(Photos: Jeff Zorabedian)

Have you ever experienced the symptoms of burnout — whether physical, like fatigue, headaches, or stomach pain; emotional, like obsessive thinking and feelings of guilt or sadness; or mental, like a clouded mind and perfectionism — to the point that your seemingly successful life was stopped in its tracks?

Rabbi Alon Gul, a Five Towns-based social worker who overcame a personal bout of burnout and went on to become an authority on the phenomenon, knows exactly what it feels like.

I first met Alon back in 1994, when he was a shy ninth grader in the Gemara class I taught at HAFTR High School in Cedarhurst, New York. It was many years before I encountered his name again, when I was learning one day in Yeshiva Sh’or Yoshuv and opened a volume of Chiddushei Rav Akiva Eiger on Bava Metzia that had belonged to him; from the copious notes in the margins, it was clear he’d been through the entire sefer. But that was already the happy ending of the story. As I was to learn, the middle was a labyrinth of pain and confusion.

“I was 19, learning nonstop in yeshivah in Eretz Yisrael, when I burned out to the point where I couldn’t learn anything,” he remembers. “I started getting headaches and feeling tired, which I thought came from learning too much and sleeping too little. But it just kept happening, until finally, my body just shut down and my mind got fuzzier and slowly stopped working.

“I left yeshivah and couldn’t do much at all. People experience different levels of burnout, and mine was pretty extreme. I figured there had to be a way out of the hole I was in, and spent a couple years searching for a way forward. Slowly, I eased back into learning but the strong headaches and fatigue lingered. I went to neurologists and took CT scans that turned up nothing.”

Then Alon attended a lecture that would change his life. It was a talk that’s given each month by Rav Elya Katz, longtime rebbi in a prominent Brooklyn yeshivah, in his Boro Park home, free and open to all. Rav Katz has been giving these lectures for 14 years, ever since his wife, wracked by excruciating back pain, was rendered pain-free by following the “Sarno method,” an approach to banishing physical pain developed by the late Dr. John Sarno of New York University Medical Center’s Rusk Institute. For Alon, as for many religious Jews among the untold thousands who’ve been helped by the Sarno method, the road to recovery began in the Katz basement.

Dr. Sarno’s view is that the underlying source of much of the physical pain people experience is not in the body but in the mind. That’s not to say that the body doesn’t exhibit actual physical symptoms, but that the brain creates physical pain as a distraction from deeper, unexpressed emotional stress, hurt, or anxiety.

After that fateful lecture, Alon was intrigued. “I read Dr. Sarno’s books and decided to apply his method to my own health problems. My headaches and fatigue receded, as did my high blood pressure. Even the lactose intolerance I had recently developed disappeared. I’ve been chronically afflicted with head colds, but I learned from Dr. Sarno that stress can play a role in shutting down the immune system. I rarely get sick anymore.”

But Alon also exhibited a tendency that, according to Dr. Sarno, is a prime cause of the internal anger and anxiety that are at the root of much physical pain: perfectionism — the need to be flawless and do everything in the ideal way. Indeed, Dr. Ira Rashbaum, a student and successor of Dr. Sarno at the Rusk Institute, authored a chapter in Dr. Sarno’s final book, The Divided Mind, where he writes: “I have worked mainly with rabbinical students… often referred to me by senior rabbis in their communities. They relate easily to the notion that their chronic neck/back pain is a reaction to their extreme perfectionism and not the long hours studying at a desk.”

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ho was this doctor whose teachings are now being explored more than ever, especially in today’s frum world where certain emotional stressors might be having a debilitating effect on people’s health?

Once upon a time, John Sarno — who passed away last summer a day before his 94th birthday — had traveled the same path to self-knowledge and freedom from pain on which he later helped thousands of patients embark. Standing just 5’3”, with strikingly bushy eyebrows and a kindly, slightly ill-at-ease demeanor, Sarno (not Jewish, although he was born in Williamsburg) was a Columbia-trained physician who practiced at NYU Medical Center’s Rusk Institute of Rehabilitation Medicine and served as Professor of Rehabilitation Medicine at the NYU School of Medicine.

He began his medical career dispensing the conventional diagnoses and treatments for back pain he’d learned in med school. But when different therapies such as heat therapy, injections, and surgery didn’t seem to bring relief to his patients, and when months of excruciating pain dragged on into years, Sarno became increasingly disillusioned.

He began seeing a psychotherapist, seeking to explore the rocky terrain of his subconscious, with its mountains of anger and craters of sadness and low self-esteem. Slowly, he started to wonder whether a set of physical ailments he himself had been unable to shake — piercing headaches, irritable skin, and a sensitive stomach — might be linked on a deeper level to his emotional state.

