Working with Brain Injury

A primer for psychologists working in under-resourced settings

Rudi Coetzer, Ross Balchin

• Publisher: Psychology Press
• Year: 2014
• eBook ISBN: 9781317810612
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

This book provides a hands-on resource for the development of essential skills and competencies in clinical neuropsychology. On a very practical level it addresses a question frequently asked by students, trainees, interns, and newly qualified psychologists: what do I need to know in order to perform the everyday tasks involved in clinical neuropsychology? The authors distil, from a vast knowledge base, the practical skills and knowledge needed to lay the foundations for working with brain-injured patients, especially within the developed and developing world where time and resources are limited.

The book is divided into three main sections: Basic Foundations, Clinical Practice, and Professional Issues. Together these sections cover 18 fundamental topics, each representing a key part of the life of a practitioner. Each chapter contains practical tips, points for reflective practice, and suggested further reading, with a particular emphasis on issues pertaining to working in under-resourced clinical environments. The book draws upon landmark academic papers and textbooks, and also the authors' experiences of working in state hospitals in both South Africa and the National Health Service in the United Kingdom.

Working with Brain Injury will be essential reading for clinical psychology trainees and their supervisors, for newly qualified psychologists in clinical settings, and for students and practitioners in other clinical professions seeking an introduction to clinical neuropsychology.

PART I

Basic foundations

1

IDENTIFYING A KNOWLEDGE BASE

Think before you leap; it is very wise to stand back and clearly define what it is that one needs to learn before immersion (and drowning …) in studying it. It may sound like a false strategy to invest a whole chapter to the topic of deciding what to study, but bear with us and persevere. Clinical neuropsychology is an extremely fulfilling area in which to train and work. As part of the wider neuroscience disciplines, where many different professionals work, it offers much in the way of intellectual stimulation, while at the same time providing an opportunity to make a meaningful contribution to the lives of others. Not many jobs can equal the immense satisfaction that results from working in this unique area of healthcare. Unfortunately, neuropsychology is a scarce resource in most healthcare systems, in both acute diagnostic work and in post-acute rehabilitation.

Some of this lack of neuropsychological resources has to do with the length of time that training takes, along with the investment required. At a systemic level, in many countries there are simply not enough financial resources to provide extensive rehabilitation for patients with brain injury beyond the acute, life-saving stage of care (and even this critical service is not always available). This naturally affects the number of clinicians – including neuropsychologists – who work in publicly funded post-acute brain-injury rehabilitation. Consequently, in order to augment their existing clinical skills, many psychologists and other professionals find that developing core competencies in basic clinical neuropsychology can potentially make a big difference to their confidence and ability when providing care to this patient population.

While neuropsychologists rely heavily on a robust knowledge base, the prerequisite clinical skills are ultimately developed in practice, over time. In short, this entails seeing patients on a daily basis. Training in clinical neuropsychology varies widely across the world (see Chapter 15), leading to different emphases being placed on clinical skills and expertise. Nevertheless, there are probably two main strategic obstacles faced by aspiring clinical neuropsychologists, psychologists and other professionals who work in brain-injury services. The first obstacle is failure to prepare adequately for working in this specialist field. Starting clinical placements/first jobs without having received robust, direct teaching of academic knowledge is a bad strategy for any clinical profession. Inevitably, this scenario results in anxiety and, in many circumstances, avoidance of patient contact during what is a very formative period of professional development. The second obstacle is more problematic to control: after receiving foundation or specialist training, clinicians may sometimes not have the opportunity to see enough patients to develop the necessary clinical skills – if no clinical posts exist, for example. While these points may seem trivial, they are fundamental to understanding the potential stumbling blocks that one might initially face when embarking on a career or placement.

For clinicians in training who are new to hospital/clinic environments, such settings can be daunting and intimidating, especially when encountered for the first time – this can indeed be the experience of most healthcare professionals. Also, in many instances, psychologists in training are often only exposed to such environments and situations at masters or pre-doctoral level, which can make the adjustment more difficult. This is especially true when one considers the amount of new information that one has to adapt to quickly during such transitions. One is also required to learn the protocols and niceties that are involved in how hospitals/clinics function. The newfound sense of the responsibility that new practitioners experience when beginning to work in hospital/clinic settings can also be an initial source of anxiety. Something else that can be disconcerting, or make one feel insecure and/or out of place as a trainee psychologist or intern, is when one is a seeing patients for the first time and getting the sense that you are ‘using’ the patients for practice rather than offering them the clinical service they so badly need.

