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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Wounded healer or undercover crazy? Coming out (quietly)

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Back in 2013 I wrote a piece on this blog about navigating professional and personal identities online, particularly in relation to being a healthcare professional. Reading it now, so much of it still feels as relevant to me as it did then. Since I qualified last year I decided that I’d “open” up my twitter and writing and link it with my “real” name. My main rationale for doing this was that I’d taken a job outside of the NHS in a new geographical area. Without the structure of university and attending NHS professionals meetings I felt quite cut off from the rest of the psychology and healthcare world. I wondered if in continuing to stay “pseudo-anonymous” limited opportunities to connect with other professionals and also possibilities for doing more writing and public engagement.

My main hesitation about being “out” and open is that I’ve written in detail about my own life experiences, which include experiences of using mental health services. I have concerns about how my own disclosures might be judged by future employers, colleagues and therapy clients, and the impact of this. It’s hard to work out whether this is a realistic concern or my own internalised stigma. I don’t feel that my experiences limit my ability to do my job well (though I worry that others may think this). I feel well enough to do my job and I have a clear plan for what I would do if this were to change.

Going back through my blog I’ve taken out only a few pieces. These were the stories that contained information about other people in my life that would be made more identifiable. Whilst I’ve chosen to be more open, I respect others’ privacy and it isn’t for me to share their story for them without their consent.

When I first started my blog I was particularly looking for a space to marry up my experiences as a service-user and as a professional. It’s been a useful reflective space and I’ve really valued the conversations with others through this, particularly other professionals who write about their lived experience (PsychConfessions , CBTwithAlieshia, Giant Fossilized Armadillo and pd2oT) and mental health activists who write in candid detail to raise awareness (e.g. BipolarBlogger and Ilona Burton). Just before I qualified I took part in a research study about psychologists drawing on their lived experiences of distress (I hope this will be published and I’ll get a good quote in!). It was a powerful experience taking part, it really brought together all of my experiences as I was transitioning from trainee to qualified clinical psychologist. I also applied for a post where one of the “desired criteria” was experience of using mental health services. This sent a very strong message that my experience was valued, but I still felt my heart beating heavily in my chest as I typed a vague line in my application about drawing on my experience to consider client expectations and barriers to engagement! It wasn’t raised in the interview, but I felt glad I had taken up the opportunity.

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