When making that mind-body connection seemed to bring him unexpected relief, Dr. Sarno took the next, logical step, applying the same approach to his patients at NYU. He began to spend a great deal of time speaking with his patients, learning about their personal histories, and taking note of their personalities. His observations yielded two consistent conclusions: Overwhelmingly, his patients displayed the traits of perfectionism and “goodism,” and had a history of minor gastrointestinal maladies and other tension-induced conditions like migraine headaches, eczema, and frequent urination.

And for the first time, instead of tracing the source of their pain to pinched nerves and slipped disks, he began prodding them to probe what underlying emotional pain they might be experiencing. He explained to them that the pain they had experienced was real, not just “in their heads.” What was decidedly not real, however, but an illusion promoted by the medical establishment, was the idea that the cause of back pain was something structural like a bulging lumbar disc or joint arthritis or the vague catch-all explanation — “inflammation.”

He’d patiently counsel them about something he called Tension Myositis Syndrome (TMS), which sounded a bit like science fiction: that the body’s autonomic nervous system, which operates independent of the conscious brain, was directing the flow of blood away from muscles, nerves, and tendons in various parts of the body, resulting in mild oxygen deprivation. This was the doing of the subconscious mind, which sought to create the physical sensation of pain in order to distract a person from feeling the more threatening psychic pain pent-up inside him.

Dismissing MRIs showing structural damage to the spine, which he termed “normal abnormalities,” he’d cite the numerous studies showing that identical features could be seen on the scans of thousands of other people who had no pain at all. He contended there was no evidence that pressure exerted by discs on nerves was the source of back pain, and thus, cutting away those discs was pointless.

Sarno observed that when a patient had his pain treated with surgery, physical therapy, and the like, it often reappeared in another area of the body. He took this as evidence of a phenomenon he called the “symptom imperative,” meaning that when the brain’s attempt to use physical pain to distract from emotional pain failed, it simply moved on to employ the same strategy elsewhere in the body.

When other doctors would warn that failure to undergo surgery and continuing to engage in strenuous physical activities would bring further damage, even paralysis, Sarno would tell his patients to ignore the doomsayers. He advised them to cancel surgery, discontinue physical therapy and chiropractic work, put away their lumbar cushions and heating pads, and carry on normally with physically active lives. To do otherwise, he believed, would send the brain mixed messages that the pain was coming from both structural changes in the body and TMS, and that would prevent his approach from helping rid the body of that pain.

He was a vocal critic of mainstream physicians, whom he felt weren’t merely failing to correctly diagnose the source of pain, but were exacerbating it. By declaring these conditions severe and chronic, and warning patients not to engage in regular life activities, they were unconscionably ramping up in patients’ minds the very anxiety and fear that he believed were the real causes of the pain in the first place.

At the same time, however, he would advise his patients that accepting the TMS diagnosis did not preclude taking painkillers. His approach was intended to eliminate future pain by recognizing its true source and thereby defusing their fear of it, but that didn’t preclude finding immediate pain relief.

Sarno’s long-term prescription — surprising in both its novelty and simplicity — boiled down to this: “Don’t be misled by the excruciating spasm your brain has engineered. It doesn’t mean you have a disease…. Know about the anger, and know why it’s there. And if you do those two things, your pain will go away.”

He spoke of three primary sources of subconscious pain: childhood anger and sadness; personality traits, like people-pleasing and perfectionism; and the tensions inherent in aspects of everyday life, like relationships and work. Once a person recognized his pain for what it really was — a ruse of the subconscious mind to distract him from consciously feeling his anger or anxiety — it no longer served a purpose and would go away.

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nd indeed, patient by astonished patient, the pain began to recede, and oftentimes disappear entirely. Their lives, which had once revolved around agonizing pain, were being returned to them.

For some, this happened just by reading one of Dr. Sarno’s books and absorbing his ideas, while for others it required weeks or months of working to convince their conscious minds that there was no real connection between their pain and their diagnoses of physical abnormalities or ailments. And for yet others, psychotherapy was necessary to uncover the long-suppressed traumas from which their brains sought to distract them with physical pain.

To his many grateful patients, Sarno was a true hero, but his own life never followed a fairy-tale script of the lonely champion of long-suffering patients who comes in from many years in the wilderness to win professional acclaim. He’d refer to himself with resignation and a touch of bitterness as a “heretic” of the medical establishment and, in turn, it treated him precisely that way.

