Dr Judith Guedalia

Out 'Darn' Spot: Another Case In A Neuropsychologist's Journal
         In Shakespeare's Macbeth, Lady Macbeth, plagued by guilt for her part in the killing of Duncan, utters the famous line "Out, Out  ['Darn'] Spot!" while in a state of almost manic sleepwalking. "The king and queen persist in imagining that physical actions can root out psychological demons, but the play is an exposition of how wrong they are" (Macrone 106).
         She was referred to assess if EMDR might help with her nightmares and fears.
         When she arrived, there was no way of knowing or understanding the depth of her, seemingly, irrational fear of elevators.
         Other psychologists using dynamic and traditional modes of psychotherapy helped her understand that what she felt was an irrational fear might really be her, unresolved and repressed, feelings of guilt surrounding her mom's recent death.
          These therapists explained that people, who lose a significant love object, frequently go through a period of suffering from guilt. Consequently the nightmares they develop of being "entombed" in an elevator could be seen as part of the "process" of empathizing with the person who died. This perspective of her difficulties was helpful for a while, she reported, but the feelings of choking and gasping for air soon returned to what they had been prior to therapy.
         "How do you think I might be able to help you?"
         "I was just at the pulmonologist for my belabored breathing and he suggested I speak to you as my lungs are as clear-as-a-whistle," she smiled ironically, all the while breathing with great gasps. "Can you help me get rid of this feeling?
         "A psychiatrist, Dr. X also referred me to you, but, if you don't mind, I won't use his name because I'm about to quote his Lashon Ha'ra about you. He wasn't very sure you could help me. He says that, though you are a senior-level psychologist, you don't follow the accepted ways of doing things." (My ears perked up, because, for the first time in the conversation, I detected a respectful tone in this "wannabe" patient.)
         "Also," she went on, "my grandson helped me 'Google' you and I really do think that the psychiatrist is wrong and you might be the very person to help me. I feel as though I am gasping for air and yet afraid to open my mouth to let the air in.
         "Do you see this spot on my neck - it may be hard to see today - at times it is a lot larger than other times. When I look in the mirror and see it I get a panic attack. I've been to dermatologists and plastic surgeons and they say 'it is all in my head,' a statement which makes me cry in frustration, anger and, most of all, embarrassment."
         My ears perked up at the word embarrassment.
         "I want to leave my room in the senior citizens hotel. Sometimes I do. But I can never leave the building alone," said this fashionably dressed and well-coiffed septuagenarian.
         This said, she sat back and waited to see if I would pick up the gauntlet. She gave the impression that not only was she an intelligent woman but one that could see the ironies of life and especially the peccadilloes (a slight fault) of others. I assumed that was the case, considering that I do like to be intellectually stimulated by a challenge.
         As she was relaying her story, I kept asking myself what is the Neuropsychology here? What is the Brain/Behavior Relationship? What type of "standard" neuropsychological assessment might "unleash" the answers to her behavioral/medical responses? Her responses to elevators seemed to relate more to be post-traumatic stress reactions than standard, unresolved mourning, or survivor guilt - though life has taught me that there is no "standard/normal" only many single cases!
         I asked her if she would bear with me and walk to the elevator bank further down the hallway from the Neuropsychology Unit, which is on the fifth floor at Shaare Zedek Medical Center in Jerusalem. She gave me a long, hard stare, and smiled and said: "Dr. X was right, you don't do anything anyone else does! OK, let's go."
         As we walked to the elevator she was breathing loudly, all the while, answering my questions about her visit to Israel. I told her that we would wait for an empty elevator, and that I would press the stop button at any point she felt she couldn't breath, and that we would only go down one floor.
         When the elevator arrived, she looked at me and grasped her neck with her hand, much like choking herself and, in a very small voice, said: "I can't do it, I can't even go in." I said "Fine," and we walked back to my office. I did notice, though, that she had finger marks on her neck. When we got back she took out her compact from her bag, and as she was re-fixing her face, she looked at her neck and said: "See, here are the marks again." She obviously had not recalled that she had squeezed her neck herself. "Hmmm, this sounded very promising," I thought to myself.
         Our time was up and we made another appointment for two days hence. I said I'd like her to pay attention to any daydreams, night dreams or nightmares she may have and jot them down till we would meet again.
         She came to our appointment on time, again looking very well dressed in a coordinating outfit of dress, shoes, hat, and handbag. She was also carrying a small notebook.
         She smiled, and proudly said: "I did my homework, I wrote down all my dreams, day and night, and though I am somewhat scared, I am also very excited about this meeting."
         Once I explained EMDR* and set up a "Safe Place" for her to imagine when any thoughts that came up might be difficult. I asked her to choose one of the dreams from the notebook as a focus of what would be our first EMDR session.
         She described an image of being in an elevator going to a wedding hall. There were other people in the elevator and it was a little crowded. She felt that she was being "pushed" into a corner. She began to breathe in a labored fashion. I continued to do the bilateral movements. All of a sudden, she stopped and said that something very odd happened. The elevator changed into her bedroom in her old house and the man next to her changed into her ex-husband.
         "Go with that" (pretty standard EMDR statement when things look like a break-though is about to happen).
         "I am upstairs, in the laundry room, I feel I am being pushed against the wall"
         Silence, then I whispered: "Go with that."
       She continues: " and all of a sudden, I see my ex-husband with his hands around my throat. He is trying to strangle me!"
       She is now perspiring profusely and breathing very heavily. Her tone of voice though, is strong, and gives the impression that she is both surprised and angry.
       "How dare he put his hand around my neck! You know what, I'm not so scared - I'm really angry with him for being drunk again. I had called the police the last time, but look what good it did! As soon as I realized he was drunk, and I was more angry than scared, I stepped on his foot really, really hard and ran out of the small laundry room to my bedroom and locked the door. I didn't want to scream and wake up the kids.
       "I knew in a few hours he'd come out of it and begin knocking on the door, crying that he was so sorry and that I should forgive him.
         "That night, before he woke up, I called the police and they helped me leave the house with the kids."
         She opened her eyes, looked at me with resolve and said: "You know, I haven't thought about that in 30 years, I put it out of my head. I felt I needed to move on. The police had taken pictures of the scene and the marks on my neck and testified in court for me. I got full custody of my children and moved on, until the breathing problems began."
       "Can you recall when the breathing difficulties began again?"
          "Yes, I was at a family wedding and my ex-husband's cousin (who looks a lot like him) walked into the elevator.
       "Oh my, the laundry room in my old house wasn't much bigger than an elevator!"
         Once again, I am in awe of the power of Hashem's creations, the strength of this woman to save herself and her children, in more than one way, in order to survive. Now, in her new home in Israel, she was starting life over again, feeling good about her independence and joining her children and grandchildren who had previously made aliyah.
          Her "declaration of independence" was achieved in a "breath-taking" moment. On the brink of a different independence, living in a new country - a new beginning, the circumstance of being in the elevator and seeing her ex's cousin, brought the buried - or I would say, "safe-deposit" memories - out into the open.
       We had a few more sessions, essentially consolidating what was achieved and, at the last one, she brought me a plant, which she had nursed to health and it was now flourishing, transplanted in a beautifully decorated pot.
        *EMDR - Eye Movement Desensitization and Reprocessing integrates elements of many effective psychotherapies in structured protocols, which are designed to maximize treatment effects. These include psychodynamic, cognitive behavioral, interpersonal, experiential, and body-centered therapies. See www.emdr.com 
Originally published in the Jewish Press on August 22, 2007.

Tags: EMDR | Jewish Press | Post-Traumatic Stress