Neuropsychology – Niagara Neuropsychology

What is

NEUROPSYCHOLOGY?

Neuropsychology is a scientific discipline that examines the relationship between cognition/behaviour/emotion and the brain. It can be conceptualized as falling between neurology (study of the central and peripheral nervous systems) and cognitive psychology (study of higher order cognitive functions of the mind). Clinical Neuropsychology applies the findings from neuropsychological and other neuroscience disciplines to people and their problems. Neurologists on the other hand, tend to be focus more on signs and symptoms of neuropathology in the brain, spinal cord, and peripheral nervous system and less so on higher behaviours and cognitions mediated by the brain.

What is a

NEUROPSYCHOLOGIST?

A clinical neuropsychologist is a professional within the field of psychology with special expertise in the applied science of brain-behaviour relationships. Clinical neuropsychologists use this knowledge in the assessment, diagnosis, treatment, and/or rehabilitation of patients across the lifespan with neurological, medical, neurodevelopmental and psychiatric conditions, as well as other cognitive and learning disorders. The clinical neuropsychologist uses psychological, neurological, cognitive, behavioural, and physiological principles, techniques and tests to evaluate patients’ neurocognitive, behavioural, and emotional strengths and weaknesses and their relationship to normal and abnormal central nervous system functioning. The clinical neuropsychologist uses this information and information provided by other medical/healthcare providers to identify and diagnose neurobehavioral disorders, and plan and implement intervention strategies. The specialty of clinical neuropsychology is recognized by the American Psychological Association and the Canadian Psychological Association. Clinical neuropsychologists are independent practitioners (healthcare providers) of clinical neuropsychology and psychology.

The clinical neuropsychologist (minimal criteria) has:

1. A doctoral degree in psychology from an accredited university training program.

2. An internship, or its equivalent, in a clinically relevant area of professional psychology.

3. The equivalent of two (fulltime) years of experience and specialized training, at least one of which is at the post-doctoral level, in the study and practice of clinical neuropsychology and related neurosciences. These two years include supervision by a clinical neuropsychologist.

4. A license in his or her state or province to practice psychology and/or clinical neuropsychology independently, or is employed as a neuropsychologist by an exempt agency.

What is the purpose of a

NEUROPSYCHOLOGICAL EVALUATION?

A neuropsychological evaluation is used to obtain several types of information. Reasons you may be referred for or request a neuropsychological evaluation may include, among others:

to help determine if there are problems with your brain functioning,
to help in determining a diagnosis,
to define your brain-related strengths and weaknesses,
to guide treatment for your personal, educational or vocational needs, and make relevant recommendations to your other health care provider(s), or
to document possible changes in your functioning over time.

What is a

NEUROPSYCHOLOGICAL EVALUATION?

A neuropsychological evaluation typically involves assessment (testing) with a group of standardized tests that are sensitive to the effects of brain dysfunction. Unlike CT or MRI scans which show abnormalities in the structure of the brain, or EEG, which shows electrical abnormalities in the brain, neuropsychological testing is used to show the ways in which a person can or cannot perform certain functions or tasks that are dependent upon brain activity.

These functions or tasks (for example, memory and learning) form the necessary building blocks of successful living in the individual’s daily life. Impairment in many of these functions may exist because of brain abnormalities that cannot be detected on CT or MRI scans. Therefore, neuropsychological assessment is a procedure with a unique purpose; it can be used to reveal or diagnose brain dysfunction when no structural brain abnormalities can be seen.

Furthermore, when structural abnormalities have been found, neuropsychological assessment provides a way to determine what functions may be impaired because of the structural defects, and to determine the degree to which they may be impaired.

However, a small minority of neuropsychologists are trained in the use of quantitive electroencephalography (qEEG) which is the measurement of electrical patterns at the surface of the scalp which reflect cortical activity, and are commonly referred to as “brainwaves”. Quantitative EEG (qEEG) is the analysis of the digitized EEG, and in lay terms this sometimes is also called “Brain Mapping”. The qEEG is an extension of the analysis of the visual EEG interpretation which may assist and even augment our understanding of the EEG and brain function.

