Dr Vaughan Bell is neuropsychologist in neuropsychiatry services and a clinical psychologist in psychosis services at the Maudsley Hospital in London. He also an academic at UCL where he researchers neuropsychiatric disorders and leads neuropsychology teaching within Clinical Psychology.
Dr Bell argues that the roots of clinical neuropsychology lie in neurological and neurorehabilitation services and the roots in clinical psychology lie in psychiatric services. As evidence accumulates that neurological difficulties are common in people seen in mental health services and mental health problems are common in people with neurological difficulties, and patients with both often struggle to find adequate care, is it time to re-think how we orient neuropsychology at doctoral, post-doctoral, and professional level?
This conversation builds on our BPS Division of Neuropsychology perspectives lecture delivered by Dr Bell
https://youtu.be/3mSKiRyS0dg
Dr Vaughan Bell is neuropsychologist in neuropsychiatry services and a clinical psychologist in psychosis services at the Maudsley Hospital in London. He also an academic at UCL where he researchers neuropsychiatric disorders and leads neuropsychology teaching within Clinical Psychology.
Dr Bell argues that the roots of clinical neuropsychology lie in neurological and neurorehabilitation services and the roots in clinical psychology lie in psychiatric services. As evidence accumulates that neurological difficulties are common in people seen in mental health services and mental health problems are common in people with neurological difficulties, and patients with both often struggle to find adequate care, is it time to re-think how we orient neuropsychology at doctoral, post-doctoral, and professional level?
This conversation builds on our BPS Division of Neuropsychology perspectives lecture delivered by Dr Bell
https://youtu.be/3mSKiRyS0dg
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Ingram Wright: so welcome to the Neuro clinic. We have the pleasure of the company of Dr. Vaughan and Bell Vaughn. We are very welcome.
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Vaughan Bell: Thank you very much, and I'm accompanied, as usual, by my co-host cleaner. Carol.
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Cliodhna Carroll: Hello, everybody.
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Ingram Wright: And I'm Ingram, right? So for. And we're going to start, as we usually do in the Neuro clinic, and I think you've kindly
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Ingram Wright: offer to introduce yourself.
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Vaughan Bell: Thank you very much. So I will, indeed.
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So my name's Vaughn Bell, and I'm partly an academic at Ucl.
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Vaughan Bell: Where I lead the neuro psychology teaching on the doctor and clinical psychology. There. I also work in the Nhs. And I'm partly based in psychological interventions for people with psychosis click. And I'm partly based as a neuropologist in neuroscientology clinic both in the Mulsey Hospital in
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Vaughan Bell: in in Gloria, South London.
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Ingram Wright: Very welcome, Vaughan. Thank you for that. I think we obviously well, we we've discussed some of the questions, some of the themes we're going to explore, and this comes on the back of A at a
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Ingram Wright: a lecture you gave, which was.
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Ingram Wright: I think, designed to be
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Ingram Wright: provocative, or at least we had a conversation in the background about it being provocative. But on re, listening to it before this, podcast I utterly persuaded by your arguments that we need to think about
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Ingram Wright: what neuro psychology has to offer an understanding of mental health, but also individuals who have mental health problems, how services need to be reconfigured. And II think we'll make sure that link to that talk is is available alongside the
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Ingram Wright: the podcast. But we wanted to spend some time today, sort of exploring some of those themes that that you advanced in that in that talk.
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Ingram Wright: And they were really helpful to understand how you got into
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Ingram Wright: neuropyology. I think our listeners are often interested in hearing stories about how people got into neuropology. Could you tell us your story?
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Vaughan Bell: Oh, so mine is probably the least interesting story. Actually. So I wanted to be a clinical psychologist since I was 16.
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But it just turns out that what I had in my head of what clinical psychologist was was completely different to how it is, but it turns out well regardless.
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Vaughan Bell: I went and did a psychology degree which I found really boring and it wasn't until the third year where we had a module on clinical psychology, and someone handed me rather predicted predictive predictably.
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Vaughan Bell: Oliver Sacks book.
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Vaughan Bell: and I read that and went brilliant. That's amazing.
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Vaughan Bell: And and then I got jobs compute program off the university and saved up and didn't have a C. And then, you know, work for a bit, and then
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Vaughan Bell: got tricked into doing a Phd. By my supervisors actually, and I did a Phd. On on cognitive psychiatry and then trained as a clinical psychologist.
