Breaking the Stigma of Mental Illness – Yom Kippur 5777

There is a town in Belgium called Geel (Hyale), with a remarkable 700 year old custom of compassion.

Its origin lies in a legend about a seventh century Irish princess named Dymphna.  When Dymphna’s mother died, her father went mad, insisting on marrying her.  Dymphna fled to the continent.  When he caught up to her in Geel, he beheaded her.  Dymphna was sainted, and pilgrims began visiting the site of her martyrdom in search of miraculous cures, especially for mental illness.

A church was built in 1349, and later, an annex to house the visitors.  Eventually, the townspeople began to welcome the mentally ill relatives of pilgrims into their homes as “boarders.”  For the townspeople, it was an act of charity to open up their homes.  “Boarders” stay with their hosts for long periods of time, as many as fifty, or even 80 years, becoming part of the family.

At its peak in the 1930’s, there were 4,000 boarders living amongst a local population of 16,000.

The residents do not use terms like “mentally ill,” “psychiatric,” or “patient.”  Behavior that in any other part of the world would be considered odd or crazy, like people talking to themselves on the streets, is normalized in Geel.

This system does not take the place of medical treatment.  There is a psychiatric hospital on the outskirts of town.  What it does is treat people with dignity who would in any other community likely be hidden away or abandoned on the street.

Since the 19th century, Geel has been held up in psychiatric circles as the best way to address mental illness.  It is an ideal model for integration and normalization within a supportive community.

Sadly, as the world has changed, Geel is changing along with it.  As the result of the pressures of modern life, and the increasing medicalization of mental illness, there are today only 250-300 boarders left.  But for the residents of Geel, this custom of compassion is an important part of their heritage.

Let’s try to imagine, for a moment, what it would be like if our community was so accepting and welcoming to those who do not conform to what we typically think of as normal behavior.

Psychiatric care in the United States used to center on institutionalization in asylums.  People who were “crazy” were sent away to facilities that often had terrible conditions, where they received treatments that were often tantamount to torture.  In 1972, the psychiatric hospitals began to close.  This was supposed to be accompanied by investment of resources into community-based treatment centers.  But the investment did not happen.  As a result, many of those living with mental illness became homeless.  This is a tragedy that persists to this day.

Unlike the example of Geel, there has been no normalization of mental illness.  The mass shootings that we have seen over the past few years has prompted discussions of the need to invest more money and resources in mental health screening and treatment, but little has been done.

There is still so much fear and stigmatization.  The truth is, members of our community live every day with mental illness, whether it affects them personally, or someone close to them.

But we don’t talk about it openly.  We are scared of “strange” behavior.  When someone exhibits signs of mental illness, we tend to back away.

Think about language that we toss around casually: crazy, cuckoo, nuts.

Mental illness is so much more widespread than we typically acknowledge.  One out of every five adults in America experiences mental illness.  One in twenty five live with a serious chronic condition.

1.1% of the adult population has a diagnosis of schizophrenia.  2.6% has bipolar disorder.  6.9% suffer from major depression.  And 18.1% have an anxiety disorder.

Most signs of mental illness present themselves when we are young, with half of all chronic mental illness beginning by age fourteen.

We do not adequately treat mental illness.  60% of adults and 50% of youth aged 8-15 with mental illness did not receive mental health services in the last year.

There is a terrible price that we pay.

Depression is the leading cause of disability worldwide.  It is estimated that serious mental illness costs America over 190 billion dollars per year in lost wages.

Suicide is the 10th leading cause of death in America overall, and the second leading cause among those aged 15-34.  It is estimated that 90% of those who die by suicide suffer from depression.  As much attention as there has been to the mass killings, twice as many people die in America by suicide than by murder.

Rabbis give lots of sermons this time of year about teshuvah, repentance.  It is a wonderful concept – truly one of Judaism’s most insightful principles.  Every year, we engage in cheshbon hanefesh―self-reflection―examining our lives, and identifying ways we can be better.  We reach out to those we have wronged and seek to make amends.  We turn to God, confess our sins, and ask for forgiveness.

But what if there is no getting better?

Many of us live with mental health conditions for which there is no “cure.”  No amount of cheshbon hanefesh is going to enable us to “fix” ourselves.

But that does not make us failures.  “Depression is a flaw of chemistry, not character,” reads a Manhattan billboard.6fe75f9ff1353866f3da9ebdcc988d8c

The field of human psychology is just over a century old.  Our understanding of mental illness, and our ability to treat it, ha experienced a sea change in that time.  But that does not mean that our ancestors did not have any appreciation or compassion for those whose behaviors did not conform to social norms.

In the Bible, the best depiction of a major character suffering from mental illness is King Saul.  Listen to how the Bible describes the onset of his condition:  “Now the spirit of the Lord had departed from Saul, and a ruach ra’ah – an evil spirit – from the Lord began to terrify him.”  (I Sam 17:14)  Saul’s courtiers do not know how to address their king’s new state of mind, so they suggest searching for a musician to soothe him whenever the ruach ra’ah manifests itself.  A search leads to David, who, among other talents, is a skilled lyre player.

