Dr Judith Guedalia

Consultation Across A Seemingly Great Divide.

There was a request from both the nurses and social workers of Pediatric Oncology, to see a patient.  The patient was a 9 year old girl but the person "we REALLY need help with, is the brother!"


Being as each department has a Social Worker assigned to it , and having experience that our specific services are generally requested when all else has been tried, this referral, to see a young patient "but more-so her brother",  piqued my curiosity.  I also know that going in and acting as: Hacol Yachol, or "know-it-alls", was sure to backfire.  This ‘consultation' would need to be handled in a ‘discrete' fashion so that we would not be an excuse for failure, but rather, the tools for success.  

We are a 500 bed medical center that services Jerusalem and its environs, so that our patient population reflects the cultural, religious, and political diversity that is day-to-day reality in Israel.  In this case, as I went upstairs, to the pediatric oncology unit with an intern, I did not know ‘who' we were going to meet.   Certainly, I had the ‘facts':  Patient's name: Wafa aged 9* (her name and identifying information have been changed here); Address: a small village near Jericho; Citizenship: Israeli; Religion: Arab Moslem. Those are obvious ‘starting points', but "who" was I really going to be seeing?

On entering the room I observed the following ‘tableau'.  Mom in traditional Moslem garb; father, no beard but unshaven in ‘secular' jeans; son, early 20's in traditional garb, very hirsute and unkempt,  beard, mustache, a lot of head hair and a large knitted white Kippa, or as it is known in Arabic: Kufi, skull cap.  And there, almost forgotten on the upper far corner of the bed, lay a small 9 year old girl.  She had a distinct pallor, brown rings under her eyes, and little wisps of hair peeking out of the triangular fabric wrapped around her almost bald head.  Wafa's body was held in an almost fetal position, she looked sad, with a far -away gaze, which I had seen in the past with so many other young oncology patients.  Though the room was full of people, her pose said: "I am alone, and there is no one to protect me".

Just before I entered the room, the social worker for the unit pulled me aside and said: "The brother goes to a Madressa (‘Yeshiva" for Moslems) and seems to be ruling-the-roost with the family.  I tried to work with them, but they were unresponsive. 

Though I can speak enough Arabic to make a patient feel as though I ‘am trying', I do not ‘do therapy' in Arabic.  Luckily this years' batch of psychology interns also includes an Arab student of psychology.  Abdel (not his real name) is Israeli born, and doing graduate work in a European university.  I have been impressed with his knowledge of psychology and especially his willingness to learn during these, his first few weeks of his internship at the Neuropsychology Unit which I head.  As we walked up to the sixth floor, to the Pediatrics Department, he was expectably anxious and excited at the same time.  This would be his first patient and his reactions were appropriate, too much confidence would not have portended well, vis-à-vis my perception of an optimal ‘learning infrastructure'.  A little anxiety is a good motivator for learning and achieving, too high a comfort level, generally signifies a student who will miss important ‘clues/information' because of over-confidence.

On the way upstairs, I notice Abdel putting the Cross he wears around his neck, into his undershirt.  He notices that I notice, and says: "If the son is in Madressa, I don't need to begin by showing that I not a Moslem, but rather a Christian Arab".  (His sensitivity and preparedness makes him go up another notch in my estimation!). 

We were introduced to the family, just as ‘big brother' aged 19 years was reading to his sister, and the parents were looking morose in their chairs.  "What are you reading" I asked curiously, ‘big brother' looking downward and trying not to make eye-contact with me (for Tzniut/Modesty reasons), answers: "poetry".  There was an overall mood in the room that didn't ‘compute' with what I expected "reading poetry" in a patient's room would evince.  We talked about ‘cabbages-and-kings' (nothing really, the view, the food, the pictures of beautiful photographed flowers which are hanging on the walls).  In this fashion they have an opportunity to meet/see us, and we them, as well as give them a ‘heads-up' that we'll be back.  We haven't ‘intruded' too much, and we have given them a measure of ‘control' regarding contact with us.   It also gave me an opportunity to check out what ‘poetry' they were reading.

I found out that the ‘poetry' was about ‘death' and ‘the sacrifice of the dead' for the holiness of the rest of the family.  It seems that Brother, ‘required' that the whole family be present whilst he read these ‘poems' to his nine year old sister, both at home and in the hospital.  Further, the brother was ‘newly ardently religious', having been somewhat of a ‘problem child' in the past (cutting school, possible drug abuse and other ‘non-conformist' behaviors). 

There was something very familiar about the scene, I recalled a case where a Jewish teen was severely injured in a terrorist attack.  The brother blamed himself for her injuries, had he been more religious, then his sister wouldn't have needed to suffer for his sins.  With each passing day in the ward, the brother thought of another act of piety the patient should take on to ‘clear' herself of the punishment. 

The similarities between the cases helped me formulate a plan. I decided that the Mom would be our ‘therapist' and that Abdel would use Gerald Caplan's Consultee Centered Psychotherapy/Intervention (Model Of Mental Health Consultation, 1973, 1994).  Caplan developed a model where he would elevate the professionalism of caregivers which in turn, created an attitudinal shift among them leading toward their establishing a professional identity and a sense of ‘newfound' abilities.  Collaboration among child care center staff appeared to support professional growth, while empowerment surfaced as an important part of this process involving increased competency among caregivers (Schien, 1997).

In my professional life, especially that of working in a multi-cultural environment, I try to seek the similarities rather than differences in observing human behavior.   I attempt to enlist the strengths and abilities of all those concerned to further our goals.  In this case adding the ‘spice' of understanding of the effect of  behaviors on family dynamics that the ‘re-entry' of a ‘prodigal son' (a Ba'al Teshuva of sorts) might cause, we were able to enhance the parents', nurses' and social workers' active understanding and empathy.  Not being ‘misled' by obvious cultural differences, but instead using our combined ‘across cultures' experiences, we were able to ‘construct' change in how the parents related to their son and daughter.  In supervision with Abdel, I was able to help him reframe and ‘translate' the brother's feelings of misplaced responsibility for his sister's illness as he ‘co-opted' the Mom to be the family's ‘therapist'.

Most of all we were able to engender trust and mutual respect and help our patient, nine year old Wafa.


Originally published in the Jewish Press on June 7, 206.

Tags: Jewish Press | Madressa | Neuropsychology | Pediatric Oncology