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Vaughan Bell: And so it's it's I went to a Oliver sacks talk, and I took my book along, and I was kind of sit down and say to Mom, on your, on your psychology, just because of you. And then someone in in the talk to introduce him said, I'm sure we've all been
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Vaughan Bell: influenced in our careers by reading Oliver Sacks book, and virtually everybody in. The audience nodded.
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Vaughan Bell: So I think I'm I'm one of many people who are. And you're a psychologist because of all of us. Thanks. Which book was it 10, it was that the man who mistook his wife, her hat
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Vaughan Bell: fabulous. Yeah.
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Cliodhna Carroll: I think part of my bookshelf has an entire Oliver Sacks collection, and which is slightly embarrassing when people come to visit. And you see this entire like homage to Oliver Sacks. So yeah, totally totally empathize with that position. Sure many people have one cleaner. We have promised our listeners a kind of tour of cleaners, bookshelves which are proudly displays behind her. Because,
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Cliodhna Carroll: You read a lot. Books. Don't you cleaner back a small selection? Ingram
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Cliodhna Carroll: moving house with me is not a lot of fun. We're gonna get to that bookshelf soon, aren't we? We will, we will.
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Ingram Wright: I had a question for on that, I said.
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Ingram Wright: starting with one that wasn't on the list, but I remember in my undergraduate days late 80 s. Early 90 s. And lectures on schizophrenia and psychosis that were looking for a
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Ingram Wright: sort of cognitive and a phenotype. I think some of the things that you're talking about. So at least talked about in your lecture about you know what what a neuro, cognitive neurop psychological understanding has to offer to mental health context and to patients. And
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Ingram Wright: I suppose I wasn't particularly thinking of where the field has got to since the late 80 s. But
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Ingram Wright: you think there's still an important strand of work around understanding
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Ingram Wright: cognitive features that commonly underpin
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conditions symptoms like psychosis.
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Vaughan Bell: Yeah, I mean, I think it's a really important focus.
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Vaughan Bell: I have to say, progress has been really slow.
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Vaughan Bell: particularly in psychosis. I don't think we have
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actually, many even confirmed mechanisms.
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Vaughan Bell: cognitive findings in psychosis. And actually, one of the most confirmed and replicable findings is not about mechanisms. It's about cognitive difficulties.
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Vaughan Bell: So we know that people with psychosis on average
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cognitive difficulties with memory problem solving concentration in real kind of neuro psychological area.
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Vaughan Bell: And it's interesting that there is so much attention paid to mechanism
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Vaughan Bell: and in clinical work, so little attention paid to cognitive difficulties I'm not suggesting it's completely ignored. There has been some good work, but it's it's amazing
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Vaughan Bell: how much of clinical psychology
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Vaughan Bell: does not
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focus on cognitive difficulties in psychosis, and is much more about people's
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Vaughan Bell: kind of, you know, emotional and and you know, adaptive struggles, which, of course, are really really important.
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Ingram Wright: Yes.
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Cliodhna Carroll: I guess as a it's interesting, isn't it? Because I guess in your position as an academic
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Cliodhna Carroll: and a clinician. I can imagine that a lot of your work phone is thinking about the theory, but also the the practice. What is it to sit in a room with somebody who is experiencing symptoms of psychosis. And how do you help that person?
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Cliodhna Carroll: I just will be really curious to hear kind of your views of kind of that, that link between being an academic
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researcher. And I guess it's that theory practice link which influences which
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Vaughan Bell: it's a really interesting question. And I and I think they influence each other at different times and in different ways.
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Vaughan Bell: And you know you can. You can
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Vaughan Bell: sometimes more clearly see the lack of progress when you're a clinician.
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Vaughan Bell: because you realize actually how
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Vaughan Bell: some areas of of research have had so little impact actually in in
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Vaughan Bell: in kind of clinical areas. And then you can also see on the clinical side how many areas that people struggle with are not. you know, kind of. Let's call them popular subjects of
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Vaughan Bell: clinical research. So cognitive difficulties in psychosis, which are a massive predictor of people's difficulties with functioning, just get so less, so much less attention
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Vaughan Bell: than mechanisms, for example. And so you you really do notice
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Vaughan Bell: sometimes
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Vaughan Bell: how we're not necessarily well equipped and well trained for some of the common problems we do see which is partly
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Vaughan Bell: why I'm I've become more and more interested in kind of
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Vaughan Bell: the lack of
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Vaughan Bell: neuro psychiatric focus in clinical psychology and neuroplanet.
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Cliodhna Carroll: Hmm!
