Bitul Ha-yesh

Every medical student, I am told, is assigned at some point to read the article referred to as “The Hateful Patient.” Writing in the New England Journal of Medicine, Dr. James E. Groves describes four different kinds of “hateful patients” that a doctor may encounter over the course of his or her career or more likely, his or her day. Beyond the medical condition for which these individuals have ostensibly come to see their physician, these patients also exhibit a variety of other pathological conditions. Specifically, Dr. Groves identifies four distinct patient typologies: the “dependent clingers,” the “entitled demanders,” the “manipulative help-rejecters” and the “self-destructive deniers.” The “dependent clingers” demonstrate an intrusive and persistent pattern of reliance on the doctor, well beyond normal doctor-patient relations. The “entitled demander” is a patient who like the “dependent clinger” exhibits an excessive and unhealthy neediness from health care professionals; however, they combine it with “a repulsive sense of innate deservedness,” a notion of entitlement that if not sated, turns hostile with threats of litigation, withholding payment and otherwise. We can go through the entire list another time, but the point of the article is not only to identify types of patients, but to give doctors the tools with which to administer care to such problematic individuals. The full title of the article is “Taking Care of the Hateful Patient.” The focus of Dr. Groves’ concern is the deleterious effect these “hateful patients” have on physicians. By exhausting a doctor’s reserves of patience and good will, such individuals evoke negative feelings in caregivers, resulting in anything from a diminishment of empathy to clouded medical judgment to outright abandonment. A physician cannot necessarily control who enters his or her office, but must nevertheless seek to extend the best care possible. Groves’ article charts a way for a doctor to identify the tell-tale signs of a “hateful patient,” resist the tendency to personalize the patient’s destructive behavior, and in that awareness, find the tools to re-channel the understandable urge to confront or counterattack. (NEJM, Apr 20; 298(16):883-7).

Given the blessing of a Bat Mitzvah whose mother and father are both physicians, I have to imagine that while everyone here may not be familiar with the article itself, many here are well familiar with the world it describes. The truth is that everyone who works with people on any level – physicians, lawyers, teachers, investment advisors and even rabbis – all face “hateful patients.” These are individuals to whom you wish no harm and to whom you are, by virtue of your relationship, expected to extend care, but their behavior makes you disinclined to do so. Some defect in their disposition causes you to recoil with negativity. In all these interactions, the difference between failure and success, between anger and shrugging off the offense, is the same self-awareness that Dr. Groves counsels to physicians. There is a split second in which one must both sublimate one’s own ego and seek to understand the pathos of the “hateful person” and that makes the difference between whether we let another person’s behavior cause us injury or whether we use that awareness to deflate a potentially volatile confrontation.

It is impossible to go very far into your day without believing yourself to be victimized by another. Someone stole our taxi, cut in front of us in line or did any number of things New Yorkers do to each other every day as an expression of being … New Yorkers. Some of these infractions are done intentionally and some are an unfortunate consequence of living in a Darwinian universe of the survival of the fittest. Most of these wrongs are not committed personally against us, but that is a very hard truth to bear when we are standing in the rain having lost our taxi. But no matter what the wrong may be, most often, as with the hateful patient, the root cause of our anger is not actually situated in us, but in a character defect of the offending party. All of us, I hope, can recall an instance when we have been on the receiving end of the sting of a person’s hurt, but rather than counter with our own anger, we have found ourselves feeling sorry for the other person. We realize that a person’s condition, no matter what its toll may be on us , is actually far sadder and more enduring for them. Sometimes, our anger actually turns to compassion for that person, or for that person’s family, who has to deal with that flawed individual every day. Our hurt, inevitably, will fade, but that person will remain trapped in his or her condition long after we have left the room. It happens to me as a rabbi not infrequently. I am called into a family situation – there has been an unspeakable loss – and the aggrieved, understandably, believe the world and God to be unfair. I may not even have known the family until I walked into the room, but in that moment, a man or woman of the cloth becomes a target for all sorts of hostility. All of which means, that if you want to last more than a week in the rabbinate, you need to learn very quickly how to say to yourself, “This isn’t about me. This is not personal and I am not, under any circumstances, taking the bait. I will react with compassion, with kindness, and I will be, above all, a mensch. God knows – the things these people are saying, compared to the hurt they are feeling – how very lucky I am to be able to go home and tuck my kids in at night.”