After John Sarno’s passing in June 2017, Sam Dolnick, a New York Times assistant managing editor and self-described “Sarno believer,” wrote about his recollections of the doctor. Suffering from severe back pain when in his thirties, he was headed for spinal surgery but went to Dr. Sarno for a second opinion. “Limping into his office, I found a tiny, owlish man sitting behind a giant wooden desk. It looked as if his lab coat might swallow him, leaving behind just a pair of heavy, dark-rimmed glasses. He asked why I had come to see him, and I described my problems with my back and then with my life.

“He was kind and inquisitive but firm. He had seen people like me before. ‘There’s nothing wrong with you,’ he said. ‘Don’t have surgery. Stop acting sick. Your back is fine, and so are you.’ He gave me his book, and I watched his videos… but mostly I tried to stop treating myself like an invalid. I threw away the back braces, started playing basketball again, and watched, amazed, as the pain gradually went away. I can’t say that I quite understand what happened with my back, but Sarno believed that I was suppressing a white-hot anger I could not articulate.”

It’s tales like that one that earned John Sarno legions of devotees who say they owe their happy, pain-free lives to him; there’s even a website filled with their emotional testimonial tributes to him. But Dolnick says Sarno was also a tragic figure, a “medical laughingstock” who ate alone in the NYU cafeteria while colleagues huddled at other tables. He was ignored at his department’s monthly meetings and fellow doctors wouldn’t refer patients to him.

He responded in kind, bypassing the normal route for gaining peer acceptance through research and case studies (although he did publish two patient follow-up surveys, and a student, Dr. David Schechter, published a 2007 peer-reviewed study). Instead, he wrote four nontechnical books for public consumption, which sold over a million copies between them. Having a number of celebrity patients who swore allegiance to him also helped raise his public profile.

Although Sarno conceded that “99.999% of the medical profession” rejected his views, here and there physicians did embrace the TMS approach. His book, The Mind-Body Prescription, featured a plug from the vice-chairman of psychiatry at NYU attesting that the author had “cured thousands with debilitating chronic back pain,” and a later book, The Divided Mind, included six chapters written by other physicians who use the TMS approach in their own practices.

Still, his certitude that he was right about his diagnosis of pain, and the rest of the world terribly wrong, apparently didn’t provide him with inner peace. He’d always had self-described “substantial problems with self-esteem,” Dolnick writes, and being marginalized professionally only made things worse. “His colleagues” slights ate at him. His suppressed rage at the constant disrespect made him physically sick; an itchy, agitated exhibition of the very mind-body connection he championed. ‘I can’t stand not being recognized!’ he said in a 1994 interview. ‘I hate it!’ ”

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lon Gul’s own dark days spent wandering in the land of the burned-out eventually led him to ponder further: What if perfectionism is also a culprit in the phenomenon of burnout? He decided to informally survey many friends he knew who had gone through experiences like his, and they admitted to being driven and perfectionistic.

Eventually he published Overcoming Burnout (with a foreword by Rabbi Dr. Abraham Twerski), a guide for diagnosing, addressing, and preventing burnout that emphasizes the central contributing role of perfectionism. In some yeshivos, he’s been told, it can be found in many a dorm room.

Elaborating on the connection between perfectionism and anger, Gul says, “Dr. Sarno believed that a lot of pain is the result of repressed anger. But why do people repress their anger? Because they know it’s wrong to get angry and since they think they can control getting angry, they feel bad when it happens and try to keep it down.”

Gul explains that a perfectionist feels bad when things he believes are in his control go wrong — like getting angry — because he’s thinks it’s his fault. But at that moment, while he’s feeling angry, that’s not something he can control. What is in a person’s control is to work on himself over time not to get so angry. Instead, though, people repress their anger and end up feeling it as physical pain somewhere in the body.

The same dynamic is at work, he says, in the yeshivah setting. A bochur with perfectionistic tendencies may tell himself, “I can’t waste time.” But it’s not realistically within his control to not waste time at all; everyone does, if only in order to relax and mentally recharge. Or he may say, “I need to understand this Gemara,” and because he believes it’s within his control to do so, he’s going to feel a lot of anxiety over whether he’ll be able to grasp it. If that happens every time he sits down to learn, the pressure builds day in, day out, and after a while, he’s going to start feeling burned out.

Although Dr. Sarno’s theory of TMS addressed musculoskeletal pain specifically, he referred to a wide spectrum of other physical conditions as TMS equivalents whose purpose, like TMS, is to distract from underlying emotional pain of which a person is unaware. In The Divided Mind, Dr. Sarno writes that even purely emotional conditions like depression and obsessive-compulsive disorder could function as TMS equivalents.

