Dr Judith Guedalia

September/Elul brings with it the sense of new beginnings, the beginning of the Jewish New Year and  the beginning of the School New Year.   Over the past 20 years as Director of the Neuropsychology Unit at Shaare Zedek Medical Center, Jerusalem, I have trained more than eighty interns in the field of psychology, specifically Neuropsychology, Medical, Developmental, and Rehabilitation Psychology.  Each year I await the new ‘batch' of graduate students who are doing either their first year of fieldwork (after their first year of graduate school), senior fieldwork (after their second year of grad school), and interns (four part-time years or two full time years, after graduation).  I am never sure who is more nervous, them or me.

In the ‘early' years I had one or two new students each year, but in recent years the ‘group' is generally made up of 6-8 students.  Imagine, if you can, having octopulets, earnest young students anxious to please and eagerly waiting to ‘learn'.  They are older than their American co-graduate school students.  They have finished the army; many have been officers, having added ‘extra' years and responsibility, to the mandatory three years for men (five years if they were in Hesder- Yeshiva and Army)-  and two years for the women.  Most then went on the year ‘trip'- an almost mandatory cultural norm of getting ‘ooout' of Israel and the constrictors of life here and army life in particular (to the ‘out-back' of Australia, India, South America or where-ever).  Then they take entrance exams for University, study for a three year BA in psychology; attain a 94 percent average; are accepted to graduate school in neuro, or medical, or rehabilitation, or developmental psychology, maintaining the 94 percent average, and only then begin the requirements for clinical fieldwork and internships.  For the great majority all this takes place as they are working part-time to support themselves, as their parents are not able to do this. 

These students are very smart, competitive and capable, but many have never seen a ‘child' or ‘people' culturally different than their immediate circle, nor any of the ‘disorders' they have learned about.  They know this year (or three years) will include learning about interviewing, assessment and therapy and seeing ‘the real world' of developmental, neuropsychological disorders and psychopathology under a fair but tough taskmaster (me!?!).  At the beginning of the year they are ‘observers', as the year progresses they begin to see their ‘own' patients under my supervision.  I feel the pressure of fulfilling their expectations as well as being the first step in their professional career.  The case 'vignettes' below are just a small example of what awaits them:

 ?       A referral from pediatrics with a request to speak to a young couple in their twenties, their nine month old son was just diagnosed as having Cystic Fibrosis.  The father was born in Europe the mother in the States.  The father's family is Ashkenazi the mother's Sephardi, descendants from the Spanish Inquisition.   They never would have ‘joined' their genetic history had they not met at Hebrew University during their junior year abroad,  both have the recessive gene for Cystic Fibrosis, which sadly plagues their son.  With the advent of the Internet they are not only drowning in the sorrow of the diagnosis, loneliness without family in Israel, but also information-too much and too soon.

 ?       They flew up from Eilat.  The child is seven years old; the mother is a single parent.  The child was diagnosed as psychotic and retarded in Eilat.  The mother reported that a child-psychiatrist comes to the health clinic every two weeks.  She feels her son cannot be retarded, as he is so clever in so many ways.  She collected money so that they could fly up to Jerusalem for an assessment by a neurologist.  The mother seems to be correct.  The neurologist diagnoses Tourette Syndrome but feels that this diagnosis does not tell the whole story.   The child is then referred for a neuropsychological evaluation, which means another flight up to Jerusalem.  After six hours of assessment, the data seems to point up to a child of average intelligence with a Non-verbal Learning Disorder and Tourette Syndrome. 

 ?       The distraught mother brings in a beautiful seven-year-old girl.  The principal will not let her back into school as she has had her ‘fourth' incident.  The little girl describes the incident.  A child bullied her friend.  She threw rocks at the child, causing bruising.   As I am want to do, I ask about the stones, were they round? Were they gray or another color? And other such questions.  In the conversation that ensues, she mentions that she had looked for glass shards but couldn't find them, they are better, she says, because they draw blood, and the bully deserved more than just a bruise.   The intelligence scores are low, belying what clinically presents as a highly intelligent child.  Her projective tests give us direction.  She may have an incipient form of schizophrenia, from where does this aggression stem?  I refer her for psychiatric evaluation.