Saul’s ruach ra’ah comes and goes.  He has episodes of paranoia and mania interspersed with periods of normal function.  Some modern readers have suggested that he might have suffered from a bipolar disorder, although we should be cautious about making a diagnosis based on a three thousand year old text.

Some time later, David kills the Philistine Goliath and then has to flee from Saul’s wrath.  He winds up in the court of King Achish of Gat, Goliath’s home town.  To avoid arrest, David pretends to be insane, scratching marks on the doors and letting his saliva run down his beard.  Achish, afraid of this behavior, scolds his attendants.  “You see the man is raving; why bring him to me?  Do I lack madmen that you have brought this fellow to rave for me?  Should this fellow enter my house?”  (I Sam. 21:15-16)

Many of the Psalms, traditionally attributed to King David and his court, express the anguish of a troubled mind.

My soul is in anguish, and You, O Lord―how long?

Turn, Lord, set my soul free; save me for the sake of Your love…

I am weary with my sighing.

Every night I drench my bed, I soak my couch with my tears.

My eye grows dim from grief, worn out because of all my foes…  (Psalm 6)

These sound like the words of a person living with severe depression.

In Rabbinic texts, there is much discussion about mental illness.  The term that is used to describe such a person is shoteh.  The shoteh, along with the deaf-mute, is generally not granted much legal status, as they are assumed to not understand what is happening around them.

But what constitutes a shoteh?

A single talmudic passage offers an inconclusive definition.  “Who is a shoteh?  A person who goes out alone at night; sleeps in a cemetery; and tears one’s clothing.”  (BT Chagigah 3b)  One Rabbi explains that all three behaviors need to be exhibited, while another Rabbi argues that just one is needed.  Then, the Talmud suggests that there could be rational reasons for a person would go out alone at night, sleep in a cemetery, or tear clothing.  The question is left unresolved.

Nearly one thousand years later, Maimonides is discussing laws pertaining to who may serve as a witness in court.  A shoteh, someone who is mentally or emotionally unstable, is not considered to be obligated in the mitzvot, and thus cannot serve as a witness, he says.  But who is a shoteh?  As a legal scholar, a physician, and a community judge and leader, Maimonides offers a more nuanced, and I would suggest compassionate, way of looking at the shoteh.

First he describes someone who is unable to understand basic matters or recognize simple contradictions.  He is describing what we might call someone with an intellectual disability, or low IQ.

Maimonides then writes about emotional instability.  He says that is is not merely someone who “goes around naked, destroys utensils, and throws stones.  Instead, it applies to anyone whose mind is disturbed and continually confused when it comes to certain matters, although he can speak and ask questions to the point regarding other matters.”

But his final comment is the most poignant.  “This matter is dependent on the judgment of the judge. It is impossible to describe the mental and emotional states of people in a text.”  (Edut 9:9-10)

Every person is unique.  Someone might be capable and functional in some aspects of his or her life, but troubled in other aspects.  Emotional instability might come and go.  We cannot make categorical assumptions without even getting to know a person.  We have to take the time to listen.

Pretty progressive for the twelfth century.

Today, we know that mental illness is not a punishment from God, and it is not something that can be cured with sacrifice or prayer.  Whereas it was once attributed to possession by a ruach ra’ah, we now understand mental illness as being caused by chemical and/or physical processes in the brain.

And, there is often treatment that can reduce symptoms of mental instability and make it possible for someone living with a mental illness to flourish in ways that would have been unimaginable in previous eras.  Someone who once would have been considered a shoteh, and not held accountable for his or her actions, can now have a family and a successful career.

While not perfect, we do a pretty good job of accommodating the needs of people who live with physical disabilities.  The Americans with Disabilities Act, signed into law in 1990, “prevents discrimination and guarantees that people with disabilities have the same opportunities as everyone else to participate in the mainstream of American life.”

It has changed such basic things as how we design buildings.  When our synagogue was built ten years ago, for example, we included a ramp to enable someone who uses a wheelchair or walker to come up to the bimah.  Earlier this year, we installed railings to make it easier to walk up the steps to the bimah.

We do a reasonably good job of ensuring that our synagogue is a welcoming home for anyone with a physical disability.

But what about for someone suffering from a psychiatric illness?

One of the most meaningful parts of our weekly Shabbat services is the Mi Sheberach L’cholim, the prayer for the sick.  Our practice is to invite anyone who would like to include the name of someone who seeks healing to form a line.  Each person has an opportunity to recite the names of those who are ill.  It is one of the most personal parts of the service for many of us, including me.

I recognize many of the names that are recited, and I am familiar with the illnesses that many of them face: cancer, chronic conditions, acute sickness, dementia.  But have we created a culture in which we would think to include someone struggling with mental illness in our prayers for healing?

