Malaysian Society of Clinical Psychology

NewsletterVolume 1, Issue 1 January 2016

Note from the Editor:One of the values of a newsletter is to share with a membership a variety of information. To that end, I would like toencourage all members to find some thoughts, cases, “clinical pearls”, and information to share. This also includes newsof new programs, new positions, awards given to members, articles from non-members who would like to share theirexpertise, celebrations, and training opportunities. We are all learning and with any luck, will be doing so throughout thespan of our career. I was asked to start it off with an article I wrote. I hope you enjoy it. I look forward to yoursubmissions.

Thoughts on Neuropsychology: One Practitioner’s PerspectiveRory Fleming Richardson, Ph.D., ABMP, TEP

There are many ways of

studying the brain and

nervous system. We can

examine it anatomically or as

a static picture of brain

structure through magnetic

resonance imaging. We can

examine it physiologically, or

the brain in action through SPECT scans, PET

scans, functional MRI and others. Based on the

research of Penfield and other neurological

researchers, we can estimate the impact that

damage in specific locations has on function. We

can explore the neurochemical processes and likely

implications. What is of interest is that all of

these may suggest a level of function which simply

is not consistent with the anatomical and

physiological results. The brain and nervous

system is part of a total body. Our assessments

are also based on the present findings, not always

taking into account the adaptive skill and ability of

the organism to survive and adapt. For example,

if a child suffers a brain injury early enough in life,

other parts of the brain may compensate taking on

the functions usually controlled by the damaged

area. In a case I assessed a 45 year old adult had

suffered severe brain damage as a infant, resulting

in a quarter of his brain being destroyed. As he

developed, the functions which were impacted

were assumed by other parts of his brain, and the

localization of different brain functions were fully

compensated for in other parts of his brain.

Although the current MRI presented the absence

of the brain tissue in key function areas, these

functions were shown to be housed in a different

location of his brain (based on PET imaging).

Without the completion of functional testing, the

level of dysfunction could not be determined. A

neuropsychological examination is an assessment

of the level of function of each brain function

which, when added to the history of the patient

and various imaging, can provide not only a

snapshot of current level of function, but also

clues as to the prevailing maladies that the

individual may be suffering from.

It is important to understand that any assessment

is a picture of current status, and only a point, in

a continually changing picture of an individuals

condition. The individual’s current condition is a

continuum of change as events occur that impact

the condition for the better or for the worse. The

picture of current status also includes the

adapting and compensating the patient has made

since the injury or malady occurred.

As a psychologist, I have come to believe that

everything that we call a disorder is made up of

something that we absolutely need, but at levels

which are too high or too low. The focus is to help

biochemistry, neural plasticity, thought processes,

and behaviors to move into a range where the

individual can function best, and achieve the best

quality of life possible. Obviously, to achieve this,

a comprehensive assessment is needed.

Unfortunately, many services that are provided

focus on the symptoms rather than attempting to

achieve a balanced gestalt (whole picture) of the

causes of the imbalances. When the etiology can

be found, treatment can be honed to match

individual needs.

Therapeutic Psychological and Neuropsychological

Assessments are for purposes which include:

(1) to identify current neurological and/or

psychological conditions which the patient is

suffering from,

(2) to determine possible dynamics and their

interplay which could affect treatment,

(3) to determine possible treatment and

accommodation needs,

(4) to provide recommendations for further

treatment and assessment, and

(5) provide a prognosis given the information

available.

As part of this evaluation, it is likely that

treatment contacts will or have been included and

that the assessment is to improve the quality and

effectiveness of services.

To achieve the best results in an assessment, the

neuropsychologist wants to obtain the patient’s

best effort as free from fatigue, distractions and

other factors as possible. A neuropsychological

evaluation is not a short assessment. Different

tests are used to test each function. For example

the Halstead-Reitan Neuropsychological Battery is

made up of at least ten separate tests (including

the Wechsler Intelligence Scales and the Wechsler

Memory Scales). Commonly, additional tests are

added to this battery for specific conditions and to

examine specific questions. It is not unusual for

different combinations of testing to result in 12

hours or more, of face to face testing; in addition

to the time necessary for interviewing the patient,

the family members, reviewing records, and the

rigors of scoring, interpretation and writing of the

report. Collectively, a comprehensive

neuropsychological examination could result in 20

hours or more of clinical time. The results of the

neuropsychological examination provides necessary

specifics to clarify the condition, likely contributing

factors and diagnoses, directions for rehabilitation,

and a baseline for changes. The

neuropsychologist is highly trained and must

understand the impact of various medical

conditions on neurologic function, and be able to

interact fluidly with neurologists and physicians in

ferreting out the interplay of psychological and

neurological conditions. It is important to be able

to understand the interplay of the endocrine

functions, the importance of body cycles, and

subtle changes which can impact function.

