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.

 

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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…

Nange Magro’s EEG-activated dress

Inspired by modern technology and Sci-Fi and driven by a ‘passion for surrealism and obscure, alternative worlds’ , London-based designer Nange Magro created the ‘Mechapolypse‘. The futuristic ‘electronic couture creation includes a cap with an EEG chip, detecting the electrical activity of the wearer’s brain. The designer states that when the outfit changes depending on the level of concentration, which I presume means that levels of alpha waves (associated with relaxation) are being measured. Changes in activation lead to the dress’s spine lighting up and the skirt opening up, rather like an insect’s wings, to reveal a transparent latex skirt. With a bit of practice, the wearer should be able to control the dress (and perhaps avoiding revealing themselves at the wrong time!).

On her website Nange describes her fascination with the concept of garments that are ‘technological sculptures’, “Which move and are in synthesis with the person who is wearing them represents both her ideal future and passion. A garment should represent an extension of the body and brain, and not merely be a mask that aims to divide or mediate the connection between a person and the surrounding world. Clothing should be something more than skin. It should be something that we can choose to describe ourselves in our own personal way; controlling it, means a lot more than we usually think. Being conscious of our body and its surrounding environment is one of the most important issues today.”

So what’s next, underwear that disintegrates with high levels of arousal? A shirt that shocks you if you start nodding off at work? I love the Giger-esque spiked helmet and spine but I’m not sure how I feel about my dress opening and closing according to my brain-waves. I applaud the unusual hybrid of science and fashion but I think this style may just not be practical for everyday wear (and also rather open to abuse!).

Brains @ The Wellcome Collection

I visited London’s Wellcome Collection for the first time a couple of months ago, and I think it’s already one of my favourite museums. It’s a wonderful conglomeration of two things I love: science and art. It’s a strange and eye-opening place, not too big, but perfectly contained.

Henry Wellcome, innovative pharmacist and businessman, was also a very keen (and rather obsessive) collector of all things medically-related. The collection housed in the museum is a cornucopia of historical artefacts, implements, paintings, photographs and sketches and all number of delightful curiosities. Here you’ll find shrunken heads, chastity belts, paintings of individuals with deformity and Chinese medicine dolls. I found it utterly fascinating.

Often seen as opposites, the second main exhibition  is a collaboration between the worlds of science and art. It houses a collections of pieces of art inspired by science, and science at its most artistic. Exhibits offer artistic interpretations on topics such as malaria, obesity and the genome project, and items such as a large glass sculpture of a virus, show the natural world in its beautiful intricacy.

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Box-model of the brain, used for teaching in mid-20th century

With this in mind, I’m very excited that the upcoming exhibition is on one of my favourite topics, Brains! The Wellcome say ‘Our major new free exhibition seeks to explore what humans have done to brains in the name of medical intervention, scientific enquiry, cultural meaning and technological change. Featuring over 150 artefacts including real brains, artworks, manuscripts, artefacts, videos  and photography, ‘Brains’ follows the long quest to manipulate and decipher the most unique and mysterious of human organs, whose secrets continue to confound and inspire.’

I shall be all over this. I expect there will be some items like kits for trepanning, old fashioned brain-maps and a few obligatory brains-in-jars. Quite excited. It’s on from the 29th March – 17th June, I shall report back when I’ve actually gone. In the meantime, they have this nifty game on the website where you can grow your own neuron cell (and compete against a mean rival neuron who keeps getting in your way). It’s pretty distracting.

Gifts for Brain Enthusiasts #1

Scientists can be hard to shop for. It’s a profession that seems to attract rather obsessive characters with very little delineation between work and home-life. What do you get them for birthdays and Xmas, a subscription to Scientific American Mind? Is that too ‘pop science’? Here are a couple of thoughts and suggestions for a little something for the neurologist, psychologist, neuroscientist or otherwise all-round brain-prodder in your life.

‘Brain is for lovers’ t-shirt

As worn by Pharrell Williams, Kele from Bloc Party, and me. I found this top on ebay, I assumed it was a parody of those cheesy slogan-ed American state t-shirts, perhaps aimed at zombie fans. A quick google now suggests that this was a t-shirt put out by the band N*E*R*D. And that ‘brain’ is slang for oral sex. Who knew?

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