Dr Judith Guedalia

Sometimes The Diagnosis Is As Clear As The Nose On Your Face...
She came into the office with her mother. They sat down. The mother, facing me on an angle, her back towards her daughter; the daughter, on the other, hand was facing me, but her shoulder was defensively up "against" her mom. Well, I said to myself, they are both here together; that's one step in the right direction.
She was a compact, 14 year old; her brown hair neatly combed and pulled back, twisted and pinned to the back of her head with a clip that looks likes the jaws of an uncompromising barracuda (or shark). I imagine it painfully "clenched" in the back of her head. Personally, those clips hurt me when they get their "teeth" firmly around any wisps of hair of my Pe-ah (head covering). To do it's job, the clip has to attach itself not only to my hair but also to some of my scalp, and I go through the day feeling no kalut rosh (lightheaded) for sure, but rather I get a painful reminder that I'm being held up by outside forces. I think of this when I look across my table in the Neuropsychology Unit at Shaare Zedek Medical Center at my new patient and her mom.

These associations and the feelings they have engendered in me are interesting. Why am I suddenly having visceral reactions to the back of her head? Hum, I think, transferrential and counter-transferrential feelings. Associations to the back of the head of the 14-year-old girl who is in reality sitting in front of me?! What am I avoiding?

"Transference" and "Counter-transference" refer to any distortion of a present relationship because of unresolved (and mostly unconscious) issues left over from early relationships, especially in childhood. All distortion of the interaction between doctor and patient (or boss-worker, teacher-student, any hierarchical relationship) by the needs and behaviors that were most meaningful in childhood are forms of transference. When the manifestation is in the patient it is just "transference." And when the manifestation is in the doctor it's generally called "counter-transference." Classic Freudian psychotherapy tries to make it apparent how this 'plays out' in the-here-and-now. (*see footnote)

I take a more directive and less associative (or Freudian) approach to this the "first impression" meeting with a girl and her mom. Essentially the "intake" is an opportunity for us all to meet and interview each other - me, her and she, me. And so, I take another look at her, and see what cues/clues ease across the table in the nanoseconds that our senses: visual, auditory, haptic (touch), olfactory search to make cognitive sense out this moment in time and create a pathway for a brain/behavior (neuropsychological) response.

Her eyes are staring right at me, almost challenging me to do something. I look again at the area around the challenging eyes and get a glimmer of understanding as to why my first conscious (or semi conscious) thoughts were directed to the back of her head.

Hemda (not her real name), was staring out of her eyes, her eyebrows had a metal post with a ball at either end pierced through them - they looked like two mini dumb-bells, that a weight-lifter might hold. Her cheekbones on both sides had a metal button, more like cylinders going through them. She had a nezem (a nose ring) in each nostril. Her mouth had a stud on the lower lip, and her ears were rivulets of metal on the helix (outside of her ear).

I asked her name and age. I always ask questions that the person can answer, without making them an issue, and once we began talking, we were having a conversation. I scanned the rest of her face and hands. "Any more 'piercings' that are I can't see right now?" Her mother begins to cry, silent tears running down their own rivers on her face. Hemda looks into my eyes and says two on either side of my chest. As she says this I notice a slight lisp, and look more closely at her mouth and see something glistening on her tongue, another stud.

I say, because I am not just curious, but also interested: "Do you have piercing in the same places as Michael Jackson?" (Now most of you may not know who Michael Jackson is or what he represents, to my modest assessment he is "The Poster Boy/Man" - The USA "role model" for dysfunctional child/adolescent/adult behavior - big time! Anyway, in a "professional" quest to be somewhat au courante for my patients, I read Harry Potter, the News, etc., and am not totally oblivious to what happens in the non-frum-world. I try to temper this "quest for information" with shiurim and learning of our material.)

At any rate, Hemda's eyes opened wide, she stared at my pe'ah, and said: "You know Michael Jackson?" "Well, he doesn't' daven (pray) in my shul, but I have heard of him," I answered, somewhat tongue-in-cheek. She thought that this was quite funny (so did I - well, you had to be there!). Her mother was still crying, but now she stared at me, wondering, what in the world was going on here. How could her daughter and I be sharing a joke! This, after all, was a crying matter!

