Finishing a placement and then having to prepare for a new one is disorienting. You still have your old cases whirling around in your head, as well as reminders about weekly to-dos like team meetings, case reviews, referrals, bits of theory you want to read up on, things to chase up like metabolic screening, questionnaires, and you remember the nice Japanese and Thai cafes and the little greengrocer right next to the train station and the amazing Greek cake shop and how convenient it was to have a Woolies basically inside the station…and then it all changes. You have to let go of all that, and make yourself familiar with a new team, new names, new admin, a new hospital/clinic, a new way of doing notes, and a completely new location where you don’t know all the good places to eat, the coffee shops, if you’ll have time for breaks, what parking is like, etc etc etc. (My next placement happens to be somewhere I used to work a long, long time ago so I’m somewhat familiar with the location, although it’s all changed now.) It’s like starting a new job every 6 months.

Not to mention an entirely different patient group. So far my external placements have been in adult settings, whereas the one I’m going to is in paediatrics. I haven’t worked with children and families in about a year. I need to dust off my developmental books and my family therapy skills. I was fortunate to get a good amount of time in the university clinic both assessing children with suspected learning disorders and attentional difficulties, as well as doing therapy for different age ranges and presenting problems, but I still feel unprepared. What if…?

I was lucky enough to get a 1.5 week break between placements, which I’m using to recruit and test participants for my research, and to catch up on TV shows (The Killing, The Fall, and Jonathan Strange & Mr Norrell are current favourites) and on knitting. I’ve also got a weekend trip out of the city coming up, where the plan is to walk around a lot, eat lots of food, play lots of games – can’t wait. I hope it clears my mind a bit.


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.

Season change

I much prefer autumn and spring to summer and winter – I see them as transitional seasons, which of course isn’t quite accurate, as every season is a transition. But in spring and autumn, it feels like the transition is somehow more extreme, and so it’s not as monotonous as three months of heat or cold.

This summer has left me battered and bruised, and I’m glad it’s now autumn. I can feel the cool change in the air, especially in the morning and at night, a touch of crispness. It feels like I’m slowly waking up – opening my eyes, moving on. This is not really a personal blog so I won’t go into the details, but the past few months have played havoc with my internal and external life. I hope now is the time to get some distance and heal.

My course continues and I still love it, although it’s hard at times. In this clinical rotation the emphasis is much more on process, a notion which is hard to describe. Basically it’s focusing on the dynamics in the therapy room between therapist and patient, rather than solely on the presenting problems. This is challenging for me as a novice therapist, as it is quite a confronting process, both for therapist and patient, as it involves pointing out the “backstage” elements of what is a constructed social interaction. Therapy is about being truthful, rather than being nice, but it’s hard to be truthful in a nice way at times. I’m also learning about different ways of “being” in the therapy room with different types of patients, which is also challenging. Being “nice, supportive therapist” will not get some (most?) people to shift.

There’s also only a couple of months until we are released into the “real world” for our external placements, which is quite scary/exciting. In the mean time, I’m also learning lots of neuro, and there may be some brain dissectin’ going on in the future. Not having done a human brain before, this is exciting.

Things I am loving right now: coffee, Swedish crime fiction (everyone in these books drinks so much coffee), and that it’s cool enough to wear leggings. Yes, sometimes it’s the little things that get you through.

How long is a piece of string?

Here’s the thing: changing careers is hard. Not just because of the need to pick up completely new skills, and hit the ground running, but also because everyone expects you to be unwaveringly enthusiastic about how you’re going in your new field. You feel a need to prove to everyone that this is not a mistake, that you’ll make it, that this is ‘it’.

So when the going gets hard, there’s still this need to keep smiling, because ‘you chose this’ and ‘if you don’t like it, why don’t you go do something easier’. This week, the going got hard. I’m trying to get my research off the ground, conceptually, and it’s like hitting my head against a brick wall. I have to bring something new to the table, so I had a couple of ideas that I thought would be pretty nifty to look at, and they are – but it turns out they’re also too involved for the scope of my current degree. It’s hard finding the ‘right’ idea: one that’s above all, interesting enough to sustain you throughout the degree, but that will also let you graduate at some point, and that’s also possible given the chronic lack of time. Not too little, not too big. (Hence the title of this post.)