In his own therapy practice, Alon Gul has implemented the Sarno approach to successfully treat conditions ranging from irritable bowel syndrome to addictions, and is at work on another book detailing his experiences. He has also seen success in greatly reducing, though not eliminating, the symptoms of ADHD, which he believes can also act to distract from deeper anxieties.

Still, treating burnout and unexplained fatigue has become somewhat of a mission for him. “Feeling tired all the time may seem to come from lack of sleep, but even those who get a good night’s sleep still feel tired,” he says. “The reason is because the body feels fatigued to avoid repressed feelings.”

Gul explains that once the person delves into these feelings in a safe, responsible framework, the fatigue will usually dissipate. Headaches, he says, are also a common result, but are usually just doused with Advil. “Did you ever notice that some people get sick all the time?” he asks. “I’ve seen time and again how people can limit their sickness to a minimum if they deal with their feelings.”

Does Gul make an equation between the perfectionist tendencies and personal demands of the Torah-observant world and burnout? Not really, he says. Being frum in and of itself has nothing to do with having emotional burnout, but he explains that a person who is driven by perfectionism will have a harder time coping with environments that are more demanding.

“A demanding yeshivah will have more people with burnout than a relaxed yeshivah,” he notes, “and a person who is frum will have more demands on him because there are more halachos to follow. But a person who understands what he can’t control will not be unduly affected by the pressure. Even someone in the public eye who understands that he can’t control what others think of him will be able to let go of that stress.”

Gul says that even though many sufferers might entertain Dr. Sarno’s methods, there is a certain fear that they’ll be labeled as “crazy” if their pain stems from a psychological source. “But,” he says, “does anyone feel bad for going to the doctor for any of these physical problems? Not at all — that’s considered normal. As bizarre as it sounds, a person would rather suffer from burnout than admit he has burnout because that will make him feel abnormal. I see this type of denial all the time. But now that we have a handle on how all these chronic physical pains are sourced in painful feelings and unresolved emotions, we don’t have to be embarrassed about the emotional turmoil. Everyone in the world has some emotional pain. It’s totally normal.”

Sometimes it seems like the only valid way to take a break from the pressures of life is if a person is in physical pain, and, Gul acknowledges, people really do receive more sympathy when they have physical pain. If you’re feeling stressed, no one wants to hear that it’s preventing you from pushing forward, but physical pain gets you off the hook.

“It’s ironic,” he notes, “because now that we know how stress causes physical pain, there should be more sympathy. Still, if someone doesn’t make it to minyan because he’s overwhelmed and suffering from burnout, he’ll have much less sympathy than if he has a backache.”

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nder the Sarno approach, freedom from pain and how fast it comes back both depend on how completely a pain sufferer is willing to put aside everything he’s been taught about the physiology of pain and how to eliminate it, and instead embrace the reality that the pain is unrelated to his body’s physical condition.

Rabbi Benzion Scheinfeld has spent over two decades teaching at New York-area yeshivah high schools, but he’s also a sports enthusiast who runs a summer ski and travel camp for Modern Orthodox teens. In May 2017, he spoke to an audience of 1,000 people at a ceremony in Crown Heights honoring Dr. Sarno on behalf of his many patients.

A self-described “real skeptic, who needs to understand how things work before I accept them,” he injured his back 23 years ago while dancing at a high school shabbaton, resulting in searing pain that worsened to the point where he couldn’t bend down to take off his socks and often had to crawl to the bathroom at night. Sports and skiing were out of the question; he struggled to perform daily tasks like dressing and getting into and out of his car.

“The pain was not receding, and I finally went to a respected, cautious orthopedist who generally did not suggest surgery, but after seeing the herniated and fragmented L-4 L-5 disc on my MRI, he reluctantly told me that only an operation would enable me to lead a normal life. I spent months trying to avoid surgery by getting second and third opinions and pursuing alternative solutions.

“Then I heard about a doctor in New York who spoke to you and fixed your back, which sounded like the most ridiculous thing I had ever heard. In desperation, I made an appointment with Dr. Sarno. After doing a thorough examination and looking at my MRI, we sat down in his office and he said to me, ‘Son, there is absolutely nothing wrong with your back.’

“He said he could find hundreds of people walking around outside right now with the same MRI as mine who don’t have any back pain, and that my pain was emotional, not physical. I didn’t believe him, but, hedging my bets, I asked, ‘So how am I going to get better?’ He asked me, ‘What do you like to do?’ ‘Play basketball and ski,’ I said. ‘Then go skiing!’ he responded.

“I almost couldn’t believe my ears: Every other medical professional I’d consulted told me that if I’d ski I might become paralyzed — and Dr. Sarno had just told me that to get better I needed to go skiing!

