Tested and found wanting: The experience of completing cognitive assessment 

This piece was originally written as a shorter commentary of a piece in Clinical Psychology Forum. It was scheduled to be published but then got put on hold amidst their various special issues so I thought I’d share it here.

For those unfamiliar, neuropsychological assessment (also referred to as psychometric or cognitive testing) refers  to the process by which professionals (usually but not exclusively by clinical and eductional psychologists) aassess cognitive functioning. This usually involves carrying out a series of tests and tasks with an individual that cover a range of cognitive skills, including memory, concentration, planning, organising, language and visuo-spatial abilities. An IQ test is a form of this testing. Situations in which an assessment might be requested include assessing the impact of a brain injury, asssessing for the presence of dementia, learning disabilitiy or specific learning difficulty. A neuropsychological assessment can provide useful information for gaining a greater understanding of an individual’s difficulties and considering interventions that might help them. 


From my own experience, neuropsychologial assessment is often not a favourie activity for psychologists. Some people see it as impersonal and rather arbitary – just running through tests that seem to have little relevance to everyay life in an automated fashion. It can be hard to see the person beyond the list of test scores andpercentiles  generated. I think some of the issue here is the way that neuropsychological assessment is taught and written about. Often there is a lot of foccus on selecting tests, carrying them out in a standardised way (which is of course important), scoring and analysing the data, looking for patterns. What can be left out is how to use neuropsychologial assessment information within a clinical formulation, consideration of ethical issues raised by the testing and how to best use interpersonal and thereputic skills within the assessment.

There has been increasing discussion around separating out clinical neuropsychology from standard clinical psychology training. This isn’t a move I suppport  and I think it’s essential to highlight how the core skills and knowledge of the clinical psychologist are incorporated in neuropsychologial work, including  when carrying out a good quality assessment. If we don’t bring psychology to these assessments, we may as well have clients complete them on a computer. Time pressures and perhaps a lack of professional enthusiasm for neuropsychological tetsing can squeeze out some of the human component. Below I detail a few areas that I believe are  sometimes left out and require attention.

The Stroop Test, one of the best known psychometric tests, is used to measure switching and inhibition (components of executive functioning)


Informed consent

The client’s consent to complete the assessment should always be sought. It is not uncommon for individuals to arrive at their session with little idea of what to expect, and less so the potential implications of the results. We should inform clients of the benefits of the assessment but it is important to also discuss potential negatives. The results may have a far-reaching impact, including contributing to the allocation of a diagnostic label and the potential stigma of this (such as intellectual disability), impact on eligibility for services and associated benefits including fitness to hold a driving liccense. Ideally this is a time for collaborative discussion about the questions the client would like the assessment to answer, and tthis can be used to plan the assessment. Misunderstanding the purpose of the assessment may also impact on the level of effort that clients put in. These converations take time and may be difficult to achieve when there is pressure from referers and other parties to get the assessment ddone quickly or not to “encourage” the client to decline the assessment. 


Creating meaning within the assesment 

In addition to contributing to formulation and intervention planning, there is potential for the assessment itself to be a meaningful and therapeutic experienceThe assessment may be the first time the client has had their difficulties heard and given sufficient attention, and psychometrics may provide a medium for discussing issues that can feel intangible and hard to express to others. IIve been amazed at the relief some clients have flt when I was able to give them words to describe previously nebulous difficulties. AAssessments can be long and stressful, they put people through their paces and can highlight the very things people find most difficult. Rapport needs to be built and maintained throughout the assessment to keep clients engaged, and empathic support provided if the experience triggers anxiety.


Feedback – Concluding the proccess

The provision of feedback brings the assessment results together and maximises the opportunities for the client to understand the outcome of the process and to take away something useful. Providing personalised feedback can enhance clients’ sense of control and engagement in their treatment. It can also be an opportunity to provide psychoeducationand discuss strategies for managing cognitive difficulties. The provision of thoughtful and sensitive feedback is especially important when the results indicate impairment or are suggestive of pathology. Feeding back need not always be a lengthy process and not all clients will wish to have a formal session, but offering this validates the time and effort they have put in to what can be a stressful experience, and also represents a conclusion to the piece of work.


The recent viewpoint article in The Psychologist magazine exemplifies a worst-case scenario where a neuropsychological assessment is experienced as a disjointed process without meaning. 


“The psychologists produced a range of memory, attention and executive function neuropsychological tests without telling me the names of the tests or why it was important for me to complete the assessment. I performed these tests obediently while feeling immense frustration and confusion inside. The results of the tests were never revealed to me. Strangely, the implications of my injury were never highlighted and coping strategies were not discussed. Instead, I spent hours performing these monotonous and challenging neuropsychological tests, while trying to deal with the emotional impact of the car accident and my brain injury alone.”


Experiences like these are regrettable and really an embaressment to the profession. Collaboration is however very possible and can bring the focus back to the client and their needs, helping them to get the most from the process.

 

Brain Injury Awareness Week: Survivors are already aware of difference, it’s time for everyone else to catch up

This week marks Brain Injury Awareness Week in the UK. In the neurorehabilitation service I work in we’ll be celebrating with a range of brain-related activities. We’ll be watching injury related films such as The Crash Reel, having a quiz and getting crafty with brain-themed cake decoration. We’ll be promoting the importance of looking after your brain – wearing a helmet, eating well and taking time to relax. Whilst it’s appropriate for us to throw these events, I can’t help but feel that are energy can be somewhat misplaced. Brain Injury Survivors aren’t the one’s who need their awareness raised. They live with disability and difference every day. Though some have difficulty fully understanding their injuries, they are experts in their own experience. The problem relates more to everyone else, the vast swathes of the population who have little understanding of brain injury and limit the social inclusion of survivors in their ignorance.

