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.


Knowing you, perhaps

Rules of Attraction: “What does that mean know me, know me, nobody ever knows anybody else, ever! You will never know me. ”

Rules of Attraction – “What does that mean know me, know me, nobody ever knows anybody else, ever! You will never know me. ”

The woman in front of me frowns, frustrated. “It makes me really angry, I feel like they’re not listening to me, they just don’t understand how things are for me.” We talk about the different ways she can make herself heard, express her perspective in a way that others could be receptive to. Finding a common language to share her experience, that others can translate.

But I wonder if what we’re chasing after is actually something of a myth. This idea that if we found the right words, the right time, and said it in just the other way, others would get it. They’d be able to step into our shoes, inside our skin and really see the world as we see it. The truth is that another person can’t ever truly know what it is to be you. We don’t even know if we’re all staring at the same colour ‘blue’. The same words spoken will be heard and interpreted very different by different people, depending on their own experience and stored knowledge, or how they happen to be feeling at that moment. No matter how clearly you put it, you can’t be sure of what others will take away. And someone can spend a lot of time with you, learn all your history, your interests, your little quirks and mannerisms. And then they will know an awful lot about you, but they won’t know what it’s really like, your own private, subjective experience, what it is to be you.

Like Nagel says, despite everything we know about mammal anatomy, physiology and infra-red, we don’t really know what it’s like to be a bat.

But we want to be understood. We want to be known. The imagined intimacy that comes from someone really knowing you so entirely. Total understanding. But there will always be a limit to this (or at least until we find a way of plugging in to each other’s brains). How can we tolerate this? That total understanding is a fantasy and reality others will always get it just that bit wrong? That no matter how well you know someone, there will always be a mystery there that can’t be solved.

Three Good Things – The positive data-log

Sometimes things are a bit shit. So what are you going to do about it?

Things have been quite stressful for me lately and I got to thinking about some of the clinical techniques I use (which I too-often completely fail to apply to myself!). I thought I’d share with you a little technique from the school of CBT. When I was doing my own therapy, my therapist tried this with me, it’s very simple, you can do it on your own, and even weirder still, it really does seem to help with depression.

When you’re feeling low, you look at the world and your life in a different way. At least, I did. Often you don’t realise you’re doing it, it seems a wholly realistic way of looking at things. When I was depressed, it was almost as if I have a loop in my head that replayed all the bad things that had happened to me, all the things I had done wrong, all the things that were wrong with me. It rolled around continually, and each time something bad happened, or even semi-bad, I added it to the list. So it was no particular surprise when bad things did happen (as they do to everyone). I expected it. Getting caught in the rain, losing my keys, getting a bad mark on a piece of work, someone giving me a dirty look, these were all reasons that life was bad and so was I. I’d mentally make a list of all the things I was bad at. It was almost like I took a kind of morbid enjoyment in collecting these things, further evidence of just how worthless I was.

The positive data-log is a simple idea, so simple that I scoffed a bit at how worthwhile it could actually be. Each day you write down a few good things that have happened. Admitedly, for a depressed person, this will be very challenging. It may seem like there is absolutely nothing to put on the list at all. This is where you have to start really small. Things that may seem ridiculously, perhaps pathetically small. A nice cup of tea. Finding a convenient parking space. A pretty view. You don’t have to show anyone the list and actually it’s not so much the content that’s important, as the process. The process of each day taking a few moments to consider things that are good, or even just ok, is beneficial. It probably won’t come naturally, depression tunes you into the negatives. But you try and write down a couple of things for each day and it gets a bit easier over time. This method is associated with improvement in mood, and I think it’s something that most of us would benefit from trying from time to time.

Here is mine for today:

  • I ran for the bus (in heels!) and actually made it, much to my surprise
  • A had a client cancel today, but it actually gave me some extra time to finish some work
  • My supervisor complimented me on my technique today – wahoo!
  • Caught a beautiful pink and gold sunset on the way home
  • The man downstairs from my flat offered me a cup of tea. I didn’t have time to have one, but it was a nice offer.

There you go, it’s not been an extraordinary day by any means. Just a few simple things. You might be surprised at how well this works, I’m curious as to other people’s view on using this technique, both on yourself and with others.