Another, perhaps more obvious stumbling block relates to the perceived complexity of clinical neuropsychology and the neurosciences in general. While neuropsychology is indeed a complex field, it is no more so than any other of the specialist fields within psychology. There are many areas of neuropsychology that most aspiring clinicians, and many other professionals who work in brain-injury rehabilitation settings, should ideally be familiar with. For this reason, it is not unusual to feel overwhelmed and anxious when embarking on a training programme, placement or career in neuropsychology, or any other clinical profession involved in service provision for patients with brain injuries. This problem is not only limited to the sheer depth of knowledge required in a given area, but also the fact that in order to be competent, several areas have to be mastered.

Topics that fall under the domain of neuropsychologists include, but are not limited to, assessment, anatomy, report writing, rehabilitation techniques and neuropathology. Adding to this, in multicultural/multilingual settings in countries, such as South Africa, the degree of diversity met in the patient population can be overwhelming at the best of times, especially for trainees and recently qualified professionals. As in most specialist areas, it is essential to organise and integrate the information that requires assimilation into a model that makes sense and facilitates learning. Perhaps then, the process of defining and organising is a good starting point for this book, not least to try to change the false perception that neuropsychology is overwhelmingly complex in terms of both its practice and the body of knowledge that it encompasses.

In everyday practice, practitioners tend to be immersed in the business of applying clinical techniques and skills. Over time, repetition starts to make these skills almost automatic and lessens some of the anxieties one may have. By default, clinicians are then set free from concentrating on technique and can instead focus on patients’ clinical presentations – this can occur during assessment or rehabilitation endeavours once practitioners becomes less ‘manual-bound’. Clinical tasks and the application of skills take place very much ‘in the moment’. However, while performing these tasks, we draw on more fundamental academic knowledge. This body of core knowledge can, to some degree, be ‘hidden’ in the background – it informs and shapes the application of technique at an almost subconscious level.

There are also more delayed outputs of our application of techniques and skills. Some occur fairly soon after patient interventions, such as writing clinical notes and reports about patients’ assessments. Other outputs are much more delayed or slow-moving. These are often in response to external, non-patient-related demands, such as the planning and maintenance of continuing professional development (CPD). Let us now return to the point about organising or structuring information in a progressive way, which facilitates learning and the development of practical skills. The first step is to identify key areas of clinical neuropsychology, before embarking on learning their essential content.

Three areas within clinical neuropsychology

How can the overwhelming amount of information that is potentially relevant to clinical neuropsychology be organised in order to reduce information overload? Can we facilitate a step-by-step approach to developing practical skills? There are almost certainly as many takes on the answers to these questions as there are teachers in the field! However, choosing to follow a stepped, problem-based learning approach, and then gradually increasing the information that is directly applicable to clinical practice, may help to simplify things somewhat. This way, it is possible to retain an overall perspective of what is being learned, while gauging one’s progress. If ever there were a strategy protective of morale, this is it!

Learning applied skills in neuropsychology should not be a process creaking under the weight of labyrinthine complexities. First, there is a core body of knowledge needed as a foundation; this should cover the relevant basic sciences (foundations) required. These topics/subjects are in turn fundamental to the second general area – the clinical application of knowledge from the basic sciences. Finally, as the application of clinical skills becomes entrenched, everyday, ongoing professional practice issues then become increasingly important. Many training programmes do not have time to address these professional practice topics in great depth and, consequently, many newly qualified psychologists report that they find the transition from trainee or intern to their first job quite difficult – at least in part due to this potential gap in their training.

In this book, three broad parts – Basic foundations, Clinical practice and Professional issues – cover the topics outlined below. Here follow the knowledge areas that pertain to the basic sciences, which clinical neuropsychologists should have training in: neuroanatomy (note this is listed first); neuropathology; pharmacology; neuropsychological theory; medical investigations; and psychopathology. Building upon these basic foundations follow clinical practice skills, including: clinical assessment; neuropsychological testing; neuropsychological rehabilitation; psychological therapy; and record keeping. These skills are utilised daily, but clinical neuropsychologists also have more enduring tasks for which they need knowledge, skill and, importantly, experience. These tasks are covered in the third part of this book and include: professional practice; ethics; supervision; research; team work; management; and service development.

