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Potential for the Ubiquity of Neuropsychological Assessment by Davynte Pannell

I chose to take this class because my major is in Neuropsychology and at a glance, the title of this class, Neuropsychological Assessment, seems like something I should understand and master during my matriculation here at Howard. Taking a step back for one second, I joined the Neuropsychology PhD program because I wanted to get a deeper understanding of the inner workings of the human mind. My background in philosophy empowered me to construct and deconstruct ideas and my background in therapy empowered me with an understanding of how to apply psychology in practice to help people, but something was missing. Embarking on this journey to add some neuropsychology to my knowledgebase was expected to empower me with an understanding of what the brain is doing during philosophy and therapy, and how that relationship can be manipulated to create desired outcomes. Coming back full circle, this class helped push me further in achieving my purpose for enrolling in this doctoral program because it helped me perceive cognitive functioning in new ways.

By learning the domains of neuropsychological functioning, I was gifted the language needed to wrap my mind around the activities of the brain and mind. Through participating in the assessments and class lectures, I realize that the psychologist endeavoring to administer the neuropsychological tests has to be able to attend to the constructs and phenomena which the tests are designed to tap into. A healthy grasp of the conceptual underpinnings of the tests now emerges as a reasonable prerequisite for administering them and I liken this to a mechanic attempting to check a car’s computer for error messages – the mechanic needs to know what the codes mean and how the codes are determined.

I am thankful for my awareness of this proverbial bar and I welcome the challenge to contemplate what the word “attention” truly refers to from both first- and third-person perspectives. What does “memory,” or “reasoning,” or “sensorimotor functioning” truly mean in the everyday lives of humans? Through this academic experience, I am closer to honing my own theories and definitions of these terms, how they are measured, and how they could possibly be measured.

How can the assessment process be collaborative and therapeutic for you as the examinee? Are these important facets of assessment for you? Why or why not?

The assessment process can be collaborative and therapeutic for the examinee pending the examinee understands the reason(s), purpose(s), and requirement(s) prior to engaging in the assessments. Informed consent and the examinee having an intrinsic motivation to participate can greatly increase their buy-in into the assessment process. Additionally, having an examiner who speaks the same language or is from the same ethnic group or geographic region can help engender some semblance of familiarity or representation in the examinee which might invite them to be more forthright with their symptomology and motivated to try their best on the assessments even when fatigue begins to set in. Rapport between examiner and examinee is crucial.

These are important facets of assessment for me because assessment is supposed to serve a purpose, not just check a box. In some settings, it may feel like checking a box – such as in the justice system where examinees may already take issue with the state and authority figures and the examiner seems to be just another face of the system – and in some cases, if examinees are beholden to that paradigm, checking a box may be all that is possible,  but ideally if the work is to be collaborative and therapeutic, assessment should answer questions the examinee has about themselves and expose those areas to the examiner so they can serve the examinee. A simple example of an ideal collaborative and therapeutic assessment process would be that of an athlete who goes to a coach or trainer, requests they analyze the athlete’s game, and hopes to get feedback so they can improve. Neuropsychological assessment should follow this trend.

What were you distracted by during assessment? How did you navigate this? What did the examiner do (or didn’t do) that helped you handle the distractions?

During assessment, I was distracted by my hunger at times, my sleepiness, and my general responsibilities such as work obligations. I navigated these by catching myself, to the best of my ability, and redirecting my attention to the task at hand. During one test specifically – I don’t remember which one because many of them have merged together in my mind as if it were one long test – I remember dozing off. At times, I would look up and be waiting for the question and then the examiner would ask me to answer and I’d have to tell them that I didn’t hear the question. It was difficult to get through but we did it. The examiner validated my tiredness and encouraged me to do my best. We completed the assessment and agreed to do the rest another day. Since these distractions were intrinsic, there was not much the examiner did or could do to help handle them – it was really up to me to make sure I ate before testing, got enough rest, and handled my work obligations while at work so I wouldn’t have anything carrying over but life flows that way sometimes. One could argue that examiners could be explicit about the importance of examinees managing intrinsic distractors by reminding them to eat, get rest, and compartmentalize other obligations during testing time so that examinees who don’t do those things organically can be prompted to follow suit.