The use of advanced techniques such as Independent Component Analysis (ICA) and neuro-imaging techniques such as Low Resolution Electromagnetic Tomography (LORETA) can map the actual sources of the cortical rhythms. These advanced approaches are changing our understanding of the dynamics and function of the human brain.

WHAT TESTS ARE USED?

The standardized tests used in a neuropsychological evaluation typically assess functioning in the following areas: attention and memory, problem-solving and other complex abilities, visual-spatial functions, language functions, sensoryperceptual functions, and motor functions.

Assessment of academic skill development and emotional functioning, while not exclusive to neuropsychological evaluation, is typically performed, as well. The perspective of the neuropsychologist is frequently requested to understand subtle brain-related factors involved in academic failure or impaired emotional functioning, even when no biological causes are suspected. However, the specific areas assessed depend upon the referral questions presented. An interview with the individual and/or family members is typically included. Observations in other settings, such as school or hospital, and review of school/medical records also may be included in the evaluation process.

qEEG or “brain mapping” can also be used which may assist and even augment our understanding brain function by providing normative-based brain imaging that may help determine the source of the dysfunction.

WHAT IS THE OUTCOME?

The product or outcome of a neuropsychological evaluation is a conclusion or set of conclusions made about the individual’s functioning. If requested, the product also may include specific recommendations to guide treatment or otherwise enhance the individual’s functioning. The conclusions and recommendations are developed by integrating information obtained from the standardized testing, interviews, records and other observations.

DECIDING TO SEE A PSYCHOLOGIST:

HOW TO CHOOSE ONE AND WHAT TO EXPECT

Making a decision to see a psychologist or other mental health practitioner can be a difficult one. Acknowledging that you have a problem, and arriving at the point where you are ready to talk about it, can be difficult.

DO I HAVE A PROBLEM?

Many people feel uncomfortable about the prospect of talking about things that are distressing or even embarrassing to a complete stranger. On the other hand, people often find it much easier to tell their problems to someone they do not know and who has no expectations of them.

Talking to friends and loved ones can be very supportive but sometimes it is difficult for people we know well to be objective and honest because of their feelings for us and of their roles in our lives. Further, our family and friends cannot recognize the type or seriousness of a psychological problem nor the best way to help us cope with it.

WHO DO I SEE?

Once you have made the decision to see a mental health practitioner, you need to decide whom to choose. There can be many different people who claim to treat mental health problems. Not all of them are well trained professionals in the mental health field. Whomever you consult, it is important to ask them if they are regulated – in other words, do they have a license to practice?

WHY SEE A REGULATED PROFESSIONAL?

Provincial and territorial governments give a few health professions the responsibility to license or regulate their profession. Regulation or licensure is important because it ensures that the practitioner has met a high standard of training and provides a high standard of care.

If you have any concern about the behaviour of a regulated practitioner, you can contact the provincial or territorial regulatory body that licenses his or her practice. The role of the regulatory body is to protect the public by ensuring that its practitioners are properly trained and are competent. You have no assurance that an unregulated person is competent to provide the service offered and no regulatory body to contact if you have any concern about the service provided.

HOW CAN I TELL IF SOMEONE IS REGULATED?

You can verify a regulated practitioner’s credentials yourself by calling the regulatory body and asking if the practitioner is in good standing. The Canadian Psychological Association’s website lists the names and coordinates of all the provincial and territorial regulatory bodies of psychology: Provincial and Territorial Regulatory Bodies. Because psychologists are regulated provincially and territorially, contact the one in the province or territory in which you are receiving service because that is where the psychologist would need to be registered.

HOW DO I CHOOSE A PSYCHOLOGIST?

People often access psychologists through local clinics and hospitals, upon referral from their family physicians, or upon the recommendation of friends, family members, religious leaders and teachers. Provincial and territorial associations of psychologists also often maintain referral services and can direct you to psychologists in your jurisdiction who work with problems such as yours. CPA maintains a listing of all the Provincial and Territorial Associations of Psychology. The Canadian Register of Health Service Providers in Psychology also has a referral list at www.crhspp.ca.