While these three parts build progressively from foundational knowledge through to everyday clinical skills and the more strategic skills and experience we ultimately learn to apply over time, this division is, at best, somewhat artificial. It is important to note that there is considerable overlap. Nevertheless, it is reasonable to posit that defining the outline in this way has potential benefits for organising specific neuropsychological topics. It is conducive to developing a curriculum for learning that can be applied to practice in under-resourced systems, across different cultures. Furthermore, this structured approach may help to identify and emphasise the ‘absolute essentials’ necessary to develop at least some neuropsychology in settings where no neuropsychologists are available – while limiting the ‘nice to have’ knowledge and skills.

A general observation about professional development

While we divide the areas of skill into sections, there is no expectation that, once completed, a specific section is ‘done and dusted’. On the contrary, CPD is both an expectation and a prerequisite for practising clinicians, providing evidence that one is still competent. Furthermore, it is an ethical obligation to stay up to date with professional practice if you are providing a service to patients (see Chapters 14 and 16). However, is good CPD always necessarily about attending the latest research conference? Should we, in addition, not also aim to periodically revisit the basics, and should we not use supervision and other vehicles of CPD more proactively to achieve this goal?

We argue that this book’s contents are not necessarily only for those in training or those working in under-resourced areas, or specifically for newly qualified clinical neuropsychologists embarking on their first hospital job. How important is it for various professionals, including psychologists, to regularly refresh their knowledge in these broad areas of neuropsychology? The answer is perhaps more than we realise. Colleagues often report that they derive enormous benefit from attending workshop-based training events and by rereading key textbooks on clinical neuropsychology. This is certainly a sensible and valuable approach to CPD in its own right. Perhaps this is CPD – continuous practice development – the perfect companion to lifelong continuing professional development.

Continuing professional development is a somewhat mercurial concept. Employers fund and support CPD and we assume that it is a natural part of professional life. Is CPD something that we engage in every year in order to learn about the latest research findings? Or is it equivalent to an ‘MOT’ (the vehicle-roadworthiness test in the United Kingdom), periodically ensuring that at least the basics are in place to guarantee safe functioning? Some might argue that it is much more representative of a process of reflection on current practice. CPD is probably all of these things combined and more. However, there is something to be said for revision being one of the more effective antidotes for staleness in clinical practice. The importance of remaining abreast of current best-practice policies, and the latest research findings, cannot be emphasised enough; this can only be achieved when a clinician has a sound, up-to-date knowledge base that can be used as a baseline against which to compare new ways of doing things. In essence, reflective practice involves considering what is essentially already historical, and how something was done in the past, with the purpose of learning from, and improving upon, current practice.

In countries where neuropsychology is either not an established or regulated profession, or where it is a new and emerging clinical discipline, colleagues from other fields may need to be educated as to what neuropsychology is, what the role of neuropsychologists is and what clinical skills and services neuropsychologists can provide. This may seem like a strange thing to say, but it is highly relevant to the field of neuropsychology. It comes from first-hand experience that often physicians, and even neurologists, for example, have very little knowledge or understanding as to what neuropsychologists do and what skills and services they offer. In more extreme environments, where even very basic resources (such as telephones, clean water and paper) are lacking, there is a more fundamental task required in informing people about what psychologists offer. At this level, community-based individuals, such as religious leaders and interpreters, will frequently need to be drawn upon to aid in the dissemination of information.

Neuropsychologists must be prepared to educate colleagues within the broader medical field and the general public, and to ‘market’ the profession. One of the best marketing strategies is to see as many patients as possible, thereby facilitating regular contact with other professionals. This often requires a gradual process of raising awareness by psychologists who work within multidisciplinary teams. Perhaps unsurprisingly, this task is often necessary in countries with relatively well-established neuropsychology services. Historically, the profession started to grow very gradually due to this process taking place in academic and clinical settings, often involving collaborative work with other professionals.

What can we learn from history?

Before proceeding to the next chapters, let us consider, very broadly, the practice of clinical neuropsychology and whether we can learn anything from the history of this field. It immediately becomes apparent that the dilemma is what to choose from an overwhelming selection of topics. Clinical neuropsychology, although a relatively young profession, already has a rich history. There are many pioneers in the field from whom one can learn. Interestingly, a fair proportion of these figures are not actually clinical neuropsychologists, or psychologists of whatever speciality for that matter. Nor are many of the other historically pertinent pockets of information in a sen...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Foreword by Mark Solms
• Preface
• PART I Basic foundations
• PART II Clinical practice
• PART III Professional issues
• References
• Index