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Cliodhna Carroll: I wonder what what your thoughts are on the why of that? Why is it that the research isn't been done around cogniz like kind of cognitive and symptoms. There's no right answer to that, is there? It's just a
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Vaughan Bell: curious question. I think I think there's a a number of reasons actually. And and and some of it is
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Vaughan Bell: that it falls uncomfortably between neurop psychology and clinical psychology. I mean, one of the interesting things about clinical psychology and neuropology is actually, they come from very different roots.
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Vaughan Bell: So clinical psychology was very much. you know, founded
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Vaughan Bell: in psychiatric services and for the purpose of working in psychiatric services
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Vaughan Bell: and neuropyology. This is particularly true in the UK. Comes very much from brain injury clinics. The early work of Oliver Zangor and Andrew Patterson. and there. There has been 2 very clear traditions that we still see in in the way we're trained.
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Vaughan Bell: which
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Vaughan Bell: clinical psychology is very much for psychiatric difficulties broadly conceived
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Vaughan Bell: and neuropology is very much for neuro rehab. That's a lot of weather trading is focused.
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Vaughan Bell: And actually, there's very little
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Vaughan Bell: formal attention for. And the the big
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Vaughan Bell: grey area in the middle, which, of course, is not a grey area for people who experience either psychiatric difficulties and have
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Vaughan Bell: cognitive problems or associated
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Vaughan Bell: things like epilepsy and things like this head injury, which are very common, or folks with brain injury or neurological difficulties, who also experience mental health problems. And it's not a grey area for them
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Ingram Wright: born, I mean. Lots of I mean. Lots of questions come up for me, and we might track back and and discuss the
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Ingram Wright: I suppose, the
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Ingram Wright: lack of value. I suppose you you've seen in this historical emphasis on mechanisms around what might, what cognitive features might underpin.
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Ingram Wright: and people's experience of psychosis, and what you're suggesting is
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Ingram Wright: a greater emphasis on understanding cognitive difficulties that are often associated with psychiatric
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Ingram Wright: conditions is helpful in in in in guiding us towards effective treatments is that is, that is that right? And if we, if we don't get involved or we aren't informed neuroplogically, we are correspondingly diminished in our capacity to help. Right?
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Vaughan Bell: II just clarify, don't see a lack of value in research or mechanisms. I just think that it's be slow going. Science is hard.
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Vaughan Bell: you know. There were, I think, maybe
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Vaughan Bell: 200 years before the mechanisms of the heart were understood, and how that was applied to, you know, cardiovascular difficulties. And so, you know, science, science can be slow going. So I don't think it lacks value. I just think we've not made the progress that would be ideal.
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Vaughan Bell: what was the second part of your question? Well, I suppose it was about
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Ingram Wright: what tools we have to understand
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Ingram Wright: and neurop psychiatric presentations, mental health presentations. And I think your argument is that neuroplogy has a lot to offer in our understanding of of how to treat chronic alcohol
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Ingram Wright: alcoholism, and it has a lot to offer in our understanding of how to treat psychosis. It has clearly has a lot to offer, perhaps conventionally, but there are challenges around
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Ingram Wright: epilepsy and mental health around stroke and mental health than
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Ingram Wright: I think. Your argument, as I understand it, is essentially that we need to bring more neuro psychology into that space in order to better treat patients. But I think what you're also saying is, we also need to advance the neurop psychological science that might
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Ingram Wright: underpin our understanding of those conditions
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Vaughan Bell: absolutely. And and I would, I would say, and I realize the audience I'm speaking to.
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Vaughan Bell: I think we also need to think and more about mental health
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Vaughan Bell: for folks with neurological disorders. And it's not that neuropologists are completely ignorant. Obviously, not in the Uk, neuropologists have all done clinical psychology training? But it is
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Vaughan Bell: certainly still a case that people with neurological difficulties
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struggle
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Vaughan Bell: to get support for mental health.
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Vaughan Bell: Yeah, and that neuroplogists.
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Vaughan Bell: and not able as a profession to provide that help in in the quantity that is needed. And it is also the case, I think that we, as a profession struggle sometimes to accept that there is some
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Vaughan Bell: specialist knowledge
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Vaughan Bell: needed for neurop psychiatric conditions. That is not simply the experience largely focus on mental health. We get as clinical psychologists plus cognitive neuro rehabilitation
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Vaughan Bell: that is taught for postdoctoral training. And you know, it's not that there aren't neuro psychologists doing excellent work in mental health. I've worked in your rehab. I spent quite a bit of time doing Cbt for folks with
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depression and anxiety.
