Coming to terms with mental illness in Judaism and in our communities

‘Remember that davening is worship of the heart, and some people’s hearts are busy just finding the will to get up in the morning’

 (photo credit: NEEDPIX.COM)
(photo credit: NEEDPIX.COM)
One of the most beloved hassidic stories of the High Holiday season tells of an orphaned shepherd boy who knew little about his Jewish heritage. On the day before Yom Kippur, he joined a group of people traveling to Medzhybizh to spend the holiest day of the Jewish year in prayer with the sainted Baal Shem Tov. Standing in the synagogue among the devoted worshipers, the boy desperately wanted to pray, but couldn’t read the letters of the alef-bet. He drew a deep breath and let out a piercing whistle, the identical sound he would make each evening to gather his sheep from the fields.

The people in the synagogue were aghast at the interruption, but the Baal Shem Tov calmed his followers and said, “This boy’s whistle penetrated the heavens, and canceled God’s terrible decree. It was sincere and came from the very bottom of his heart.” This story not only emphasizes the importance of sincerity in prayer but the significance of tolerance and understanding for those who may be somewhat different than others.

“Someone once said to me that the story always bothered him,” says Rabbi Yoni Rosensweig of Beit Knesset Netzach Menashe in Beit Shemesh. “He said, ‘If that kid walked into our shul, we’d shush him. We wouldn’t be the Baal Shem Tov – we’d be the people silencing him. We marvel at the story, but honestly, if someone walked in at the Neilah prayer and started whistling, we would kick him out.’” “We like the story,” continues Rosensweig, “but we like our order and we like our structure. Having a mentally unwell person within our community always upsets that structure. Can you really put up with someone who has Alzheimer’s or dementia coming to shul and speaking loudly or acting out? Can you put up with someone with autism or a child who comes with ADHD and needs to have a spinner to keep himself occupied in shul? It’s not just a question of Halacha. It is a communal question: Are we willing to sacrifice to accommodate those individuals?

“If we are not willing to accommodate those individuals, then we shouldn’t be surprised if they don’t want to let us know what they are doing and what is going on with them. They don’t want to expose themselves or put themselves out there, only to be shut down or shut out from any sort of communal activity. But if we are really willing to make a space for them, then people will be more willing to come out, say what is going on with them and ask for the help that they need.”
ROSENSWEIG, WHO has served as rabbi of the Netzach Menashe community since 2010, says that over the past three years, there has been an increase in the number of questions addressed to him about mental health. Today, he notes, between 30% and 50% of the questions he receives each week are on that topic.

Rosensweig mentions a question he received. Someone suffering from anxiety and depression can control his anxieties during the week by listening to music or taking a bath. On Shabbat, he usually would not do either of these activities and instead is vomiting or cutting himself to release stress, which is unhealthy and dangerous. Is he permitted to listen to music on Shabbat?

Responds Rosensweig, “If Jewish law is up to the challenge, and says, ‘Okay, maybe we can allow you to listen to music under those circumstances,’ then what you are saying to the person is, ‘I believe you are ill, and just like I would allow someone who is physically ill to do certain things on Shabbat, I am going to allow it for you as well.’ But if I tell the person, ‘No, you can’t do those things, and you’ll just have to cope some other way,’ I am sending a message that says, ‘You are not really sick.’ “You wouldn’t tell a person with fever to just ‘walk it off.’ You would tell that person to take a pill and bring down the fever – not just mentally ‘work it out.’ With mental illness, we are sometimes more dismissive, not because we are trying to do harm. We think we are giving good advice, but we are sending the message, ‘I have nothing that I can do for you because I don’t really see this as an emergency situation.’” Rosensweig feels that Judaism has unwittingly attached stigmas to mental illness. One reason, he says, is due to the lack of sources within Jewish law on the subject, and the second has to do with the not-uncommon lack of positive response when confronted with questions of mental health.

When the rabbis of the Talmud described matters pertaining to health, he explains, they were describing phenomena of which they were aware.

“If you understand that the issues, the things that they describe are things that were clear to them as being illnesses, we can also understand that the things we have in our classical sources are usually the more extreme cases, because those were very clearly identifiable. It’s clear that the kinds of things they talk about are nearer to psychosis than neurosis,” he says.

“When you tell a kid in yeshiva or the community that he has a personality issue and should talk to a rabbi, and the rabbi tells the person that he has to work on himself and his middot (behavioral traits) – it’s not that those things are sometimes not good to hear – but for a person who is really suffering, it’s like someone is suffering from cancer and you’re putting a Band-Aid on it. That’s not going to help.” Rosensweig says that many people need help and guidance in modifying their behavior, and in some cases, need medication.

“It’s not just a matter of willpower and saying, ‘You can do it if you really try hard.’”