Although you may need a referral from a physician to see a psychologist on staff at a hospital, you can self refer to psychologists in private practice.

In addition to choosing a regulated practitioner such as a psychologist, you want to choose one with whom you feel comfortable. It is very important to psychological work that the client and psychologist have a good rapport and develop a good working relationship. As is the case with any other kind of professional, one practitioner might be a good fit for one person but not a good fit for someone else.

Once you have established the practitioner’s credentials, the best way to determine if he or she is right for you is to use your feelings as a gauge. Does this person appear kind, understanding and non-judgmental? Do you feel listened to and uniquely appreciated? If not, perhaps you need to try someone else who might be a better fit.

WHAT IS THE DIFFERENCE BETWEEN A PSYCHOLOGIST AND A PSYCHIATRIST?

In Canada, the professionals who most commonly treat people with mental health problems are psychologists and psychiatrists. A psychologist holds a master’s and/or doctoral degree in psychology that involves from 6 to 10 years of university study of how people think, feel and behave. Psychologists who hold doctoral degrees, can use the title ‘Dr.’. Psychologists who practice (and hence those who are licensed) typically will have completed their graduate university training in clinical psychology, counseling psychology, clinical neuropsychology or educational/school psychology.

Although psychologists are licensed generally and not in specific specialty areas, they are required to declare their areas of competency to the regulatory body and required to practice within the bounds of their competence. It is important that, for example, a psychologist practicing neuropsychology (assessing and treating problems in thinking or brain function that might occur after an accident or stroke for example) has been trained in the area of neuropsychology.

A psychologist working with children should have been trained in the area of child psychology and so on. Typically, the psychologist will have received this training while in graduate school where he or she will have chosen the courses and training experiences to prepare for working within a particular specialty area. Sometimes, psychologists pursue specialized training after graduation by completing a post-doctoral fellowship for example.

A practicing psychologist is trained to assess and diagnose problems in thinking, feeling and behaviour as well to help people overcome or manage these problems. A psychologist is uniquely trained to use psychological tests to help with assessment and diagnosis. Psychologists help people to overcome or manage their problems using a variety of treatments or psychotherapies.

Psychiatrists are medical doctors who go on to specialize in mental health and mental disorders. Psychiatrists often use medication to help their clients manage their mental disorders and there are some disorders for which medications are very necessary (schizophrenia and some depressions for examples). Some psychiatrists also do psychotherapy much like psychologists do. For more information on the study and practice of psychiatry, please visit the website of the Canadian Psychiatric Association at http://www.cpa-apc.org.

Sometimes a client might consult his or her family physician about medication while seeing a psychologist for psychotherapy. Some family physicians have an interest and training in treating psychological problems.

DO MEDICATIONS WORK?

It is important to recognize that medications most often manage, but do not cure psychological problems or mental disorders, as is the case for other types of physical problems. For example, if you have an infection and take an antibiotic, the infection typically goes away. However, if you have diabetes, you may need to take insulin for the rest of your life.

Most medications for psychological problems or mental disorders do not cure the disorder but relieve it and make it easier for the person to manage, often with the help of psychotherapy. As mentioned, there are some mental disorders for which medications are very necessary (schizophrenia and some depressions for examples). Research tells us that medication and psychotherapy work better than either medication or psychotherapy alone in managing some types of psychological problems. Some types of problems might even be better managed with psychotherapy alone.

HOW ARE PSYCHOLOGICAL SERVICES PAID?

In Canada, the services provided by a psychologist are covered by provincial health insurance only if the psychologist is employed by, for examples, a hospital, correctional facility, community clinic, social agency or school.

The services provided by a psychologist in private practice are not covered by provincial health insurance plans and the psychologist bills the patient directly. Many people have extended health benefits through their employers that cover some amount of psychological service annually. The services of a psychiatrist, whether they work in a hospital, clinic or in a private office, are covered by provincial health insurance plans. As is the case for psychologists employed in hospitals or schools, wait lists to see a psychiatrist can be long.