While trying to get my research off the ground, I’m also trying to memorise hundreds of symptoms (plus changes from one diagnostic system to another), trying to learn different therapies and techniques so I can provide adequate treatment in the clinic, make weekly session plans, and prep for upcoming neuropsych assessments that we do throughout the degree. (And this is my ‘mid-year break’ – soon, coursework will start up again.) All these components are pretty much separate. Patients don’t (and shouldn’t have to!) care that you have to do research; the research supervisor doesn’t care that you have to do coursework; the neuropsych supervisor doesn’t care that you’ve had a hard clinical week and don’t feel like writing reports. And exactly zero people care that you also have to work for money. And the admin. Oh, the admin – it never ends, and I’m sure one day it will provide the subject for an absurdist play. So this is where I’m at right now.

I started writing this post a few days ago, but wanted to cool off a bit before submitting it. Now, looking back at it, I have to smile a little, because this really is what I want to be doing, and I do generally prefer to keep busy. But, the point is, there most certainly are bad days, and just because something is done by choice, there shouldn’t be an expectation (often self-imposed) of permanent cheerfulness.


So, I’m now almost a full semester into my clinical program, and a few short weeks away from starting the first placement. I’ve learned a lot in the past few months – I’ve picked up knowledge and skills, and I’ve heard plenty of both inspiring and shocking things (which doesn’t mean I feel at all prepared, by the way). What I am coming to learn about providing psychological therapy is that, essentially, its purpose is to get people to do all the things they don’t want to do: face terrible situations they don’t want to face, perform actions that they really don’t want to perform, do things that are really hard and painful.

Because the training program is demanding, we are told to implement as many self-care strategies as we can, now as students, and as future clinicians, to avoid burn-out and damage to our own health (pity these things aren’t built into the program).

So I thought I’d run through some of the things I do for self-care, as a reminder to myself when things get even more full-on, and also for anyone else looking for ideas.

1. Live life.
There’s often a temptation to hole up and shut the world out while you get through study. At some point last year, I noticed that if I held back from social occasions or other fun things I would stay home, possibly mope, most likely procrastinate, whereas if I did go out/have a holiday etc, even though that would leave less time for study, I would be more efficient. So this year I’m doing things outside the course (within reason – as there are some hard limits on my time and energy).

2. Exercise!
I cannot emphasise this enough. I started running 6 months ago and I’m *very* slowly building up to 5km. (In honour of Dr. Isis, I now refer to this as “rundouchery”.) I believe that I finished 4th year with my sanity mostly intact because of exercise. It’s an antidepressant, anxiolytic, analgesic, promotes neurogenesis (= will make you feel good *and* SMRT!), and also can give you a goal to work towards. WIN.

3. Good food.
Get your 5-6 veg + 2 fruit a day and everything will be better, I promise.

4. Be around people.
Family, friends, pets, professionals – whatever your needs are, don’t isolate yourself, as tempting as it may be when you have a mountain of work to conquer. Let people know you’re struggling, and that you need help. Get the help you need, practical, emotional, whatever it may be. Spend whatever time you can afford with the people who make life good.

5. Games and TV.
I am a big fan of games that have defined points where you can leave, e.g. finishing a chamber in Portal or a chapter in a story-driven adventure game. Also TV shows that are interesting but don’t leave you hanging (like Elementary). Sometimes you need to ‘switch off’ for a while, without getting sucked in.

6. Maintain interests outside of study/work.
It’s good to have interests outside of professional ones, however, this I haven’t very good at. I haven’t written, drawn, painted, taken photos, gone bushwalking or caving in a long time – I hope to get back into this sometime soon.

This is what helps me – I’d be happy to hear about what works for other people, when the going gets tough.

