The Yale Journal for Humanities in Medicine

Spirituality, Religious Wisdom, and the Care of the Patient

Shame and Illness:  A Jewish Perspective

Michelle E. Friedman, M.D.
mefriedman@aol.com

I approach the topic of "Shame and Illness" from my twin perspectives as psychoanalyst and traditional Jew.  This written piece contains material prepared for the forum held at New York Medical College on June 14, 2004 as well as issues raised that evening via case vignette presentation and audience participation.

I hope to discuss a number of points. My starting place is a definition of shame, especially as contrasted to its sister emotion, guilt. I then look at shame from a Jewish point of view, using three classical texts and mentioning a variety of cultural traditions. Next, as most of my professional medical experience is in psychiatry, I highlight the specific shame of psychiatric illness in the Jewish and larger community. The last portion of my spoken presentation was a practical charge to health care professionals - suggestions as to how understanding of Jewish attitudes towards shame and illness, can better serve our patients. Discussion at the forum expanded my topic in two directions that I will mention in this paper. Firstly, people wondered if traditional religious attitudes and customs continue to be meaningful for assimilated Jews.  The group also voiced interest in exploring how the roles of psychiatrist and chaplain (or other religious personnel) differ in the face of illness.

Shame and guilt live side by side. Guilt, perhaps the most personal and internal of emotions, is born out of identification with and internalization of parental and societal prohibitions. These superego standards forbid various boundary transgressions. Inevitably, boundaries are overstepped and rules are broken. The person guilty of such violations suffers a sense of wrongness and a fear of punishment. He/she seeks to relieve the isolation and burdensome secret of sin.

 Shame, on the other hand, must be understood in the context of group culture. Shame implies a failure to live up to internalized parental and larger societal goals, i.e. what a person "should be like". The shamed person experiences his/her failure as a lowering of personal dignity in the eyes of the group and fears ridicule, contempt or expulsion. In his book Feelings,1 my teacher, Dr. Willard Gaylin, brilliantly offers a literary handle which helps differentiate shame and guilt. Simply think of Nathaniel Hawthorne's classic, The Scarlett Letter. Hester Prynne, the accused adulteress forced to wear the emblem of her sin on her clothing, lives with public contempt on a daily basis. In contrast, Reverend Dimmesdale, suffers his sin in isolation - as Hester Prynne's secret lover he knows that he has violated a most basic code of his society. Each day brings new agony of being found out and destroyed.

Traditional Jewish view posits a divinely created universe. God's plan calls for Jews to live as holy individuals in holy communities in accordance with precepts and rules as explicated in the Bible (here I refer to the Pentateuch, also known as the Torah or Old Testament). From the first chapters of Genesis on, we see humankind struggling to resolve interpersonal and intergroup conflict. These meaning making narratives depict their characters wrestling with powerful and sometimes contradictory impulses. Later texts, comprising what is known as the oral tradition, include the Talmud and generations of commentary. These works establish an essential tension regarding illness. In a divinely ordered and ultimately just universe, sickness must be determined by God. Mankind seeks to understand the scales of God's judgment  and interprets infliction of maladies as punishment for wrongdoing. In this view, illness becomes a public sign of sin, a visible stigmata of shame. At the very same time, however, Jewish tradition brings enormous attention to attitudes and behaviors regarding the support and comfort of the sick.

Shame is a powerful operative dynamic in Jewish tradition where individual personal and religious destiny can only be truly fulfilled through membership in the larger units of family, tribe, and nation.  The concept of individual salvation plays a much less dominant role in Judaism as compared with Christianity.  Shame relies on group context. Shame sanctions figure significantly in classical Jewish texts. For example, Levirate marriage, outlined in Deuteronomy 25:5-10 requires that a widow spit in the face of the brother-in-law who rejects her as a wife. His refusal to redeem her plight as a childless widow sentences her to low social and economic status. Hence, he too must share the burden of shame.

Shame is closely tied to sexuality. Mary Douglas2 describes how the body, like the community, is a bounded system. Any substance produced by the body is acceptable while in the body, but becomes unacceptable, polluting and taboo when expelled from the body. Spit, as in the cited Deuteronomy passage, blood (especially menstrual blood), and  semen are among body products for which there are many Biblical and later text injunctions.

