The Real World! First External Placement

Hello! It’s been a while.

Mid-last year I was sent out into the Real World on my first external placement, in the neurology department of a large hospital. Got to see plenty of interesting presentations, both in inpatient and outpatient. I learned to use lots of cognitive assessment instruments, and I’d like to think that I improved my history-taking and assessment skills. I also got to shadow neurologists, neuropsychologists and techs, become very familiar with the ward, and see some interesting procedures, and some neurosurgery. This was a full-on assessment placement, meaning no therapy. This is somewhat uncommon for clinical psychology interns, but because of my love of brains and the nervous system in general, and because of my area of research, I decided to do it, even though it meant taking a 6-month break from psychological therapy.

While clinical neuropsychologists are experts in assessment in a neurological context (i.e. when there is an organic basis for perceived deficits, such as stroke, traumatic brain injury, etc.), all psychologists are trained to do some types of cognitive assessment in the general population. Cognitive assessment is a core aspect of any psychologist’s training and duties, and yet it’s not very common in the popular perception of psychologists – certainly not as much as therapy is. Many psychologists also do capacity assessments.

Before starting in my course, I’d considered doing a Master of Clinical Neuropsychology instead, due to the aforementioned love of the brain. And I continued toying with the idea of doing this later on in life. However, this placement made me reconsider, to my surprise: I found the short-term nature of involvement with patients, and the fact that you don’t typically do any treatment yourself, unsatisfying. That being said, I do very much enjoy doing cognitive assessments, so ideally I’d like to work in an area needing both therapy and some assessment.

To respect confidentiality, I’m not going to talk about any specific cases. But I thought I’d write about the general process of getting a neuropsych assessment, as I understand it from this placement. It is possible that this process is different in other settings where these assessments are often done, such as brain injury units.

1. You, or your family, develop concerns about a change in some aspect of cognition or behaviour: increased forgetfulness, problems following directions, recklessness or impulsivity, lack of concentration, speaking/reading/writing difficulties, not coping with job or education demands, etc. Maybe your family have concerns about your capacity to manage finances, consent to medical procedures, or manage day-to-day life.

2. You see your GP, who does the first-line investigations, but if these do not suggest an immediate answer/solution, will refer you to a neurologist. (Or to another type of specialist if a non-neurological problem is suspected.)

3. The neurologist will often get some further investigations done (e.g. neuroimaging), and if appropriate, will then make a referral for a neuropsychological assessment. A neurologist may also make such a referral following a stroke, or for chronic diseases affecting the nervous system such as multiple sclerosis, Parkinson’s disease, etc.

4. For the assessment, you come in for 1-2 sessions, during which a history is taken from you and (preferably) a close family member as well, and an assessment is conducted, tailored to answer the referral query (which is sometimes really vague: “X may be prone to being taken advantage of by others”; “please assess cognitive function”) and taking other factors into consideration, such as your English language fluency, general cognitive status, if an interpreter needs to be used, physical impairments such as missing limbs, blindness, pronounced tremor etc. The assessment consists of a test battery – different tasks that look at different aspects of cognitive function such as memory, speed of information processing, attention, verbal abilities, reasoning, problem-solving, etc depending on the referral question and clinical judgement.

5. The assessment is then scored, and a report is written up and sent to the referrer, that typically includes a brief history, findings, and the impression (i.e. if the findings appear to support or not support a particular diagnosis, opinion regarding capacity, etc).

6. Feedback is often also given to the patient and family, with easy-to-understand major findings and general recommendations on what would be helpful in terms of managing day-to-day activities, given the pattern of deficits found (if any). Often the recommendations will involve having other investigations (e.g. sleep studies – if the patient reported having disrupted sleep), seeing other professionals (such as a clinical psychologist – for adjustment to a diagnosis, implementing day-to-day strategies, or if the cognitive deficits found seem more in line with depression or an anxiety disorder), or becoming involved in support groups (e.g. for MS, PD, etc).

7. There will often be a recommendation for follow-up testing in 12 months’ time, or sooner if further changes are noted.

And that’s all for today…I’m now almost at the end of my second external placement, in a very different setting – but I’ll cover this in a future post.

Cultural competence

It’s been a full-on few weeks/months, not leaving me with much time to post, even though I’ve been doing lots of psychology- and neuroscience-related things.

I recently attended some talks on mental health in refugees, people from CALD1 backgrounds, and Indigenous people. Really interesting and important stuff. How appropriate is it to assess someone with these backgrounds using established “mainstream” tools? How do mental illness symptoms manifest themselves differently in different cultures? What are some of the signs to look out for in terms of trauma, torture, domestic violence? And what are the risk factors for developing a mental illness in these populations? These are some of the points raised in the talks, and things I’ve been thinking about lately.

It all comes under the umbrella of culturally-competent practice, which in a nutshell, is not imposing assumptions, and being open to information that may conflict with your beliefs/stereotypes/established norms, etc to be able to treat people from cultural backgrounds different to your own. The main point I took away regarding culturally-competent practice is that it’s not necessarily “how much” you know, but how open you are to receiving information. I would add to this the need to be aware of your own context, and of biases and beliefs that influence you – no one is a blank slate and I think the only way to deal with this is to be mindful of your own position and what you’re bringing to the table.