And yes, if I could bottle whatever it is that enables one to redirect hurt away from one’s ego and leverage it into compassion, believe you me, I would. I would, and I would sell it online – and probably make enough money to sponsor a kiddush or two – for all of humanity. To sublimate ego, to prevent narcissistic injury – that is a task far easier said than done. Probably the closest our tradition comes to recognizing this task is in this week’s parashah, with the introduction of the Nazirite, an individual who, by way of self-imposed vows, acquires an elevated plane of spiritual existence. The regimen prescribed for the Nazirite is not one of total abstinence, asceticism or self-mortification. Rather, the Nazirite vows were meant to induce a paradoxical state of both attunement and detachment. The behavioral adaptations were meant to run parallel to a spiritual transformation whereby the Nazirite could transcend the pettiness of ego, becoming at one and the same time, both more and less in touch with humanity – his own and that surrounding him. Unlike a kohen, there was nothing inherently special about the Nazirite, but by his choice to be kadosh l’Hashem, “Holy unto God,” the focus of his spiritual energy was directed away from the punch/counterpunch of a rough and tumble human existence.

If the very goal of the Nazirite regimen was to subdue the self in order to be raised up to a transcendent spiritual plane, then it is precisely by this criterion that the anti-hero of our haftorah, Samson, misses the mark. The instructions in the haftorah were clear. Unlike every other child born into this world, Samson’s arrival was preceded with a list of do’s and don'ts, all of the things by which the oracular promise of his Nazirite status could be fulfilled. But though he grew, Samson never actually matured. To say that this skirt-chasing, hard-partying judge fell short of expectations is an understatement. But flawed as he was (and he was), Samson’s foundational imperfection was that for all his physical strength, he lacked the inner strength to control his impulses. Every one of his battles, as the scholar Edward Greenstein explains, takes the form of a personal vendetta. His impetuous and impulsive nature made him interpret every wrong as a personal affront against him. Whether it was setting the fox tails on fire or killing thousands of Philistines with a jawbone, time and again he takes vengeance, when he could have and should have just walked away. And throughout it all, Samson never seems to see or absorb the effects of his own actions. Blinded by his captors, Samson’s final act is one of vengeance, a triumph that tragically comes at the cost of his own life. Mighty as Samson was, even mightier was his ego. And it was his ego, as much as the pillars themselves, that brought his life to a crashing end.

Samson’s personality may have been larger than life, but the narcissism that led to his downfall touches close to home, his superhuman fall altogether akin to our own flawed humanity. Like Samson, our egos are still in need of a Copernican revolution, a realization that no one of us sits at the center of the universe. It is so easy to walk around in this world believing that your hurt must be the result of malice and ill will. How could it be otherwise if I believe everything is about me? A good first step towards spiritual rehabilitation is to forgo the unhealthy insistence that we are the lead actors of the narratives in which we live. We are all bit players, supporting players in a script much bigger than any one of us. In the Hasidic tradition, there is the mystical ideal of bitul ha-yesh, translated roughly as “self-nullification.” It is a state of being filled paradoxically with both confidence and humility, indifference and engagement, whereby an individual is able achieve a mystical state of serenity. Not unlike what some eastern religions counsel, and in the same way as the biblical Nazirite, we subvert our egos from being all-consuming. It goes by many names, in many languages, but the easiest way to describe it may be by using a word we all knew before we walked into this sanctuary today, and that word is “maturity.” It is in this maturity that we become more attuned to the things in life that really matter. It is not all about me, not everything needs to be taken personally, not every hurt is worthy of our attention, and not every wrong is in need of being righted.

According to tradition, the darkest moment of our people’s history, the destruction of the Temple, resulted from causeless hatred – in Hebrew, sinat hinam. The Talmudic story goes that once upon a time, a wealthy man was hosting a feast and he sent his servant to deliver an invitation to his good friend, Kamsa. Mistakenly, the servant delivered the invitation to a man named Bar Kamsa, a man who was actually a sworn enemy of the host. When Bar Kamsa arrived at the party, the host publicly ordered him to leave. Despite Bar Kamsa’ s pleas, including an offer to pay for the entire party, the host humiliated him and sent him away. Shamed, Bar Kamsa sought revenge against the rabbis who sat idly by as he was embarrassed, and went on to engineer a complex vendetta that ultimately led to the Roman destruction of the Temple. How striking that at the root of this story describing the start of our people’s two-thousand-year exile was the causeless hatred of individuals unable to overcome the narcissism of turning every injury into a personal affront. How different our history would be if these individuals had been able to put aside their egos and attend to the things that really matter.

Given such a telling of our people’s history, we can understand why some two thousand years later, the first chief rabbi of Palestine, Rav Kook, explained that if the Temple was destroyed due to causeless hatred/sinat hinam, its rebuilding can only come by way of ahavat hinam, causeless love. In other words, only when individuals are able to restrain themselves from the vicious cycle of attack and counterattack, and even go so far as to counter an attack with unfounded acts of love, then and only then will redemption come. (Orot Hakodesh III) It is a big ask – I know. But perhaps this Shabbat, we can begin with those of us in this room, or maybe just ourselves – to allow for the possibility that it is not always about me, to lessen our egos and thereby enlarge our hearts. In doing so, perhaps we can bring this world one small step closer towards redemption.