I certainly agreed, but Hemda would never have opened up to me had I not 'joined' with her a bit, and had she not recognized that I was trying to find a modus vivendi a "place we could meet" in this "conversation" without being judgmental.

I asked Hemda to have patience with me, and said that almost every person who has piercing does them in a sequence. I asked her if we could take some time now and make a list of the sequence of these "events". I took out a ruler, colored pencils and paper, and with great care, and enlisted her help to keep the lines and columns straight, and after a few minutes, we had a chart. Each column had a heading that represented date; time; place on body of piercing; location of the shop that provided the service; and who was with her at the "event".

· What struck me at first was that Hemda had been alone each time she had a piercing. Usually there is peer pressure, or peer support for this type of acting out and, as noted, Hemda had been alone for each of these painful occurrences.

· Secondly, the sequence of events began three months prior to our visit, in November. Until then, she had only one hole pierced in each ear, done in early childhood and in her mother's presence.

· The ear studs were both made of silver and gold metals.

· The sequence of piercing was: lip/mouth; eyes; many more in the ears; and finally the tongue, the chest was the final two piercing. She told her mother about them and it immediately precipitated the visit to a host of psychologists, who didn't "click" with Hemda. And now, they came to me, a neuropsychologist, thinking that perhaps a visit to someone in this field would have a different result/diagnosis (?).

The chart laid it all out in front of us. I stopped in my tracks. I said to her: "You've already figured out, that I am a 'little different' than the other psychologists your mother has brought you to see. I also really want to tell you how much I respect your ometz - which means bravery and also 'guts'. You must also be the most loyal and respectful person I know." Now both she and her mother just stared at me, with their mouths ajar!

(This happens not infrequently in my office, I "kinda" have that effect on people!)

I then asked them both what had happened in November. They looked at each other and said nothing. I sat and waited. "Nothing, really, except my nephew's bar mitzvah". I sat and waited. Mother answered: "We all went away for a weekend to a kibbutz - the whole family, with all the children, cousins and everyone. It was a very special Shabbat."

I said: "When did he hurt you, Hemda?" Whispering, with tears rolling down her face she said: "In the morning before anyone else was up." Was it the Bar Mitzvah boy?" " No, another cousin."

She looked at me, relieved but still crying. Her mother was dumbfounded, crying and then, crooning, took her daughter to her breast, hugged, and rocked her.

My hypothesis was that Hemda was calling out for help and no one had heard her speechless terror, nor did they see she that had been violated; her trust in her family had been punctured/stabbed, in ways she could not discuss. Her family saw the changes in her personality, the signs that were right out there "as clear as the nose on her face." But no one was able to even imagine her horror.

My clue was of course from Psalms Chapter 135.


14, For the Lord will judge the cause of his people, and he will relent concerning his servants.

·  15. The idols of the nations are silver and gold, the work of men's hands.

·  16. They have mouths, but they do not speak; they have eyes, but they do not see;

·  17. They have ears, but they do not hear; and in their mouths there is no breath.

·  18. May they who make them become like them, and every one who trusts in them!

·  19. Bless the Lord, O house of Israel! Bless the Lord, O house of Aaron!

·  20. Bless the Lord, O house of Levi! O you, who fear the Lord, bless the Lord!

·  21. Blessed be the Lord from Zion, he who dwells at Jerusalem! Hallelujah!

No more words were needed. I said that they should call me the next day to decide how to go on from here. They thanked me, and left, holding onto each other.

* Dewald, P.A. (1971). Psychotherapy: A Dynamic Approach. New York: Basic Books, Inc.;

Epstein, L. (1977). "The therapeutic function of hate in the counter-transference". Contemporary Psychoanalysis, 442- 461;Freud, S. (1933). New introductory lectures on psychoanalysis. Standard Edition, 22:5-182. London: Hogarth Press, 1964;Gardner, Jill (1995). "Supervision of trainees: Tending the professional self". Clinical Social Work Journal, 23:271-286.


Originally published in the Jewish Press on March 8, 2006.


Tags: Counter-Transferrential | Jewish Press | Transferrential | Violated