Here are some points I picked up:

1. Being an immigrant does not inherently boost the risk of developing a mental illness. Pre- and post-migration factors play a big part. Pre-migration factors may be political turmoil in the country of origin, trauma/torture/persecution of yourself or family, having to leave family behind. Post-migration factors include not having a good support network, not being able to find employment, language and cultural barriers to receiving appropriate care, and discrimination.

2. In many cultures, it is perfectly appropriate to have experiences that would normally put you in the “severe, possibly psychotic mental illness” category quite squarely – such as hearing voices. This is quite usual for many Indigenous people, who may hear family members and friends who’ve passed away talking to them.

3. It’s important to look at methods of healing traditionally endorsed by the client’s/patient’s culture. Normally healthcare in Australia stays away (or tries to) from anything to do with spirituality or religion,
but in some cases it would be appropriate to ask a spiritual leader for a prayer, or wearing a holy talisman, having a house blessed, etc.

4. Advocacy is important, especially for people who’ve left family behind – producing supporting documentation to help reunite the family, for example, or that shows that certain types of work are not appropriate, or to help secure disability services as needed.

5. Respect for boundaries is very important, for example choosing age- and gender- appropriate health providers for people from cultures that emphasise a separation of values between such groups.

6. Body language may not always be read correctly. For example, avoiding eye contact may be a way of showing respect. Also, short “yes/no” answers may be a way of avoiding real issues in an attempt to make an assessment/interview/session come to an end quickly, so these are to be avoided. Open-ended questions and plenty of time for answers are best (although it’s frustrating that the health system in general really doesn’t encourage spending a lot of time with each individual).

7. This is really basic but also really important: explaining every procedure, therapy, medication, etc in a way that can be easily understood and making the treatment process collaborative, rather than something being ordered “from above” by an authority figure (which, let’s face it, would make many of the people in the above groups quite uneasy, frightened or non-compliant, and with really good reason – or, on the flipside, some people may comply too easily and not ask enough questions, without fully understanding a procedure). It’s best to have an interpreter or a cultural consultant present, rather than family members (although interpreters can be hard to find with languages that are not common community languages).

These are the things that come to mind – I may add more if I remember other points later.

And some links:

    NSW Multicultural Health Communication Service

    Health information and resources in languages other than English – by language or by topic

    NSW Service for the Treatment and Rehabilitation of Torture and Trauma Survivors (STARTTS)

    The Australian Indigenous Psychologists Association (AIPA)

1. CALD = culturally and linguistically diverse

DSM-V: outline of proposed changes

Here is a short summary of the proposed changes in the DSM-V draft, from The Medical News: APA releases proposed draft diagnostic criteria for DSM-5 and from Medscape Medical News (you have to register to access Medscape, but registration is free).

I like the collapse into “substance use disorders” of “substance dependence”/”abuse” – for example, Alcohol-Use Disorder, as opposed to Alcohol Abuse and Alcohol Dependence (click on the “DSM-IV” tab for details).

There will also be new suicide risk scales, adult and adolescent, chronic and acute. I’d be interested to look at the details, but can’t find these on the website at the moment.

DSM-V: hope and controversy

The draft DSM-V will be released tomorrow, 10 Feb 2010. Its website, (which launches tomorrow) will include proposed revisions and draft diagnostic criteria. The final version of the DSM-V is scheduled for release in May 2013.

The new edition is generating a lot of discussion, which is A Good Thing. The significant levels of unrest in the mental health field are because the DSM is seen to at least partly control the psychiatric diagnosis process, which in turn regulates treatment (pharma and non-pharma), as well as insurance pay-outs and allowances for psych care items.

The APA is framing the new edition as nothing short of revolutionary and at the same time, as usual, it runs an extremely tight ship regarding input and output. There have been calls for greater transparency into the process of creating the DSM-V, including from Dr. Allen Frances, the head of the APA taskforce that produced the last edition of the DSM.

Some of the problems that Dr. Frances has with DSM-V production process and taskforce are:

1. The very idea of a “paradigm shift” in the new edition. Psychiatric diagnosis is still descriptive, pretty much. Even as we have seen great advances in neuroscience, molecular biology, and brain imaging since the release of the last DSM edition, causality has not been proved to a level where biological tests can be a part of the DSM, and the findings of neuroscientific research are not yet suitable for clinical practice, and won’t be for quite a while.

2. The creation of new instruments, which is slow and resource-intensive, was not necessary.

3. Indirect involvement of pharma companies. To promote drug sales, pharma companies may sponsor selective “education” campaigns focusing on the diagnostic changes that increase the rate of diagnosis for disorders that will lead to the increased writing of prescriptions.

4. The inclusion of many new categories to capture subthreshold versions of disorders (for example, “pre-psychotic”, for those considered at risk for developing psychotic disorders). The intended purpose is to reduce the occurrence of false negatives (missed cases), hence boosting early detection and preventive treatment. However, this could also have the negative consequence of increasing false positives and, in Dr. Frances’s words, the “wholesale imperial medicalization of normality that will trivialize mental disorder and lead to a deluge of unneeded medication treatments.” (Eeek!)

