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.

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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.

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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.

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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.

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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

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FreePsychArticles #9   “Angels on The Head of a Pin?”

As a child I heard there was a discussion among the clergy of past days addressing the question, “How many angels were there on the head on a pin?”   I laughed and scoffed at the idea and couldn’t believe anyone, especially educated people could consider such a question.   Many years have passed and in recent days something similar has come to my attention.    The last thing I would have expected is a question of “How many Angels?”  Yet, this is the topic of the current article.

Dr. Igal Goodman, of Netanya. Israel, a clinical psychologist and close friend told me a story of how his study of Torah and the Talmud gave his clinical work in positive thinking a whole new spin.  The following attempts to bring to light his chidush (new & fresh  observation), with his permission,  on angels and positive thinking.

Dr. Goodman told me about a study done not long ago, that among other things observed the average number of thoughts that pass through the mind daily.   With the aid of electroencephalography the study approximated about “50,000 thoughts per day” on average.    We’ll return to this later.

According to the sages,   and notably the Maharsha (medieval rabbi and sage) wrote in his book “Chidushei Aggados” an explanation for the sentence in the talmud (Makkos): “From the Torah, from the Prophets, and from the Holy Writings, we can derive that in a way that a man wishes to go, in that way {they} will lead him…”

“They” refers to the angels that are created by man’s deeds.   Accordingly “Every thought, expression and action of a person causes an angel to be created: if evil, G-d forbid, destructive angels are created.  If they are meritorious, good angels are created.” It follows that good thoughts create a positive (spiritual) advocate while bad ones create critical or judgemental ‘angels.’

Let us return to the modern world of clinical cognitive-behavioral psychology.    It has been well-demonstrated across the vast field of psychology. psychiatry and neurology the simple fact that thoughts, speech and action leads to the emotional state of each of us.  As we act, so we feel.   Usually, consciously or not, our thoughts give rise to our speech or subsequent behavior.  So, what we think has a great bearing on our basic emotional stability and sense of well-being.

On the other hand, if we allow our emotions to dictate how we act, and what we say,  we open ourselves up to great risk.   Like the dog who basically just wants to have fun, almost exclusively follows his own emotions or instincts.   This might lead, unfortunetly, to a dash across a road after a ball or some other misadventure.   When we follow our feelings and what they seem to dictate, it’s as if we put the collar and leash around our own necks and hand the dog the handle signaling him to “walk us.”   No one would actually do this but if we feel we must respond with anger because we feel angry, or stay in bed because we don’t feel we can face the day, we are in essence doing just that.

We want to feel fully while acting under the guide of our better judgement and our intelligence.   If we do what we must do, and know we will feel better afterwards we will be making the right decisions.  By the way,  the word for righteous (being right or correct) in Hebrew is tzadik.  And right(eous) behavior leads to peace of mind and joy.

One last word on angels:  I assume the idea of angels has a broad set of different definitions and beliefs.   For the purposes of this article an “angel is a spiritual operative much like a simple computer program.    The “good angels”are designed to assist and help one move forward toward beneficial goals while “bad angels” tend to undermine or distract one from those goals.  For some they are conceptual constructs and others spiritual realities.

Regardless of where you are,  through the thousands of thoughts you have throughout your day,  you should try to focus on positive things, happy thoughts, and make the best of as many as possible.   Try to make all your angels be the good ones for your own good, not to mention everyone around you.

If you enjoy these articles please forward them to your friends and family.

Gershon Freedman, MD

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