PROF. RAEL STROUS, director of psychiatry at the Maayanei Hayeshua Medical Center and professor of psychiatry at the Tel Aviv University faculty of medicine, says the fault lies not within the religion but with its practitioners.

“We think that Judaism stigmatizes,” says Strous, “but that’s our stigma.” In Strous’s view, people attach stigmas, not the Jewish religion. Strous suggests that the lack of understanding about mental illness and its causes creates a stigma.

“There is a mystique about it,” he says. “Because we don’t understand it, we feel we have less control over it. Therefore it is threatening and scary and people stay away from it. The opposite is true. Judaism very much de-stigmatizes mental illness.” Naomi Raz, a Jerusalem-based psychotherapist says that the stigma associated with mental illness is connected with shame and a fear of losing control. “I think that what it touches in all of us is a feeling of being out of control and a feeling of being helpless. When we see that, it scares us. Could we be like that? Could that happen to us – could we lose touch with reality and behave in way that is bizarre and weird?” A neurologist, Strous points out, can diagnose and explain the cause of an illness, but depending on the circumstances, may not be able to treat the ailment. Psychiatry, he explains, is the opposite.

“We don’t know what causes the illness, but the vast majority of psychiatric illnesses can be treated. Psychiatry is at the interface of behavior, philosophy, and human nature – the bottom line is all biology. That doesn’t mean you don’t treat some of it with therapy. Talking can change your biology. We just don’t have the technology to understand it, because the brain is the last frontier. We’re not there yet.” Two-thirds of the population, at some stage in their lives, have some form of mental illness, says Strous, but only a third get treatment because of the stigma that is attached to therapy. He suggests that the stigmas attached to mental illness are reflected in the level of mental health facilities in Israel. Most hospitals in Israel have received donations from wealthy families, but rarely do people donate to psychiatric hospitals.

“An incredible amount of money goes into diabetes and muscular dystrophy, and that’s important, but what about psychiatry? Mental illnesses – depression and schizophrenia, for example – are much more common, but there is a stigma. If you go into any of the big hospitals, you can buy flowers from a machine. In the 25 years I’ve been in psychiatry, I’ve never seen anyone bring flowers to anyone in a psychiatric hospital. Why? It’s the stigma.” Strous also wonders why there are so few visitors to patients in psychiatric hospitals. He adds that the lack of allocation of funds for mental health is not specific to Israel, but is a universal phenomenon. In his opinion, in the United States there is much less stigma attached to mental illness and thus more private investment and donations.

A well-known Talmudic term for describing a type of aberrant behavior is that of the shoteh, which the Talmud defines as one who goes out alone at night, spends the night in the cemetery, tears his clothes or destroys all that is given to him.

Strous, who is also the editor of the Israel Journal of Psychiatry and chairman of the ethics committee of the Israel Psychiatry Association, explains that the shoteh portrayed in the Talmud is best understood today as manifesting symptoms typical of the insane, or what in clinical terms is known as the psychotic individual. How did the rabbis of the Talmud treat the shoteh?

Strous says that the shoteh lacks the critical judgment necessary to perform basic tasks of daily living and social adaptation, and the ability to correctly assess a situation and act appropriately. Therefore, he is exempt from the performance of both positive and negative commandments of the Torah. Moreover, Strous notes, the shoteh is also absolved from accountability if he injures another individual. Additionally, the courts are obligated to appoint a guardian to protect his rights.

“According to Jewish law, you are not allowed to put them aside,” notes Strous. “You are supposed to make them part of the community.”

WHILE THE sages of the Talmud were well aware of the abnormal behavior of the shoteh, they were understandably not aware of many of the more commonplace issues that confront people in today’s society. How do Judaism and Jewish law deal with issues such as depression, anxiety disorders, obsessive-compulsive disorders and eating disorders? OCD, for example, can be particularly challenging in a religion that emphasizes rituals and can create torment and overly scrupulous behaviors around areas of kashrut or family purity.

As the number of halachic questions he was receiving on mental health issues increased, Rabbi Rosensweig found there was a dearth of written material on the subject.

“I’m sure I am not the first person to ask these questions,” he acknowledges. “Whatever answers were given, were given from person to person. It was very hard to find answers for a lot of these questions.”

Rosensweig studied weekly with a psychiatrist friend to broaden his understanding of mental health and read the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association. After two years of research, he spent a year writing a book on Jewish law and mental health. Additionally, he consulted with leading Orthodox rabbis both in Israel and abroad.

The title of his book, Nafshi BeSh’elati, is part of a verse from the Book of Esther. The term ‘Nafshi’ in a broader sense refers to mental issues, and the word ‘Sh’elati’ refers to questions, thus meaning questions about mental health. Rosensweig expects to release the book by the end of 2020, in Hebrew, with an abridged English translation. Some sample questions from the book include: • May someone with depression listen to music on Shabbat?

• Does someone with anorexia fast on Yom Kippur?

• Can mindfulness be practiced despite its idolatrous history?