Shame is recognized entity in Jewish legal tradition. The Talmud, the multi-volume compilation of Jewish law, edited in the 4^th-6^th centuries, discusses specific categories of monetary compensation for shame caused in different circumstances. Linguistically, ""shame" has a rich heritage in Hebrew and Aramaic.3 Several different word roots convey states of "shame" bw-sh, klm, plh, hrp hpr, sh-pl, mkk . These roots can be grammatically worked into noun format, referring to the state of shame, or into active verbs, referring to the activity of causing shame or being shamed. The same could not be said for "guilt". A person can be sh-m,  guilty of committing wrong doing, a "sin", or considered a ra-sha, or wicked/guilty one, but there is no ancient Biblical word for a state of guilty feeling.

As Judaism is a text-based tradition, my presentation includes a source sheet containing three passages from classical Jewish literature arranged in chronological order. I now refer to the first and earliest source, the Torah, Numbers 12, where the link between punishment for wrong doing, illness, and shame is established.

The passage describes Miriam's punishment for speaking out against her brother Moses. Both Miriam and Aaron criticize Moses for marrying a Cushite woman and for being God's favorite prophet. God becomes angry and strikes Miriam with a plague, commonly referred to as leprosy. The passage poses many perplexing questions that have occupied the attention of countless exegetes, not the least of which is why Miriam alone is singled out for punishment. For the purpose of this paper, however, I focus only on sin, illness and shame. 

Once stricken, Miriam remains silent for the rest of the chapter. Aaron, on the other hand, immediately mobilizes into action. He acknowledges his culpability along with that of his sister and implores Moses to intervene with God. A plaintive wave of urgency moves the verses as Moses cries out the most succinct prayer of the entire Bible "Heal her, O God, I beseech thee".

God's reply secures the connection between shame and illness. Miriam must be temporarily ostracized; kept separate from the camp just like a shamed daughter whose father has spit in her face. Yet the very next sentence yields completely different information. The entire camp waits a full week until Miriam can rejoin them. The people need and love their flawed heroine. Illness and shame are counterbalanced by compassion and community support.

The many volumes of the Talmud incorporate the central legal precepts and ethical teachings of ancient Judaism. This corpus, edited between the 4^th and 6^th centuries covers all facets of practical and religious life. The second text on the source sheet, Mishnah Peah 1:1; Talmud Shabbat 127a, comes from the Talmud and is recited every day in morning prayers.4 It outlines a number of activities that "know no limit", i.e. can not be overdone. Performance of these positive commandments, or mitzvoth, promises reward in this world and in the hereafter. In addition, each mitzvah requires personal commitment and participation. The list is demanding - besides visiting the sick, it includes honoring parents, practicing kindness, regular attendance in prayer and study, hospitality to strangers, dowering the bride, attending the dead to the grave, and making peace between fellow men. Not all people can perform every task but all are obligated to remind themselves daily of the noble goal of trying to make the best possible effort.

Maimonides, the great 12^th century commentator,  and also a physician, further explicates the above mitzvoth. The third source, Chapter 14 of his Mishnah Torah  details specific behaviors and attitudes incumbent on visitors to the sick. These passages demonstrate an extraordinary sensitivity to the shame and loneliness of the sick person. A deep understanding of shared vulnerability underwrites Maimonides' instructions and injunctions. We all share in this human condition; we are all potential patients. Our goal is to be a Godly community. To support the sick is to identify with a caring God.5

Visiting the sick is not just a kind, charitable activity. Section 4 clearly states the imperative nature of the mitzvah - failure to visit is likened to shedding blood. Sections 5 and 6 prescribe proper visiting times and protocols.6 Visitors should refrain from visiting when the patient might be most exposed or regressed. Such precision restores dignity. Like Miriam, the sick person hovers on the margins of society. Community must be created with that individual to undo his/ her shame.

Traditional Jewish liturgy responds to the need to cure illness and relieve the burden of shame. The central prayer, known as the silent devotion or Amida is written in first person plural and contains a section petitioning God to heal the sick, "Heal us, O Lord, and we shall be healed; save us and we shall be saved; for thou art our praise. Grant a  perfect healing to all our wounds. This grammar enjoins the individual at prayer to be mindful of fellow Jews who are sick.  Jews, who are mandated to recite the Amida three times each day, may insert the name of specific ill persons during this petition. In addition, those attending public prayer services customarily recite out loud names of the sick during a special blessing made during the Torah reading. Individuals faced with life-threatening illness sometimes change their first name - hoping that their luck will change for the better as they assume a new name.