5. Ditto for a new series of behavioural addictions (to sex, the internet, etc.) which may cause a medicalisation of behavioural problems.

6. A failure to specify the level of empirical support needed to approve any changes to the information contained in the previous edition.

7. A lack of openness to constructive criticism.

These are all very important concerns and I’d like to see the APA address them – especially no. 4, 5 and 6. Regarding no. 7, the APA is inviting feedback and opinions on the draft, and the fact that the release date is more than 3 years from now could mean that they will have the time to consider suggestions and criticism received.

My own thinking on the DSM is that it’s not perfect, and it should not be a “bible” for psychiatry and psychology. No psych*ist I know only uses the DSM for diagnosis. It’s a tool to be used by qualified and experienced clinicians in conjunction with a thorough interview and history-taking. However, indirect influences such as selective education could play a part in even the most thorough diagnostic process.

Also, many instruments are based on DSM criteria, so while the DSM itself may not be specifically used for diagnosis or for research, it has a wide reach.

I see disorders as cultural constructs. By this I don’t mean to imply that they are “made up”, or that their effects are not extremely serious, but that a certain grouping of symptoms into a coherent disorder is arrived at in a culturally-grounded way. I don’t think there will ever be conclusive scientific proof that shows that a certain cluster of symptoms should always be grouped together to form a certain disorder (not that scientific research is not culturally-grounded and -driven itself). This can be seen in the significant changes that DSM disorders have gone through from one edition of the DSM to the next. Then, even symptoms can vary culturally. For example, in certain Middle Eastern populations mood disorders present more somatic symptoms than in Western populations. And then you have culture-bound syndromes as well.

I think it’s important to keep disorders (and symptoms) -as-constructs in mind when looking at DSM debates; however, since the biomedical model of illness, including mental illness, requires the clinician to draw a line – what does and doesn’t require treatment, what requires one particular treatment or another, a particular intervention, a particular dosage, what is and isn’t relevant in a court of law, what is and isn’t worthy of compensation, awareness of disorders as cultural constructs may not be very useful in a practical clinical way.

However – I think one of the biggest steps forward that the DSM has made over time, which gives heed to the idea of subjectivity of classification and diagnosis, is the fact that many disorders in the DSM have as one of their inclusion/exclusion criteria the degree of impairment (physical, psychological, social) that the symptoms are causing the individual. In other words, even considering the subclinical categories which will be introduced in DSM-V, one of the determining factors for treatment will still be the answer to the question: “how affected by these symptoms is your life?”. After all, unpleasant or painful symptoms that affect quality of life don’t need to be part of some greater and well-defined disorder, nor do they need to be universal in manifestation, to be taken seriously and treated in other branches of healthcare, so I don’t see why they should be disregarded in mental health. Of course, it’s also of utmost importance to heed Dr. Frances’s warnings of overmedication and overpathologisation.

Overall, I’m both excited and anxious about DSM-V and I will be taking the time to go through the information on tomorrow.

MINI musings

One of the components of the research project I’m currently involved in is collecting mental health information using the Mini International Neuropsychiatric Interview (MINI) Plus 5.01. This is a long-ish structured diagnostic interview for the major Axis 1 psychiatric disorders in DSM-IV and ICD-10, with most of the questions requiring a Y/N answer.

There is so much variety in how the participants I’ve tested approach the MINI, despite its relatively straight-forward structure. Some of the sections are a bit confronting (like the Suicidality section), and while some people take the questions in their stride, others are quite uncomfortable and need a lot of reassurance.

Other participants have a lot of trouble with the formal language of the interview – I know it so well that I can now simplify it and make it sound more casual – more like something that someone would say, rather than something out of a textbook (the MINI is already simplified and made more accessible to the layperson, but some parts still sound very formal). Other participants (quite rightly, in a sense), react negatively to the classifications – I don’t read these out, but some of the participants either ask me or peek at the interview sheets while I’m going through them.

There is a usually some nervous chuckling and I can see how anxious some people get – even at this informal, anonymous, completely voluntary level – about any kind of stain on their character; any kind of implication of pathology, or “strangeness”, or judgement on my behalf. The fear of being seen as an “insane subject” is alive and well.

Then there is the other end of the spectrum – people who almost seem to want to be classified, despite the fact that they are well within “healthy” parameters, as far as the MINI goes.

The MINI has a section on Anorexia Nervosa; this section requires the participant’s height and weight. Interestingly, this seems to be a touchy topic for male as well as female participants. It’s hard not to make comments at this point that reflect my own politics (i.e., you should have the body shape/size/weight you want, if you’re a healthy control), when the participant make disparaging remarks about their own weight, but I don’t feel that’d be professional. It’s a personal issue and I don’t want to add to it. But I also feel that by not responding, it might seem like I’m silently agreeing with negative comments.

Anyway, the variety of responses is really interesting. I love this part of research – talking to people to collect data – as much as I like collecting non-verbal data, and looking at squigly lines on the screen.

1. MINI Plus English Version 5.0 ©1994-2006 Sheehan DV & Lecrubier Y