“It was all too much to integrate. I attended his seminar for new patients and asked so many questions that Dr. Sarno told me we would have to meet in private if I needed to ask him anything else. I left the seminar intrigued but thoroughly unconvinced. Two days later, my back pain went away — forever. I canceled my surgery and resumed all sports activities. I’ve affected the lives of many others by sharing my experience with what I call ‘sheker pain,’ the physical pain meant to distract from emotional stress.”

Of the six physicians who contributed chapters to Dr. Sarno’s The Divided Mind, three have dual practices, offering treatment based on the mind-body connection to receptive patients and conventional treatment to the majority of their patients who won’t accept a diagnosis based on the TMS concept.

But why wouldn’t someone experiencing the misery of acute, chronic pain opt for a path to recovery that is within their grasp and does away with the need for risky and expensive procedures and medications? For some, it’s the stigma associated with anything smacking of psychology; for others it may be the implication, however mistaken, that their pain is somehow not real or that they’re to blame for it.

“People have major defense mechanisms,” Gul explains. “They’re afraid they’ll be considered ‘crazy’ if their pain has an underlying psychological source. And it also makes them feel bad if they realize they really are living with unexplored emotional pain. But in truth, everyone in the world has some emotional pain. It’s totally normal.”

From Gul’s experience, people would rather believe that their problem is purely physical than accept that there is some emotional trigger, that it’s somehow their “fault.” Physical pain seems somehow more objective and guiltless. “When people realize that feelings that come up are also not their fault, they become more at ease with the method,” he says, noting that Dr. Sarno wasn’t the first one to come up with the idea. “Actually, it’s brought down in sifrei Kabbalah how illnesses come from the stress of bad or unresolved feelings.”

But the role played by the vast majority of doctors and other health professionals in dismissing out-of-hand approaches like Dr. Sarno’s cannot be overstated. In the current issue of Psychology Networker magazine, Dr. Howard Schubiner, an internist who adopted the TMS approach under Dr. Sarno’s tutelage, describes the powerful disincentives of the medical community to change their diagnostic and treatment paradigms:

“Not a day goes by that I don’t get asked by a patient: Why didn’t my doctors mention this?.... Medical professionals who treat people with chronic pain — including physicians, physical therapists, and chiropractors — are used to focusing solely on the physical body…. It’s hard for these professionals to adapt these views without substantially changing their practices and source of income.

“Chronic pain costs more money and affects more people in the US than cancer, heart disease, and diabetes combined. Revenues from chronic pain treatment currently support a significant portion of the medical economy. More than 500,000 spinal fusion surgeries are done each year in the US. It’s unclear how many of those are medically necessary, but many of them are based on the traditional view of pain and outdated interpretations of MRI testing.”

Is the Orthodox Jewish community an exception to the prevailing societal skepticism about mind-body approaches to medicine in general and the Sarno method in particular? Perhaps the religious life of frum Jews predisposes them toward greater openness to countercultural wisdom and alternative modalities. But then again, given their naturally conservative tendencies and hard-to-shed wariness about psychology, perhaps not. —

— Rachel Ginsberg contributed to this report

Tips for Tricking Your Physical Pain

• Awareness. Try be aware when you feel physical pain coming on. Is there anything stressful happening that you’re thinking about?
• Acceptance. When you feel physical pain, accept the emotion and tell yourself that this physical pain is a distraction from your feeling. The usual suspects are pressure, anger, or anxiety. If you’re not sure which one, just tell yourself, “I accept that I’m stressed.”
• Exposure. Take time once a week to either write out or talk out (to yourself privately) any underlying feelings of anger, pressure, or anxiety. This helps to bring it to your awareness so that your mind doesn’t try to distract you with physical pain.
• Behavior modification. When you start to feel your physical pain go away, go back to your daily routine, and use that part of your body like in the past when you were pain-free.

How to Beat Burnout

• Let go of what is out of your control, or else you will feel pressure and anxiety. Not everything is your fault so you don’t have to control it. Remember that as much as we do the work, we don’t control the results. Hashem is in charge.
• Don’t be hard on yourself when you make mistakes. This fear of failure also causes pressure and anxiety. Rather, try to be understanding toward yourself. Accept that you did something wrong and try to fix it without putting yourself down.
• You don’t have to live up to anyone’s expectations. If someone is judging you, it’s their issue, not yours. If you accept everyone’s judgement, you will feel anxiety and pressure to do more than you can handle.
• Take breaks as needed and learn to be aware of when your body needs to rest.
• Don’t give up! Hashem will help you find a way out of burnout.

(Originally featured in Mishpacha, Issue 743)