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Vaughan Bell: But of course there is a whole field of neurop psychiatry
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Vaughan Bell: of which appears
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Vaughan Bell: very rarely in either clinical psychology, training or postdoctoral neuroscientology training.
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Ingram Wright: So the the cleared
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Ingram Wright: training question here phone. And it sounds like you
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Ingram Wright: value the fact that here in the Uk we would train as clinical neuropologists, first and foremost in clinical psychologists. There is that kind of foundation.
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Ingram Wright: I guess. What you're speaking to is the lack of integration in terms of how practices delivered that we don't tend to synthesize our understanding of mental health and neuro psychology, and in a very effective way, in terms of the way that
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Ingram Wright: services are delivered. I suppose I wondered
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Ingram Wright: how we might change training in order to address that. And you talked in your lecture about
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Ingram Wright: what clinical psychologists might needs to understand. That is essentially about neuropology and mental health. And you
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Ingram Wright: said, and I'm persuaded by this that we don't necessarily want to teach you a psychologist. Sorry clinical psychologist to be
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Ingram Wright: neuropologist. But what we would do want to do is to place some emphasis on the neuropology that underpins mental health understanding.
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Vaughan Bell: Yeah. And and it's it's less about mechanisms.
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Vaughan Bell: Actually, it's it's more about the sort of problems that frequently Co occur.
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Vaughan Bell: So II often do training to clinical psychologists in mental health services about.
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Vaughan Bell: Let's just call it neurocycle, you cognitive difficulties and things like this. And I ask people, how many people in your service do you see, who have neurological problems and very few hands go up. And then I ask, okay, how many people
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Vaughan Bell: have epilepsy? And then a few heads, how many people have history of head injury if you have, how many people have a you know, long standing alcohol problems, and then kind of the penny drops that actually.
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Vaughan Bell: what are traditionally considered to be neuroplogical or neurological disorders
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Vaughan Bell: are health disorders which
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Vaughan Bell: are common and more common in people with mental health conditions, particularly at the more severe end than they are in the rest of the population.
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Vaughan Bell: And the I, we have this kind of idea that there are neurological patients. And there are psychiatric patients. Yeah. And you know that a lot of clinical psychology
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Vaughan Bell: training a lot of our documents in the BPS. Actually puts it in a more extreme way. It says.
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Vaughan Bell: there are people with understandable reactions to life events. and there are people with biological problems.
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Vaughan Bell: and that if we frame things in terms of biological problems. we're less able to empathise. We strip people of meaning. and we undermine their autonomy.
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Vaughan Bell: Now, I think there is. This is a useful way of understanding certain approaches to mental health problems in psychiatry. But to be able to write that
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Vaughan Bell: you can't be keeping people with neurological problems in mind.
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Vaughan Bell: because it is quite it. It demonstrates some really quite troubling implicit beliefs
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Vaughan Bell: about what it means to have
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Vaughan Bell: not a phrase I particularly like, but biological problems, neurological problems.
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Vaughan Bell: And I think this is, you know, something we should be more aware of, because actually, that is not a neat divide.
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Vaughan Bell: Yeah, most people with neurological problems have problems with mental health and a vast number of people with problems of mental health
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Vaughan Bell: have neurological problems, even if they are not primarily treated by neurological clinics.
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Cliodhna Carroll: Yes.
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Ingram Wright: it's it's it's an interesting, I mean your again in your lecture. You talk about the organization of services, and that anybody, even working in conventional neurology, your rehab services will come across people with
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Ingram Wright: prior history of mental health problems.
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Ingram Wright: co-occurring problems with alcohol and and drug use and and those kinds of things and but might struggle because that space is less comfortable space for them to operate. And I think what you're saying is we need to think about who our services are
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Ingram Wright: for, and maybe think about sort of our biases, both in terms of service structure
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Ingram Wright: and our orientation as clinicians. I I've done some work around epilepsy and mental health in
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Ingram Wright: children, and
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Ingram Wright: I suppose I've been struck by the fact, and something you said in your lecture, which is that if you're a young person with an epilepsy and co-occurring depression.
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Ingram Wright: you can't get into camera services because your epilepsy is seen as a confound that's difficult to understand. Equally. You get poor service in terms of the management of your epilepsy because of your co-occurring mental health problem.
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Ingram Wright: but it so sort of struck me in terms of how we respond to that
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in our service. Organisation! There will be some young people who have
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Ingram Wright: depression and epilepsy, whose needs could be well served by
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Ingram Wright: perhaps a system in mental health that's better educated about how epilepsy doesn't have to be a barrier to accessing conventional treatments for mental health.