The examiner did a good job at removing extrinsic distractions for the most part, hence why I don’t have any to complain about. We typically met in a private room without any or much noise. One day there was a light flickering during our completion of the Raven’s Progressive Matrices and the Grooved Pegboard– I remember this one because it was earlier this week – and I had to ask him if I was the only one seeing the flickering in the room because it was quite subtle. He simply acknowledged it as well and we laughed about it then continued testing. I’d say that was a great way to handle it because it humanized my experience – I didn’t feel crazy and we didn’t spend an excessive amount of time adapting to it.

The examiner has the power to influence how distracting distractors can be in the session depending on whether they acknowledge them and how much space they make for the discussion of them. He could have delivered a colder response and just said, “ignore it,” but the fact we shared a laugh about it and he empathized with seeing the flicker and questioning oneself about one’s own vision or sanity minimized the distractor’s impact by facing it and discarding it quickly rather than ignoring it altogether. In that way, I realize its also important for examiners to maintain their humanity – to not get too lost in the scientific inquiry, assessment quotas, or the “box checking” that they miss the opportunity to connect with the human sitting across from them.

Based on this experience, how would you approach neuropsychological assessment differently? Why?

Based on this experience, my conceptualization of neuropsychological assessment allows for a broadened understanding of what counts as a neuropsychological assessment. After all, what makes an assessment neuropsychological? What are the limitations and benefits of it? To me, neuropsychological assessment is in the eye of the beholder – it is the lens with which someone analyzes an individual’s cognitive functioning based on their performance on any given task. Throughout the class, I saw many parallels between the “neuropsychological tests” we administered and games I played in childhood. Take the clock drawing for example – that is a simple enough task but the task itself is not inherently neuropsychological; rather, it is the 18 point system by which it is analyzed and the knowledge base of the psychologist wielding the clock drawing task that makes it neuropsychological. From that perspective, virtually any task that is assessable can be conceptualized as a neuropsychological assessment; skeptics are just not creative enough to see how. Tetris, for example, could be analyzed using an 18-point system to tap individuals’ visual-spatial, reasoning, and planning functioning.

Categorically, a neuropsychological assessment is tailor-made, performance-based, and normative. By that definition, any task satisfying these requirements fits the bill. Lezak, et al. (2012) agreed by stating, “In a broad sense, a behavioral study can be considered “neuropsychological” so long as the questions that prompted it, the central issues, the findings, or the inferences drawn from the findings ultimately relate to brain function (Lezak et al., 2012). To echo my sentiment above, the operative word is “relate” and the power of conceiving and perceiving relationships lies in the eye of the beholder. Since humans have brains and their brains are always functioning, one creative psychologist can connect any human activity to brain function, as the brain functions during all human activity.

I spoke with a colleague about taking a task such as dish-washing, norming it based on members of the same extended family, and using that as a measure of sensorimotor and visual-spatial skills. One could analyze one’s approach to washing a sink full of dishes similarly to how the Rey-O was analyzed, specifically highlighting the gross vs fine approach, whether to do the plates or the utensils first. One could also read into the individual’s strategy just like the assessor read into individuals’ delayed recall of the Rey-O using the Boston approach. One could assess or read into how an individual organizes the order of the dishes that get washed. Half the battle of making everyday tasks neuropsychological is knowing the jargon needed to perceive the cognitive demands tapped by the given tasks. The other half would be test construction and ruling out error – though some might find it difficult, it is obviously possible because the current canon of neuropsychological assessments were likely originated similarly.

The neuropsychological assessments we covered in class look like simplifications of life tasks, similar to abstract art. By breaking up tasks into constituent parts and removing details, scientists develop proxies for understanding specific aspects of life or nuances in phenomenological experience. For example, the D-KEFS assessments do a good job at breaking up cognitive faculties into parts – teasing apart the ability to inhibit the tendency to read words instead of identifying colors from the abilities of reading words and identifying colors. Those psychologists were perceptive enough to understand that both latter abilities are needed to complete the former and errors in the former might be attributable to errors in the latter so it is important to confirm proficiency of the latter as prerequisites for the former.