• Does one need to respect an abusive parent?

Rosensweig’s empathy for those suffering from mental health issues is epitomized in his recent Facebook post, which appeared before Rosh Hashanah:

“‘What if I can’t bring myself to daven on Rosh Hashanah?’ I was asked by someone suffering from depression and anxiety. As I’m sure you understand, every case is different, and each person needs to follow the path that is best for them. For some, it would be best to encourage them to take part in the tefillot in public, for others to stay home and not expose themselves to the communal prayer, and others might not be able to daven at all.

“What’s important is to try and shake that feeling of guilt, that you are somehow not doing the right thing by not davening. Remember that davening is avoda she-balev, worship of the heart, and some people’s hearts are busy just finding the will to get up in the morning. It may be too much to ask to add the full-on spiritual work and focus that Rosh Hashanah demands. So what’s most important to tell a person like that is that that’s okay. That they’re okay. That there is nothing to feel guilty about. That they should focus on their health this year, and Hashem understands, and God willing they will be better next year, and be able to participate fully, as they yearn to do.” Rosensweig adds that as people learned of his interest in the subject of mental illness and Jewish law, he began to receive a steady stream of calls and messages.

“You find out that the entire world around you is full of this.”

He relates that a member of the community told him that his daughter had an eating disorder. The father went to visit his child in the hospital ward and was amazed to see numerous people from the community whom he knew.

ROSENSWEIG WAS a student of the renowned Rabbi Nahum Rabinovitch, the late head of the yeshiva in Ma’aleh Adumim, and as such, most of his audience is from the national-religious community. Strous, medical director of the Mental Health Center at Mayanei Hayeshua Medical Center in Bnei Brak, deals primarily with members of the haredi community.

While it has often been reported that haredim tend to hide mental illness, the Mental Health Center is one of the most advanced, modern mental health facilities in the country. Strous explains that haredi community members in need of treatment first approach their askanim (communal lay leaders) and rabbis, then arrange for them to go to the hospital, which offers a broad range of treatments that include animal, music and dance therapy. The hospital accepts people of all backgrounds, but Strous says it attracts a mostly ultra-Orthodox population, by virtue of its location, most from Beit Shemesh, Jerusalem, Kiryat Sefer and Safed.

Strous explains that rabbis are often first-line gatekeepers when people have difficulties.

“When a person has a sore throat, he doesn’t go to the rabbi. When a person is feeling down, he will often go to the rabbi. Good rabbis will know when they should refer to a mental health professional.”

At that point, he explains, the askan who deals with mental health issues will then ensure the person in question sees a psychiatrist or other appropriate mental health professional.

Because of this, Strous says, he frequently gets referrals from leading haredi rabbis, who realize that depression is not something that can be treated only through prayer. Strous adds that the international medical oath now includes three new components – respecting the autonomy of patients; looking after oneself as a physician in order to best manage patients; and the ethical duty to go out to the community and share one’s knowledge.

To that end, Strous meets each month with groups of rabbis and activists in the haredi community and discusses mental illness, teaching them about depression, psychosis, manic depression and severe obsessive-compulsive behavior and learning to identify the symptoms and signs.

DR. SEYMOUR HOFFMAN, who was a supervising psychologist at the Mayanei Hayeshua Mental Health Center for 11 years and recently published Standards of Sexual Modesty, Gender Separation and Homosexuality: Rabbinic and Psychological Views, suggests there may be a greater stigma placed on mental illness within the haredi community.

“The haredi community is a very close community, and they often attempt to hide things of this nature.”

While he recognizes change is happening slowly, he says that when arranging a marriage match for a child, “they frequently hide a lot of things, because they know if they have mental health problems there is a poor chance of finding an appropriate mate – or they’ll get an inferior or second-rate partner. I think that the national-religious world is more open to this and more realistic, whereas the haredi community is defensive and hides this to a great extent, to the detriment of the people.” Hoffman adds that the building of the Mayanei Hayeshua Medical Center in Bnei Brak was a crucial step in the right direction.

“Now people have a place to go where they are not threatened by the environment,” says Hoffman, “and where people understand the sensitivities of the culture and values. It has gone a long way toward helping people cope.”

Hoffman says from a mental health perspective, religious people are by and large better off because of their sense of community, values and structure.

“Research has indicated that religious people are generally mentally healthier than those that are not. The structure, support and emphasis on helping people and the community, synagogue and festivities, family and eating together on Shabbat and holidays – this all contributes to a better-adjusted person.” Is Jewish law more tolerant and understanding of mental health than it has been in the past? Can psychiatrists and mental health professionals succeed in removing the stigma surrounding mental illness? If a child were to enter the synagogue on Yom Kippur and whistle as an expression of prayer, how would we react?

The answers to these questions are essential for all of us – for families, individuals and the community. 

This is the first article in a series on mental health.