It is important to know the right questions to ask

and to know what to do with the answers you get.

Some questions have to be asked multiple times in

different ways. For example, if a clinician were to

ask if a patient had a head trauma, frequently the

answer is “no”. If the clinician was to accept this

answer as true without further questioning, the

patient may not recall the baseball that they were

hit in the head with which knocked them out, or

being thrown from a horse and hitting their head,

or any one of a number of alternative events.

Although mild head trauma can leave little impact

on one’s life, there are multiple dysfunctions which

are linked back to mild Traumatic Head Injury.

A neuropsychologist is a detective of function, and

the causes of the limits and scope of that

function. This is a challenging task. It is essential

that new neuropsychologist gain from senior

neuropsychologists, in the course of clinical

supervision, the knowledge and wisdom in

approaching this task.

There are some neuropsychologists who attempt

to complete an assessment based on the memory

of information by the patient. This is obviously

limited since asking a person with memory

problems for a complete history is likely to result in

the omitting of important information. If someone

were to ask a person with memory problems to

provide a full history, you would think the person

silly for expecting that the history given was

complete. It requires the assistance of a

combination of interviews with family and/or

friends, and a review of medical records. Caution

should be taken with medical records. It is not

uncommon that some errors in recording history

may have been made by previous evaluators and

clinicians. In one case, I had a woman who had

never been sexually abused by her father recorded

in her record has having being sexually abused by

her father. Despite repeated attempts to correct

this, she was unable to get the record corrected,

except for a small note by a current clinician that

the previous reported event was not correct.

Part of neuropsychologist’s job is to identify which

part of the brain functions and which do not. The

parts that function can be the needed support for

rehabilitation efforts. To omit this in a report can

potentially undermine treatment efforts in the

future. It is also important to define the factors

which undermine function and the factors which

support function. These are key in developing an

effective treatment plan.

Another part of the neuropsychologist’s task is to

ask the question, “What best describes the

process which led the patient to their current level

of function?” This would appear simple at first,

but if we work through an individual’s history, with

a sustained high fever at the age of six years old,

a left temporal head injury from a baseball at the

age of 12 years, ten years of alcohol abuse, and

Carbon Monoxide posioning during the winter when

he was 20, the picture becomes more complex. To

determine key factors such as date of onset of

specific dysfunctions, premobid conditions, and

course of illnesses, collateral (i.e., family and

others) interviews are essential.

We must remember that research is published

based on findings where subjects with more

complicated clinical profiles have been excluded.

Although this does refine the research, it makes it

essential that the clinician not overgeneralize the

implications of different test scores.

To illustrate the interlinking of factors necessary

for the making of a neuropsychologist, let me

share some of my experiences.

As a zealous learner who completed his bachelors

degree before his twentieth birthday, I have had

the opportunity to study with many senior

practitioners, now considered pioneers in the fields

of psychology, psychotherapy and behavioral

sciences. I started my training, in psychodrama

and group psychotherapy, when I was 20 years

old. That being, I was one of the younger

students and practitioners.

Back in 1974, I was under the tutelage of James

Wade, M.A., a psychologist associate and primary

psychometrist for a large high school in Portland,

Oregon. I learned to administer, score and

interpret the various psychological instruments

available. I remember my interest in learning as

much as possible about the use of the Wechsler

Scales, the various personality tests, and the

projective tests such as the Rorschach and the

Thematic Apperception Test. I was especially

interested in looking at how these tests were used

to come up with prognostic rating scales (Klopher

Method), and how the Wechsler Scales

demonstrated the various functions of the

individual.

Over the years, I had the opportunity to read

about the research, and use of these techniques,

written by Drs. David Wechsler, Joseph Matarazzo,

Edith Kaplin, Ralph Reitan, and others. It was not

until I started my doctoral studies, a second time,

that I was able to continue to hone my skills and

knowledge in the use of these tests as detective

tools. During my training in the early 1990s, I

remember Dr. Ralph Reitan share a story about

how the first neuropsychological lab was put

together. The announcement of the lab had been

made, and a visit was scheduled so that officials

could come and inspect the lab. At that point,

the lab only consisted of one room. So Reitan,

and his fellow colleagues, were instructed by Dr.