In a similar way, personal trainers and physical/occupational therapists are adept at identifying muscle groups and individual muscles that are the constituent parts forming movements. They assist their clients with breaking down some gestalt movement into smaller parts, confirming the smaller parts can be completed, and then putting it all together to complete the gestalt action. For example, someone with an arm movement dysfunction might practice moving their arm at the wrist, then at the elbow, then at the shoulder, before trying to coordinate all of those movements to raise their hand in class.

In a similar way, in abstract art, the process of abstraction is comparable to the philosophical practice of inductive reasoning – generating general rules from specific details. This may look like a painting of a black circle on a white background which is subjectively interpretable depending on the onlooker. This abstracted art is equivalent to the nuance, the identified muscle, the simple task of reading words, teased out as a standalone image – it takes the adept artist to abstract – induce, deduce, or otherwise reveal – it out of their experience.

To use a personal example, I remember writing a poem about what it must feel like for a caterpillar to finally become a butterfly and experience survivor’s guilt. That is a nuanced emotion and it’s in the eye of the poet, artist, psychologist, or scientist to draw it forward from other possible foci and find some meaning in it. These examples are included to illustrate that neuropsychological tests draw from life and involve many of the same deductive and inductive processes as other disciplines. The primary difference is that neuropsychological tests tease apart specific brain functions from gestalt domain areas and global brain functioning whereas in this poetic example, I pulled out a specific emotion and disposition from a myriad of emotions or a gestalt mood typically experienced by ambivalent successful people.

The Design Fluency task required examinees to generate as many novel designs as they can with the same prompt. As I learned about it, I immediately thought this is what it feels like to love someone for a long time – to see, in many ways, the same person over and over, and find new ways of loving them; while also to experience paradigm shifts along the journey that allow one to see the same person as a different person, to reignite enthusiasm and extend the life of the relationship. I would imagine that for some people, there’s so few ways to use something simple; whereas for others, there are limitless possibilities for how one can use that simple thing. To me, Design Fluency is a kind of abstract art that challenges people to create something new out of something old without repeating something one did in the past.

The profound part about tasks like that is that usually the key to breaking out of the paradigm of limitation and the scarcity of novelty, is to turn the thing onto itself like an exponent. The way to transcend physics, for example, is through metaphysics. The way to transcend the designs would be whatever the equivalent of “meta-designs” would be – to find a way to think “outside the box.”. Due to the brief time limit for the task, people may not endure it long enough to achieve a transcendent perspective outside the box. The way to transcend boredom in a long term relationship of loving the same person for years on end might be to rise over and above the love and love love itself – to move from thinking a thought to thinking about thinking about a thought. Similar to Design Fluency, life also has time constraints and we do not have limitless time to love our loved ones. I digress but these tangents are the fruit of exposure to this class and I am thankful to even bear witness to these ideas and to have the words to articulate them.

In conclusion and to answer the question at hand explicitly, I would approach neuropsychological assessment differently by expanding the definition and considering analyzing everyday human activities as new points on the vector of someone’s neuropsychological functioning. I would consider how someone handles being ghosted as comparable to completing the Wisconsin Card Sorting Test and develop new ways to measure reactions to being ghosted as a proxy for studying perseverative thinking and errors.

Why? I would do this because this way is more ecologically valid because the situations under study are people’s real-world experiences – real life becomes the laboratory. When people become more mindful, phenomenology is possible and life becomes research. We won’t have to worry about how well a test score translates to real life because real life is the test – we would just be observing how people are living. Some of these ideas may sound lofty and I concede that but even loftiness is in the eye of the beholder.

 

 

 

 

REFERENCES

Lezak, M. D., Howieson, D. B., Bigler, E. D., & Tranel, D. (2012). Neuropsychological assessment (5th ed.). Oxford University Press.

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All content (drawings, writings, paintings, videos, art, etc.) on this entire site were created by, and remain the exclusive, intellectual property of, Davynte Pannell, artistically and philosophically known as Red [The Philosopher], unless stated otherwise. Feel free to share for educational purposes only.

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