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.