Would someone who is him or herself experiencing depression feel welcome to include his or her own name?

It would certainly be appropriate to do so.  The language of the prayer acknowledges that there are physical and spiritual dimensions to healing.  We pray for r’fuat hanefesh ur’fuat haguf―healing of spirit and healing of body―in that order.

Prayer is not a treatment for mental illness.  It is not a substitute for medications that address chemical imbalances in a person’s brain.  But religion, and a religious community, ought to be an important component in healing.  Where better for someone living with depression to turn for support and acceptance than a house of worship?

We need to do better.  Congregation Sinai needs to be a community in which those suffering with a mental illness can be open about their struggles.  We need to break the stigma that leads so many of us to keep our struggles inside.

If you feel comfortable sharing your struggles with someone else, please take the courageous step and do so.  For someone who feels embarrassed or self-conscious about opening up, knowing that there are others who have shared similar experiences can make a huge difference.  It sends the message that “you are not alone.”

I have an anxiety disorder and Adult ADHD, for which I take psychiatric medications.

Over the past ten years or so, I have experienced occasional panic attacks.  I get dizzy.  The world starts to spin.  The edges of my eyesight get blurry, and I worry that I am going to pass out.  On some particularly bad occasions, I feel like I am having a heart attack, or at least, what I imagine a heart attack would feel like.

Scariest of all is when I have a panic attack while behind the wheel of a car.  One of my triggers is driving over tall bridges.  A few years ago, I was driving over the Golden Gate Bridge with my brother-in-law in the passenger seat and our kids in the back.  Halfway across the bridge, I could feel an attack coming on.  “Keep an eye on me,” I told my brother-in-law.  As soon as we got to the other side, I pulled over to the shoulder and gave him the wheel.

A couple of years ago, I had a panic attack in the middle of the night.  I thought I was having a heart attack.  I woke Dana up, and asked her to keep an eye on me.  I was upset with myself.  “What is wrong with me?  I should be able to just get myself under control.  After all, this is all just in my head.”

Dana, in her wisdom, responded, “Your brain is the most complex organ in your body.  What makes you think that you can just get it under control?”

Looking back, I realize that I had succumbed to the stigma of mental illness.  I felt guilty for not being able to control something “that was just in my head.”

It is not “just in my head.”  It is “in my head,” and that is not something to take lightly.

While real to me, my struggles are minor inconveniences compared to the serious mental afflictions that impact some peoples’ lives.  I do not know what it is like to live with schizophrenia or a bipolar disorder.

But I can hold someone’s hand and listen.

This year, I ask that we make it a priority that our synagogue become a place in which those living with mental illness can find compassion, acceptance, and healing.  I will speak of it more explicitly from the bimah.  From now on, when I lead the prayer for healing, I will change the way that I introduce it to something like the following:

I am now going to recite the Mi Sheberach L’cholim, the prayer for healing for those with physical and mental illness.  If you would like to include someone, or if you yourself are in need of healing, please come up and form a line to my right.

I ask that we commit to being there for each other with open minds and open hearts.

We all bring our tzarot, our troubles, to shul.  Especially on a day like Yom Kippur, with its focus on sin, repentance, atonement, and mortality.

Yom Kippur is really a day for spiritual healing.  In the Temple, it was the day when the High Priest conducted the rituals that restored the spiritual relationship between God and the Jewish people.  Today, our prayers and our fasting accomplish the same.

Let this day, this synagogue, and this community, offer healing and comfort to all those who have brought their tzarot with them.

I would like to close with this prayer composed by Rabbi Elliott Kukla, of the Bay Area Jewish Healing Center.

May the One who blessed our ancestors bless all who live with mental illness, our care-givers, families, and friends.  May we walk in the footsteps of Jacob, King Saul, Miriam, Hannah, and Naomi, who struggled with dark moods, hopelessness, isolation, and terrors, but survived and led our people.  Just as our father, Jacob, spent the night wrestling with an angel and prevailed, may all who live with mental illness be granted the endurance to wrestle with pain and prevail night upon night.  Grace us with the faith to know that though, like Jacob, we may be wounded, shaped and renamed by this struggle, still we will live on to continue an ever unfolding, unpredictable path toward healing.  May we not be alone on this path but accompanied by our families, friends, care-givers, ancestors, and the Divine presence. Surround us with loving-kindness, grace and companionship and spread over us a sukkat shalom, a shelter of peace and wholeness. And let us say: Amen.

G’mar Chatimah Tovah.  May we all be inscribed and sealed in the Book of Life for a year of blessing and healing.

5 thoughts on “Breaking the Stigma of Mental Illness – Yom Kippur 5777

  1. This is very important, thank you for writing this and caring.
    The stigma of mental health is world wide. Many times what hurts the sufferer the most is the stigma more so than even the disease. You are considered ‘less than’ and weak if you are mentally ill and those around you shun you. All faiths should take this into consideration I am glad to see that my faith is, and that those who suffer, do not have to do so in silence.

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