in the past.   By the way,  the Charedi media said he believed the Rav was Moshiach ben Yosef and the day before the murder, he davened the Yom Kippur service. When asked why was he praying the YK service while we were in Tammuz, he answered “I need to pray the YK service so that Moshiach ben Yosef won’t die!” In psychiatry psychic determinism is axiomatic.   Unfortunately all too often those witnesses closest to the future perpetrator see without seeing.   Excuses, explanations and fear fueled by denial cloud judgement.   Hence, the first line of defense is compromised.    Even Baba Elazar was said to ignore the deadly behaviors of his future assassin with the belief he had repented.  We are indeed capable of denial of evil.  The problem therefore becomes “our” problem.    Our only excuse is our ignorance since seeing the signs just isn’t that difficult. First we must consider anyone is capable of extreme acts until proven otherwise.   Then we must clarify a very important question:  “Who’s business is it anyway?”  There is a saying, “One must believe Hashem Created the world for you.”   This baffled me for years until I heard the following interpretation:  When one is given something, a gift, he becomes responsible for it’s care.   Certainly each of us has been given his own world of experience whether we want it or not.   You can’t have it both ways and grown-ups know the more you love, the more you are loved.    Greatness comes with owning greatness and accepting evil is a prompt for responsibility.    Otherwise we become victims of our own making while we wait for someone else to respond to the evil in our midst.   We must try to respond to the signs, talk with each other about the things we fear or fail to understand.    Ultimately the outcomes are in G-d’s Hands while our efforts are never in vain. Gershon Freedman, M.D.

Posted in Advice on psychiatry, Uncategorized | Leave a comment

Life’s Obstacles

FreePsychArticles#21    OBSTACLES

In Parshas Shlach in the book of Bamidbar (Numbers) is the story of the “spies.”   The princes of the tribes are given permission by G-d to scout and appraise Palestine as B’nai Yisroel prepares to enter the Land Promised by G-d.   Prior to this there is a discussion between Moshe Rabbenu (“our teacher”) and G-d.   According to the commentator Rashi Moshe told G-d he had attempted to dissuade them by reminding them G-d promised He would “…bring you up out of the affliction of Egypt” to the land He promised to the Jewish people.    G-d answered by saying, “I shall give them an opportunity to err through the words of the spies.”   They were determined to go and spy the land.    When they returned ten of the twelve gave grave reports to Moshe, Aharon and the children of Israel of fierce people and fortified cities “in order to make them afraid.”  All but two expressed a unanimous opinion the land was unconquerable and “eats up the inhabitants…”

The congregation of B’nai Yisroel responded in fear and protest to Moshe and Aharon.   G-d said to Moshe, “How long will this people despise Me and how long will they not believe in Me, for all the signs which I have wrought among them!”   Initially G-d wanted to destroy them but following negotiations with Moshe He proclaimed all that generation would die in the desert over forty years and none would be allowed into the land (except Caleb and Joshua) and the generations who did not witness or participate in their loss of faith.

I want to focus on one of numerous issues brought up in this section,  the response to the obstacles seen by the spies and accepted by the congregation.    B’nai Yisroel exhibits this sudden loss of faith throughout the Torah which invariably brings about plagues and death.   They seem not to learn, nor to sustain their faith in G-d despite direct and personal experience of His Omnipotence and Omnipresence.  In this case it is none other than the princes of the tribes,  the greatest of their generation that are totally convinced their conclusions override their faith in G-d’s Promises.

Torah commentaries on this episode abound through the ages.   What were their intentions?    Why couldn’t they maintain their faith in G-d’s prophesies and continue forward as they were about ready to enter the Promised Land?  All of  these strong and righteous men saw the same things yet only two arrived at different conclusions and remained faithful to G-d’s plan.    They all saw it was an “exceedingly good land…which floweth milk and honey.”  Yet the ten spies fear of the inhabitants of the land spread the contamination throughout the camp and aroused the rath of G-d.

This brief yet ultimately influential episode gives us a powerful key to understand the nature of obstacles in our own lives to this day.   This section of the Holy Torah reveals a recurring pattern for B’nei Yiroel with the extra effect of extending the journey from slavery in Egypt to the freedom of the Promised Land from a duration of a few weeks to forty years.   In some ways the result of their behavior was worse than the plagues they had suffered in prior occasions.   Why did G-d chose to prevent the generation that witnessed the greatest miracles of all time enter the land?   To live throughout the years knowing they would never see the fruition of the Exodus?   Was it simply the loss of faith of the people and their leaders of G-d’s Promises?

Commentaries of the sages allude to some of the answers.    The princes were wise and intelligent men not without great spiritual depth.   Their leadership was deserved.    They were superior leaders and exercised sincere responsibility for thier tribes.    They also understood the nature of the change that would take place once the people entered Eretz Yisroel from a totally spiritual existance to a more independent and worldly actualization of G-d’s law into the daily life of work and toil.    On one level they believed it was too much of a challenge for a generation becoming accustomed to G-dly shelter, protection and nourishment.   On the other hand they saw the obstacles awaiting them in the land as beyond their ability to conquer.    Since this generation was to be the rishonim (first)  to leave the desert, enter the Promised Land and everything would follow from their examples,  they were essentially disqualified.   Missing was a very specific quality Hashem wanted to set the tone in the creation of the new Jewish state.

Certainly He wanted a highly developed spiritual and religious group of leaders.   The desire to spy out the land became a test brought about by their own inclinations.   There are precedents thoughout Jewish history that produced different outcomes.   One such episode is Akeidas Yitzchak (the binding of Isaac).

Avraham was informed by G-d he and his offspring would by the progenitors of a great nation.   Shortly afterwards he G-d told him to sacrifice this only son of his wife, Sarah.   This presented a great challenge since the one act would cancell out the prophecy.   Beyond the pain of sacrificing his beloved son was the sheer impossibility of the obstacles placed before him.   Never the less, without protest he moved forward ‘as if there was no obstacle at all.’    Avraham’s total faith in Hashem superceded the logical intrinsic problem.   As we know, Yitzchak was replaced by a ram for the sacrifice and Avraham “passed” this tremendous obstacle on the way.

Another hint into managing obstacles is found in Rebbe Nachman of Breslav’s story of “The Lost Princess.”  As the prime minister volunteers to search for the missing princess for the king, he travels all over until he comes upon a huge fortress staffed with armed guards stationed all around, with horses and weaponry.   He has reason to believe the princess may be held within and decides to “go and try” to enter the grounds.   But nothing happens.   He walks through the gates, passes the guards and no one even notices him when he explores throughout the rooms of the edifice.   What is going on here?   The fortress appears particuilarly menacing and dangerous as an obstacle to his mission and he thinks he may be killed.    Despite all appearances we discover the fortress is really illusory and the obstacle in truth does not exist.

This is the lesson we can take from the the episode.   Holding to the task or mission and moving forward regardless of the appearance of of obstacles is what G-d wanted of the people.   The  inclination to fear and respond to imposing obstacles is natural.   Hashem’s mission for the Jews is not merely fulfillment of nature and natural law, but rather “supernatural.”   As we can see in the course of history,   the Jewish people have defied the natural order of events and instead of being wiped out,   continue to thrive and advance.

In psychiatry the problems of encountering “insurmountable obstacles” is endemic in all people.    This can “stop one in his tracks” as he settles into a defeatist attitude or assume he’s reached the limitations of nature.   Yet, the lessons of the Bible are for all mankind, not just the Jewish people.   We will all encounter obstacles.   In such a case, the advise is to “go and try” anyway since wondrous things await us if we do.

Gershon Freedman

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

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.

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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.

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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.

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