Shame, Guilt, Anger and Rebuke in 21st Century Medicine

Were you ever taught how to rebuke? If not, how do you know what to do? How well are you doing at the task? Are you "bearing sin?" "Hating your brother in your heart?"

Have you seen the verse from Proverbs come to life in your practice?

Guilt, not Shame: A better way?

The most primitive experiences of shame are "connected with sight and being seen," but it has been interestingly suggested that "guilt is rooted in hearing, the sound in oneself of the voice of judgement; it is the moral sentiment of the word."

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Judaism, with its belief in an invisible God who created the world with words, is an attempt to base the moral life on something other than public opinion, appearance, honor, and shame. As God tells Samuel, "The Lord does not look at the things people look at. People look at the outward appearance, but the Lord looks at the heart" (I Sam. 16:7). Hence the ethic of the divine word; hence the key term in Judaism, Shema: "hear" or "listen." Hence the importance of the inner voice, of conscience, of guilt rather than shame; of repentance, not rejection; of forgiveness rather than appeasement; of the integrity of the individual regardless of his or her deeds.

- Lord Rabbi Jonathan Sacks, "The Return of Public Shaming." Morality. Basic Books: New York, 2020. pp 211-12.

Think of parallels in clinical practice for eliciting the kind of non-shameful guilt, the "inner voice of conscience" and the "integrity of the individual regardless of ... deeds" and discuss their effectiveness.

Comment on the difference between the type of shame discussed in the prior sources and the shame discussed here:

1. What is the text teaching us about words that shame?

2. On what grounds is that shame being inflicted?

3. Where do we encounter this type of shame in practice?

(Credit: Shoshanna Barnett, who included these sources in her lesson entitled "Min HaMetzar: Fat Liberation in Torah and Community," March 16, 2024, Congregation Beth Shalom, Pittsburgh, PA)

What types of speech constitute verbal abuse, according to Bava Metzia? (to really ace Talmud study, identify which Rabbi holds which opinion as you share - knowing the "system" of each rabbi and getting to the heart of the way they think is a major goal of diving into these waters).

How do these link to clinical practice?

This section of Talmud is a source text for one of the texts we examined before - do you think that text (Sefer ha Chinuch) remains faithful to the intent of this one? What is the same or different?

What is the role of anger in clinical practice? Reflect on where anger has crept into your work over the past 5-10 years. What about prior to that time. Is there a difference? How should one handle this emotion?

Definitions:

Torah - either the Five Books of Moses (first five biblical books, Genesis through Deuteronomy), or more generally, "teaching," a term referring to the whole of rabbinic Jewish learning, or the "Torah" of a specific topic (Torat HaMusica, for example). The remainder of the Hebrew Bible consists of the Prophets (Joshua through Malachi, referred to in Hebrew as Navi or Nevi'im) and the Writings (Psalms through Chronicles, referred to in Hebrew as Ketuvim).

Mishna - first layer of oral law and legend, 1st to 2nd c. CE. It tends to be very concise and organized and describes both the law as most people practiced it - and how some dissenting rabbis did it their way. The Mishna often, but not always, links its legal rulings to a verse in the Bible - usually Torah (where the actual commandments are given), but occasionally elsewhere, especially when speaking more about character traits or custom rather than concrete law.

Midrash - a variety of compilations of legend, often "filling in the blanks" in Biblical stories. Sifrei is one example of these, specifically about the book of Leviticus

Gemara - the extensive discussion of the content of the Mishna that, together with the Mishna, makes up the Talmud, 3rd-5th c. CE. Much, but not all, of the Gemara tries to reconcile differences of opinion from the Mishna by explaining them as referring to two different situations. Two versions exist, the Yerushalmi (also called Palestinian or "Eretz Yisraeli") and the Bavli (Babylonian). The latter is the more authoritative and widely studied of the two, as the Jews remaining in Roman Palestine after the destruction of the Temple, and especially after the Hadrianic persecutions, became more and more impoverished and scholarship gradually migrated to Bablyonia. Both of the Talmudic tractates quoted from here are from the Bavli.

Halakha - "the way" or "the going," the Hebrew word for the way Jewish law and tradition is practiced. "The" way may be too strong of a word, since there are different opinions on almost everything, but there is usually some range of things that are normative and things that fall outside of the norms. Traditonal Jews (pre-Enlightenment in Europe and into the 20th century in non-Western settings) all considered themselves obligated to follow halakha, or to use another word, the "mitzvot," commandments. In modern times, Jews who identify as Orthodox still hold to this obligation; the Conservative/Masorti movement identifies itself as halakhic as well, and many Jews both in that stream of Judaism and who do not choose to label themselves as such take on that obligation as well.

Works of Halakha: The Mishneh Torah (literally "second Torah" - also called the Yad haChazakah, "strong hand"), was Maimonides master work of halakha from the 12th century, one of the earliest attempts to write a complete, thematically organized legal code (the Mishna is thematically organized, but the Gemara has such severe ADHD that the theme is often lost for pages at a time). Sefer ha Chinuch is a 13th century work of halahka from Spain enumerating the mitzvot (613 of them, to be exact) and explaining both the accepted practice of each and the moral ideas behind them, based on Maimonides' list of the same type a century earlier.

Other codes of law not cited in this lesson include the Arba Turim ("Four Columns"), the Shulhan Arukh ("Prepared Table," a work of law for the Sephardic communities that even has an addendum for Ashkenazi Jews called the Mapah, "Tablecloth!"), and the Mishnah Berurah ("Clear Teaching"). These are supplemented by individual responsa (answers to questions) by later rabbis. Legal codes and responsa usually go into great depth to answer the question at hand, and their conclusions are built on sources from all the different layers of the tradition I listed - including other legal codes and responsa that came before.

Perhaps the most celebrated responsum of my lifetime? The one that pronounced quinoa to be fully Kosher for Passover, to which one rabbi reacted, "Well, now I know how the four letter name of God (yud-heh-vav-heh) is pronounced - Yahoo!!!!" Meanwhile, my personal favorite responsum was one answering the question asked by a group of Jews in far eastern Russia in 1943 who had fled the war and couldn't figure out what day to celebrate one of their holidays - because they did not know for sure which side of the international dateline they were on according to the halakhic​​​​​​​ definition!