 ?       "The school wants to place my child in a school for the retarded, he was never retarded, he's just ill".  The mother had convinced my secretary to bypass the four-month waiting list.    When I see the child, I understand why my usually determined secretary caved in.  The 13 year old has ALD, Adrenoleukodystrophy, better known as the disease described in the movie ‘Lorenzo's Oil".  It is an autosomal (through the mother) degenerative disease, presenting at about 6-9 years of age with a not so slowly degenerating neurological and muscular functions until death.  In the assessment of this young teen, was strapped to his wheelchair and could barely be understood through his slurred speech.  His cognitive function was ‘generously' plotted at about four years of age.  His school did not know how to handle and ‘teach' him.  "Nothing seems to work, we can't teach him".   I explain the disorder to the school and end the conversation agreeing that trying to ‘teach' him may not be the most rewarding of activities neither for him nor for the teacher.  It was decided to let him keep attending his ‘regular' school, with an aide, as well as with his classmates with whom he entered first grade, until such time as medically it would be impossible for him to continue.  The teaching would be of ‘chesed' to his classmates, and by letting him stay in class with an aide, we might help address mother's plea to be heard that "my child was not born retarded", not to speak of his feelings of joy at being allowed to ‘remain in regular school like all his other childhood friends'.

 ?       Her brother is Autistic.  In further intake sessions it seems he has Fragile X. She, an attractive 12 year old, is having extreme difficulty in mathematics, she has almost no friends, doesn't ‘get-it' her classmates say; can't organize her materials for school and has difficulty attending to task.   ADD (Attention Deficit Disorder) said her teachers; she needs to be on ‘medication'.  The mother wanted to do an assessment before going to the family doctor to get the meds.  The assessment profile is consistent with Fragile X -F (the female presentation of the mostly male Fragile-X a genetic disorder that in its mildest form causes ADD).  We will not know for sure, because the parents don't want her genetically tested, they have ‘enough on their plate right now', I agree and present the school with a detailed remediation and ‘realistic expectation' plan, as well as recommendations for easing testing requirements and ‘release' from the requirement to take bagruyot - statewide achievement tests-in math.

 ?       She was referred for consultation by the genetics department; they don't want to test her.  They referred her to me.  Her parents were divorced when she was five years of age, and her father lives abroad.  She is an only child.  Her grandmother, mother, and only aunt, have all died of ovarian cancer.  She wants to do the genetic testing for the genetic marker for BRCA-1 and BRCA-2, the Jewish gene for breast and ovarian cancer.  She is 20 years old.  If she has the gene she has almost a 70 percent chance of getting the disease.  The only ‘therapy' at this point in time is prophylactic oopherectomy and mastectomy (breast and ovary removal).  This is generally not done until the patient has had children and is over the age of 40 years.    In the course of our meeting she tells me the she really knows already that she has the gene.   She knows she is going to die and leave her daughter with the same pain and loneliness, and then die young as well.   Why should she go out on a date?  Why should she get married, even if someone would have her?  She feels compelled to ‘tell all' on the first date.  I ask her if she would rather be dead now and save years of uncertainty.  "What are you talking about" she yells at me, "What kind of a psychologist are you anyway, aren't you supposed to help people!  No one knows when he or she is going to die.  A terrorist might even kill me when I step out of the hospital."  We make an appointment for the next week to discuss dating.

 ?       At the beginning she came in weekly for therapy.  Now this burn survivor, a victim of a booby-trapped car bomb, comes once a month when she has follow-up occupational therapy appointments. One week she came twice.  The 'anniversary' of the bombing was coming up, as was the final healing of her 'exposed' scars.  I'm not sure which is more traumatic for her at this point in time.

 ?       She was three months old in her mother's arms when a car hit them.  This three and a half year old Arab girl is just beginning to speak.  The developmental neuropsychological assessment shows a delay in abilities that are thought to be localized in the left hemisphere of her brain.  I advise her lawyer not to settle the case, rather get speech and language therapy for the moment and re-evaluate her in two years.

 ?       I am asked to see a woman in cardio-thoracic surgery ward. "We put in a new valve and she'll do fine", said the nurse.  What's the problem, I ask.  "If we could, we would want to take it back. She's a nightmare of a patient."  I visit her and hear her complaints of all and sundry.  I tell her that she seems more afraid and anxious than my ‘regular' post surgery patients.  I tell her about EMDR-she agrees to try it.  We started and she began to laugh hard and loud, I started to really get worried.  In the course of EMDR she talks about a 'picture' she sees of herself in Russia, separated from her mother at a train station. Then she told me that when that happened she was around four years old and now she's fifty-four.   ''I guess I feel the same now, and you are my mother who just found me'.  I checked with the nurses the next day-and they said they couldn't believe she was the same patient.

Some of my friends, who are not in the field, ask how is it that I enjoy my work so much.  I answer, that I see my job as finding the healthy part of the child, adult, and situation in each individual case.  I hope I am able to communicate and ‘teach' this to my students. 

Shana Tova, Briah, Metuka ve Shekaita- blessings of a good, healthy, sweet and quiet New Year- to us all.

Tags: Beginnings