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Brain cake – delicious but perhaps not really raising awareness about the experience of brain injury

On the whole general knowledge about the brain isn’t high. It is after all, a highly complex organ that even expert neuroscientists don’t fully understand. Myths about the brain abound, ideas about “left and right brain thinkers” and the percentage of our brain we use haven’t been especially helpful. Understanding the brain requires looking at who we are as people, what makes us human, when makes up our identity, and how much control we truly have over our behaviour. This is what makes the brain fascinating, but it’s a difficult topic to confront. And then extrapolating from the delicate, blancmange like organ to understanding why it is that a survivor might suddenly get angry for no obviously observable reason, struggle to manage bills, become exhausted and overwhelmed, or any one of the many common consequences of brain injury.

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Gifts for Brain Enthusiasts: Part 3

My last post was quite heavy-going and I’m in the midst of writing something more political so I thought it might need breaking up with something more whimsical! In case you’ve forgotten, here’s part 1 and part 2

Find 1:Think Geek is a treasure trove for brain and other anatomy-themed items. These coasters are made up of slices through the brain and look incredible, I’ll certainly be ordering some when they re-stock! Postage and customs (it’s a US site) can be high so worth saving for a bulk order with others.

huir_brain_specimen_coasters

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Upcoming Wonder Season and the Brainwaves Weekender @ The Barbican

 

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Personally, I’m rather keen on brains and brain-related things. So it’ll probably come as no surprise that I’m rather excited about the Barbican’s upcoming Wonder Festival devoted to the mind, including a weekend (March 2nd-3rd)  focused on all things brainy. Ahead of the British Neuroscience Association’s festival at the Barbican in April, this season throughout March and April looks to explore the much intertwined relationship between neuroscience and the arts, through a series of talks, workshops, film showings, comedy, theatre and music events. It’s a collaboration with the Wellcome Trust, who were also behind that rather brilliant Brains exhibition last year.

Amongst the events on over the season are a few crafty sessions to help people get creative as they get to grips with a bit of neuroanatomy, including sessions where you can knit a neuron and dissect a jelly brain. I’m not sure if these events are more aimed at kids,  but they sound right up my street. Ruby Wax is doing a talk on her experiences of depression, there are showing suitably mind-related films (including Eternal Sunshine of the Spotless mind), amongst many other things. Another rather trusting looking event is ‘The Salon Project‘, an interactive theatrical experience where “You will be costumed in full period evening dress before emerging into a mirrored impression of a 19th-century Parisian salon. As you mingle with guests, pioneers in their fields will provoke discussion, speaking on subjects at the vanguard of 21st-century thought: science, politics, technology and the arts.” Which sounds wonderfully bizarre. I love this entire theme, involving science and art in a way that can get people to think (ha) about the brain and how they interact with their world, in new and creative ways.Watch this space for a report after I’ve been!


Wellcome Image Awards

I’m a little behind on this one, but thought I’d like to mention it anyway. A couple of weeks ago the winners of the Wellcome Image Awards were announced. The prize celebrates images relating to medical science, the domain funded by the Wellcome Trust.

The overall winning image by Robert Lublow at UCL’s Institute of Neurology, is a close-up photograph of the brain of a patient with epilepsy, during an intracranial electrode recording procedure. It’s hard to explain, but there’s something I find very powerful about this image. It looks like a map, the blood vessels like rivers and roads tracing across the surface of the cortex. It’s so bright and colourful, the vibrant red of the blood and the pink of the ‘grey’ matter. I’ve seen so many photos and pictures of brains, and I’ve seen brains up close in dissection classes, but they’ve never looked like this. What makes this photograph different is that it shows the brain alive. There’s blood pumping through it, the tissue is active, this really is a living organ inside someone’s skull. This is a site that I, and most people, aren’t privy to. We see the solid greyness of a preserved brain, and the gradients of an MRI scan, but we don’t actually see the brain, truly as it is, in action. This photo shows us what usually only neurosurgeons would see. And inside there, in all those little intricacies, is the very essence of a person.

N0036750 Intracranial recording for epilepsy

Gifts for Brain Enthusiasts #2 (Birthday Edition)

Time for more neurologically-relevant items, given people seemed to like the first set so much. Recently it was my birthday. I’m struggled to come to terms with my transition to ‘adulthood’ and the realisation that I may have peaked, cognitively (indeed, I think I may actually have peaked around the time I sat my AS Levels aged 17, and been on a decline ever since).

Anyway, the occasion was made all the sweeter for some fantastic presents some lovely people got me. They seem to know what I like.

Asylum – The photographs of Christopher Payne

I’m something of an amateur urbex-er and I’ve always loved the old hospitals and asylums the best. This beautiful book is full of photos of america’s old mental hospitals. Beautiful and haunting, the buildings are often derelict, left to be recalimed by nature. These images seem at once strange and startling, they serve as a reminder of the dark places psychiatry has come from. Also includes a moving introduction from the wonderful Oliver Sacks.

Usborne’s See Inside Your Head

This book may technically be aimed at a younger audience, but I’m pretty thrilled with it. So many flaps to lift! Hours of entertainment here. If I ever get a job in paediatric neuro, I may take it into work.

Old anatomical print 

Isn’t this just exquisite? This wonderful print of the inferior view of the brain is about to gain a proud place on my wall. I’d say an old print makes a really good gift for any fans of the biological sciences, there are some really beautiful and intricate ones out there. One of my best friends found this for me at an antiques market, apparently it’s over 170 years old! It’s been cut from a book and is a bit crumbly on the edges. You can find similar items on ebay too.

Yes, I’m a massive nerd and I have a rather limited set of interests. Stay tuned for part three…