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

World Suicide Prevention Day 2010

Today is World Suicide Prevention Day. The International Association for Suicide Prevention has a lot of good information on suicide and prevention and a list of activities happening throughout the world, including Australia. There’s also a downloadable activity sheet.

The issue of suicide is very personal to me: like many of us, I’ve lost a loved one to suicide.

For WSPD this year I wanted to post some information about suicide and where to get help.

National Crisis Services
Emergency: 000
Lifeline (telephone crisis counselling): 13 11 14
Suicide Callback Service: 1300 659 467

Please see the bottom of this post for state-specific resources and for national information lines.

Risk factors for suicide in Australian youth
Being male, living rurally, being Indigenous, non-heterosexual, having a mood disorder, a history of suicide attempts, substance abuse, stressful or traumatic life events, family problems, family history of suicide, easy access to means of suicide, social disengagement, unemployment.

Suicide Myths
1. Talking about suicide will cause suicide. False: Talking openly about suicide can save a life. Sometimes people don’t want to die, but don’t feel they have a choice.

2. People who threaten to commit suicide won’t do it. False: Threatening to commit suicide is not just attention-seeking. It needs to be taken seriously as a cry for help.

3. After an unsuccessful attempt, the danger has passed. False: The danger period is not over. The person needs to be monitored for at least 90 days.

4. Suicide is an impulsive act. False: Not always – sometimes it’s planned for a long time and/or in detail.

5. “Truly” suicidal people have already made up their mind to die. False: some people don’t want to continue living in their current situation but don’t necessarily want to die. Suicide may be seen as the lesser of two evils.

6. A suicide attempt is not serious and the person is just “seeking attention”. False: Take every suicide attempt seriously.

7. If a previously depressed person suddenly seems happy, relieved or upbeat it means that they feel better. False: sometimes the person may seem “happy” or “content” because they’ve made the decision to take their own life as an option to get out of current pain and suffering. Watch for any sudden swings in mood. Also watch for the person giving away personal belongings and putting affairs in order.

8. Suicide is a cowardly act. False: It’s often a desperate act for people who are overwhelmed by their circumstances, who are sometimes not thinking clearly, and who need help.

National Information Services
Beyondblue Info Line: 1300 224 636
MensLine Australia: 1300 789 978
Australian Psychological Society Referral Line: 1800 333 497
SANE Australia: 1800 187 263
Relationships Australia: 1300 364 277
Carers Australia: 1800 242 636

Crisis Assessment and Treatment Team: 1800 629 354
Gay and Lesbian Telephone Help, Referral and Outreach Bureau (THROB): (02) 6247 2726

Suicide Prevention and Support: 1300 133 911
Salvation Army Prevention & Crisis Line: 02 9331 2000 (Metro) and 1300 363 622 (Rural)
Gay and Lesbian Counselling Service of NSW: 1800 184 527 or (02) 8594 9596

Mental Health on Call Team: Top End (08) 8999 4988
Mental Health on Call Team: Central Australia (08) 8951 7777
Gay & Bisexual Mens Line Telephone Service: 1800 181 888

Salvo Crisis Counselling Service: Metro (07) 3831 9016 & Rural 1300 363 622
Gay and Lesbian Welfare Association: 1 800 184 527 or (07) 3017 1717

Mental Health Assessment and Crisis Intervention Service: 13 14 65
Gay and Lesbian Counselling Service of SA: 1 800 182 233 or (08) 8334 1623

Mental Health Services Helpline: 1800 332 388
Working It Out: http://www.workingitout.org.au/contact.html

Mental Health Advice Line: 1300 280 737
SuicideLine: 1300 651 251
Gay and Lesbian Switchboard: 1 800 184 527 or (03) 9827 8544

Mental Health Emergency Response Line (Metro): 1300 555 788
Rural Link (Rural): 1800 552 002
Gay and Lesbian Community Services of Western Australia: 1 800 184 527 or (08) 9420 7201
Samaritans Crisis Line: 1800 198 313