Halstead to gather up various tactile,

psychomotor, didactic, and testing instruments to

put in the lab to “make a good show”. After the

visit, the real work to find which tests and

instruments would be of value.

Dr. Reitan impressed upon us the importance in

that “if you are going to identify a problem,

attempt to provide a way of treating it.”

To better prepare myself for the scope of issues

presented in the clinical setting, I completed

several additional medical courses during my

doctoral studies. Without these, it would simply

not be possible to fully understand the scope of

interactions.

In a presentation by Dr. Edith Kaplan on the use of

the Boston Aphasia Screening, she repeatedly

emphasized the importance of watching the

process. It was not good enough to simply obtain

the results for scoring, but imperative to go

beyond the test and learn from observing the

subtle behavior of the examinee. She was an

advocate of process-based use of

neuropsychological assessments. This made an

impression since I had been originally trained as a

psychodramatist and learned to work with a

continuous flow of information which came from

the patient through their words, movements,

subtle prosody and less definable elements.

Each neuropsychological test provides specific

clues to fretting out the neuropsychological health

of an individual.

Neuropsychology is more than simply administering,

scoring and interpreting a set of tests. It requires

the neuropsychologist to continuously expand

his/her knowledge and skill in clarifying the

meaning of the results, being attune to the subtle

observations made during the entire process, being

a detective searching out the course and factors

contributing to a condition, and attempting to help

the patient overcome the limitations that stand in

the way of optimal functioning. These skills are

honed over years of experience, and the

continuing search for understanding the mind and

its relationship to the total person.

Training & Conferences

Gestalt Therapy: Creative ProcessThis two days’ workshop will cover principles of Gestalt Therapy and the Creative Process ofGestalt.FROM 16th to 17th January 2015 FROM 08:30 - 4:30 PMContact 016-3454 947 for further information

Dialectical Behavior Therapy for the treatment of BorderlinePersonality DisorderDr. Keng Shian Ling January 30th, 2016 (1:30-4:30 p.m.), venue is to be confirmed (see flyer below)

Meaning: Making and the Awareness of DeathSpeaker : Dr. Mark Yang, PsyD Date : 20th – 21st February 2016, 9:00am – 4:30pm Venue : Lighthouse Psychological Wellbeing Centre 18 – 2 (First floor), PJU 1/3d, SunwayMas Commercial Centre, 47301, Petaling Jaya, Selangor. Intended : All mental health trainees and practitioners, psychiatrists, lay or Participants para-counsellors, as well as Psychology students are welcome to attend the workshop Price : Normal price – RM 450 Early bird rate – RM 380 (Registration before 15th January 2016)

Student rate – RM 350

Job Opportunities

National University of SingaporeThere are several academic positions (the call is open to people with clinical psychology training)available within NUS in Singapore. As part of its expansion, the Department of Psychology at theNational University of Singapore (http://www.fas.nus.edu.sg/psy/) seeks applications to fill thefollowing positions:

• 2 Assistant Professors (Tenure-Track positions), and• 2 Lecturers or Senior Lecturers (Educator-Track positions)

Area of specialization is open, but the Department targets one hire in Industrial/OrganizationalPsychology and one hire in Developmental Psychology. Successful applicants are expected tohave a PhD degree by the time of appointment (expected to be July 2016). Remuneration iscompetitive and includes medical and other benefits. Significant research start-up funding isavailable for the Tenure-Track positions.

http://www.fas.nus.edu.sg/psy/_abtus/search2015.htm

Mahkota Medical CentreJob opening of clinical psychologist in Mahkota Medical Centre. The details are as below:

Vacancy: Clinical Psychologist (Full-time position)Department: Rehabilitation Total vacancy: 1Responsibilities: - To provide clinical psychology services to patients and work closely with ConsultantQualification/Requirements:

- Master in Clinical Psychology- Minimum 1 - 2 years clinical experience (Fresh grad are encouraged to apply)- Able to speak Mandarin will be added advantage

Kindly write to may.liumy@mahkotamedical.com should you need further information.

Announcements & RecognitionsPlease send announcements, recognitions you receive, and any member news youwould like to share to:

mscpmalaysianewsletter@hotmail.com