While all illness caries its share of indignity, I regularly encounter the shame of psychiatric illness. Patients struggling with depression, schizophrenia, obsessive-compulsive disorder, to name just a few mental disorders, feel that their very souls are defiled, that their characters are besmirched. We all feel sad or anxious at times. Why do depressives slip into abysses of despair? Why are the demons of schizophrenics so much more tormenting?

A large sign paid for by one of the national movements for mental health, graces the side of a building on 72^nd street between Columbus Avenue and Broadway. It reads "Depression is a failure of chemistry, not character". As many patients coming to my office on the west side of Manhattan pass by that sign on the way to the subway, I encourage them to look up at those words and think about what they mean. We work together to make some kind of sense out of their psychological suffering. Medications can and do provide enormous relief. Insight helps reduce symptoms and provide more adaptive responses to stressors. The borderland between chemistry and character remains unclear. Emotionally ill people surely need support in the face of struggle that is less visible than physical disease. Lack of such support may lead to denial of illness and non-compliance with treatment.

Mindfulness of the inherent shame of physical and mental illness greatly influences diagnosis, treatment and ongoing care. A health worker who is non-judgmental and respectful will not be afraid to ask important questions especially about behaviors and attitudes that may have serious consequences such as sexual habits and substance use. Bringing up such topics in a neutral tone of voice acknowledges the vulnerability of the human condition and gives patients permission to talk about their real lives.

The case vignettes brought many of these issues to life. The pediatric chief resident presented a tragic situation of a young child neurologically devastated secondary to a near drowning that occurred during the parents' watch. Each time the child comes for necessary medical attention, the parents face critical and questioning attitudes from medical personnel. Even as the chief resident presented the story at the forum, I found myself thinking "How could parents let such a terrible thing happen? Where were they, what were they doing?" The panelists and audience discussed ways in which the parents' burden of shame might be alleviated. A document of the child's history could be prepared so that the parents need not retell and relive the whole nightmare every time the child required hospitalization. In addition, joining a support group might provide a unique community to share feelings and support. 

A second case dealt with a woman with breast cancer. Her teen-age daughters seem ashamed of the signs of their mother's treatment, such as her wig. We addressed the terror people typically feel with a cancer diagnosis. Even though her medical prognosis may be very hopeful, this woman and her family harbor fantasies of her demise and death. Such fears are often displaced onto side issues. Helpful interventions might include counseling so that each family member can safely hear what the others are dealing with. Again, as in the case of the child, this woman, her husband and the children might benefit from information as to the availability of niche support groups and other advocacy organizations. Such opportunities help people struggling with devastating and demoralizing medical situations find ways to be pro-active and powerful.

Audience participation raised the issue of secular people and their relationship to religious attitudes towards illness. Do assimilated Jews for whom prayer or text study is not a regular or even occasional activity derive comfort from the sources discussed earlier? Perhaps the old adage "There are no atheists in a foxhole" might be reworked for this discussion into something like "There is no one in a hospital bed who doesn't appreciate a prayer for recovery". I have been struck many times by how the most non-traditional of Jews are touched by a more traditional co-religionist's offer to visit a sick person or to recite his/her name during prayer. To be helpful, a hospital chaplain must cultivate a sincerely non-judgmental attitude. This does not necessitate that he/she suspend religious values or standards, but rather that the chaplain be able to listen compassionately to whatever the patient needs to say. Even if that person has lived a life entirely unconnected or even contrary to religious tradition, he/she can derive enormous support during the physical and spiritual assault of illness.

Finally, I want to touch on the question about the different domains of chaplain and mental health professional. In theory, they are different. Shame, fear, sadness, rage are among normal feelings that may accompany illness. To cry or to be angry are not necessarily pathological responses. Chaplains can be enormously helpful in sitting with patients, listening to them, thereby giving permission to express these powerful emotions. Chaplains represent the wisdom of their faiths and can offer the richness of their respective religious traditions.