WHAT HAPPENS TO THE PERSONAL INFORMATION I DISCUSS WITH MY PSYCHOLOGIST?

In consulting a practitioner about personal psychological problems, people are often concerned about confidentiality. Early on when seeing a client, the psychologist should review the limits of confidentiality. Information disclosed to a psychologist is confidential and cannot be disclosed without the client’s consent except under certain specific conditions. These conditions are referred to as the “limits of confidentiality”. These limits typically involve situations where the client gives the psychologist information that leads him or her to suspect that harm might come to someone. If a psychologist suspects that a client is going to harm himself or someone else, that a child is being abused or neglected, or that another health care practitioner has sexually abused a patient in some way, then he or she has an obligation to report this information to the appropriate authority (the police or children’s aid society for examples). The courts also have the power to subpoena a psychologist’s files.

Psychologists must retain records of their contacts with clients and these records typically include details about the clients presenting problem and history, psychological test data and any diagnoses made, as well as details about sessions attended. These records must be kept and stored securely for periods of time defined by provincial regulation. Typically, records are kept for 10 years after the last client contact and for at least 10 years after a minor client reaches the age of majority. After the 10 years are up, files are securely discarded by being shredded.

WHAT HAPPENS ON MY FIRST VISIT TO A PSYCHOLOGIST?

Once you have the name of a practitioner and make a first appointment, it is usual for him or her to ask you to describe your problem and to ask for details about your personal history. These questions will include such things as when did your problem start, what makes it better or worse, how does the problem affect your work or social life. Questions about your personal history can include details about your experiences growing up, your education and work history, your marital status and interpersonal relationships, and whether you use medication, alcohol or drugs. This information-gathering phase can take one or more sessions and may be supplemented by the use of psychological tests.

PSYCHOLOGICAL TESTS

Psychological tests are used to gain a better understanding of the kind of problem in thinking, feeling or behaviour a person presents. If a psychologist plans to use a test, he or she should explain why it is being used and what kind of function it is used to assess. For example, some tests are used to assess and help diagnose mood, some are used to assess problems in memory or concentration, and some might be used to better understand personality characteristics. For example, some are pencil and paper tests that pose questions to which you must answer true or false and others might require you to manipulate objects or remember numbers or phrases. Testing is used to help the psychologist arrive at an impression or diagnosis of your particular problem.

TREATMENT

Following the information-gathering phase which may or may not include psychological testing, it is important that the psychologist discuss with the client (and/or his or her parent or guardian if a child) what he or she thinks is wrong and what he can offer in the way of help. Reasonable questions to ask a psychologist are:

Have you treated many people with this kind of problem?
What kind of psychotherapeutic approach do you use and how does it work?
What kind of success can I expect?

Treatments or psychotherapeutic approaches used by psychologists should be empirically-supported treatments – in other words treatments which research has proven to be effective. Common types of treatments include cognitive-behavioural therapy, interpersonal therapy, and systems therapy among others. Treatment might be offered in an individual, group, couple or family format depending on the problem and whom it affects

WHAT HAPPENS DURING PSYCHOLOGICAL TREATMENT?

Early on in the treatment, the psychologist will help you make goals to work towards and identify the ways therapy will help you achieve them. Goals can include feeling less depressed, feeling more comfortable in social situations, improving pain management, changing your behaviour, or increasing self-esteem. In addition, the psychologist will review your progress in meeting these goals at certain intervals and may have you fill out questionnaires designed to help monitor progress.

Important things to remember about psychological treatments are that it can be hard work to learn the skills to handle difficult thoughts and feelings more effectively so they have less impact over you, and to change our behaviour – you have to be ready to commit yourself to attend sessions regularly and follow through on recommendations. One thing that cannot be changed is the past but you can change how it affects you. It is also difficult to change the behaviour of other people. Psychological treatment is primarily focused on helping you make personal changes to improve your life.

There is often more than one way to solve or manage a psychological problem – which one to choose can depend on the training of the practitioner and the characteristics of the client. Finally, you are entitled to be an informed consumer and active participant in the psychological treatment process – if you have questions or concerns, let the psychologist know!

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