Psychiatrists and psychologists should be called into the medical setting if and when a patient's response to physical illness becomes entrenched or more extreme than usual clinical experience. Prolonged mood disturbance, hopelessness, the appearance of suicidal ideation or noncompliance with treatment, should alert a health care worker to consider a psychiatric consult.

In real life, chaplains and mental health professionals often overlap. Both need to do a basic assessment of mental health status. This should include exploring patients' strengths and coping mechanisms in the face of earlier challenges. Religious faith and traditions might be a part of those supportive strategies. In a medical environment respectful of spiritual and psychological life, chaplains and psychiatrists should be in regular contact. Together, they can provide immeasurable support and comfort for individuals and families struggling to cope with illness.

SOURCE SHEET

Source #1.  Numbers 12

When they were in Hazeroth, Miriam and Aaron spoke against Moses because of the Cushite woman he had married: "He married the Cushite woman!"

They said, "Has the Lord spoken only through Moses? Has He not spoken through us as well?" The Lord heard it. Now Moses was a very humble man, more so than any other man on earth. Suddenly the Lord called to Moses, Aaron, and Miriam, "Come out, you three to the Tent of meeting." So the three of them went out. The Lord came down in a pillar of cloud, stopped at the entrance of the Tent, and called out "Aaron and Miriam!" The two of them came forward and He said, "Hear these My words: When a prophet of the Lord arises among you, I make Myself known to him in a vision, I speak with him in a dream. Not so with My servant Moses; he is trusted throughout My household. With him I speak mouth to mouth; plainly and not in riddles, and he beholds not the likness of the Lord. How then did you not shrink from speaking against My servant Moses! Still incensed with them, the Lord departed.

As the cloud withdrew from the Tent, there was Miriam stricken with snow-white scales! When Aaron turned toward Miriam, he saw that she was stricken with scales. And Aaron said to Moses, "O my lord, account not to us the sin which we committed in our folly. Let her not be as one dead, who emerges from his mother's womb with half his flesh eaten away." So Moses cried out to the Lord, saying, "O God, pray heal her!"

But the Lord said to Moses, "If her father spat in her face, would she not bear her shame for seven days? Let her be shut out of camp for seven days, and then let her be readmitted." So Miriam was shut out of camp seven days; and the people did not march on until Miriam was readmitted. After that the people set out from Hazeroth and encamped in the wilderness of Paran.

 Hebrew-English Tanakh, (Philadelphia: The Jewish Publication Society, 1999) 310-311.

Source #2:

These are the things for which no limit is prescribed: the corner of the field, the first-fruits, the pilgrimage offerings, the practice of kindness, and the study of the Torah. These are the things of which a man enjoys the fruits in this world, while the principal remains for him in the hereafter, namely: honoring father and mother, practice of kindness, early attendance at the schoolhouse morning and evening, hospitality to strangers, visiting the sick, dowering the bride, attending the dead to the grave, devotion in prayer, and making peace between fellow men; but the study of the Torah excels them all.

Philip Birnbaum, ed. Daily Prayer Book, (New York:Hebrew Publishing Company, 1949) 16.

Source #3. 

4. All are in duty bound to visit the sick.  Even a man of prominence must visit a less important person.  The ill should be visited many times a day.  The more often a person calls on the sick, the more praiseworthy he is, provided that he does not inconvenience the patient.  He who visits the sick is as though he would take away part of his sickness and lighten his pain.  Whoever does not call to see the sick is as though he would shed blood.

5. A sick person should not be visited before the third day.  If his illness came on suddenly and his condition is growing worse, he may be called on forthwith.  He should not be visited either during the first three hours or during the last three hours of the day, because (during those hours), they who look after him are busy attending to his needs.  Those who suffer from intenstinal trouble or have eye trouble or headaches should not be visited, because it is hard for them to see callers.

6. One who visits a sick person shall not sit upon the bed, or in a chair or on a bench or any elevated place, or above the head side of the patient, but should wrap himself up and sit below the headside, pray for his recovery, and depart.

A.M. Hershman , translation, "Book 14, the Book of Judges" in Code of Maimonides, (New Haven, Yale University Press).

Ahmed Nezar Kobeisy, "Shame in the Context of Illness - An Islamic Perspective"
Shame: Introduction
Table of Contents

Published: September 17, 2004