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Ingram Wright: but in some cases it may be that there is a relationship between your epilepsy, dysfunction and these temporal structures, etc. That it? It is characteristically linked to your mental health experience. And we need to understand
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both sides of this argument, don't we? In terms of how we organise services.
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Vaughan Bell: And and you know, on paper.
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Vaughan Bell: us as clinical psychologist and neuropologist should be really good at this right? Because if we think of the causal links between
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epilepsy and depression.
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Vaughan Bell: Course, we have alteration to brain circuits that are involved in the, you know, maintenance and modulation of affect.
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Vaughan Bell: So. But we also have
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Vaughan Bell: the you know the difficulties, the life events that living with epilepsy will cause. We also have stigma and discrimination. Someone with epilepsy will experience.
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And we also have the fact that the same
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Vaughan Bell: predictors. the same social factors that raise your risk of epilepsy raise your risk of depression. And this is partly.
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Vaughan Bell: you know, something that I'm always
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Vaughan Bell: surprised and a little bit shocked by, and that often our documents. Do you make this clear distinction between. you know, problems which are reactions to life events and biological problems, which is
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Vaughan Bell: a complete ignorance of the fact that social predictors are equally as important for neurological difficulties.
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Vaughan Bell: for epilepsy, for brain injury, for you know a whole range of different disorders as they are for mental health problems.
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and as clinical psychologists and neuropologists trained in formulation.
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Vaughan Bell: trained in complexity.
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Vaughan Bell: and thinking about how to understand to what extent all of those factors maintain difficulties. For
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Vaughan Bell: for a particular person this should be something
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Vaughan Bell: that should be front and center of what we do. And yet, you know, if you
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Vaughan Bell: simply that the link between epilepsy and depression epilepsy being one of the most common neurological disorders and and depression. Probably get a lot of clinical psychologists. You're a psychologist less, perhaps, but a lot of clinical psychologists
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Vaughan Bell: to really struggle, just to give you a good account of the sorts of causal factors that link epilepsy and depression.
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Yes.
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Cliodhna Carroll: it sounds from what you're saying for, and that it's very much going back to training, isn't it? And
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Cliodhna Carroll: you know, I guess you were talking about and being the lead of the neuroplogy training at UCL.
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Vaughan Bell: I wondered if you could tell. Tell us a little bit about your experience of
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Cliodhna Carroll: bringing your psychology into a clinical psychology training course.
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Vaughan Bell: So it it had to say it was already there. I guess I can talk a little bit about my emphasis, which is.
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Vaughan Bell: I'm really keen that the neuroplogy training on our clinical doctor at Ucl is not designed for future neuropologists.
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Vaughan Bell: because
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Vaughan Bell: actually, it's relevant to everybody, no matter what service you work in.
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Vaughan Bell: and what I would like people to do is leave our training course. Firstly, with that understanding
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Vaughan Bell: that this is equally as important a skill in whatever place they were, just like risk assessment.
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Vaughan Bell: right? Nobody would kind of go through the clinical training going. Yeah. Risk assessment. Just not not for me. I didn't think it's particularly interesting or important. I don't wanna work in it. So
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Vaughan Bell: everybody knows it's the core and essential skill.
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Vaughan Bell: And that's why I would like people to leave our doctor thinking about neuroplogy. And of course, there are people who want to go into neuropicology services.
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Vaughan Bell: You know, I have a special candle for them, because I work in your Psychology service, but as someone who also works in mental health services.
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Vaughan Bell: I would love some one to leave our doctor at going. Do you know what that was fascinating and important? And it's gonna be useful.
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Vaughan Bell: And I have no intention of working in newer rehab services.
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Cliodhna Carroll: Yeah, I think it's there's something is in there, I guess, just listening to you. I was thinking about that
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Cliodhna Carroll: that fundamental link between, you know, late to on pathologize it like between our wellbeing
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Cliodhna Carroll: and our thinking skills are cognitive skills, like, if I'm tired or hung over, I can't function as well, cognitively. And there's something. Isn't that that real, fundamental understanding between these things are integrated? It's not.
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Cliodhna Carroll: It's not like just people over there have this. And I like, I didn't break into kind of psyched dynamic thinking like, I wonder if there is this splitting that goes on between? Well, if I put people over there in that category, then it's not. I don't need to kind of link with it in the same way, or something. I don't know whether there's something just kind of
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Vaughan Bell: of the psychic pain of being around someone living with a long term neurological condition that feels quite difficult for all of us. And we want to distance from. That's a very far off cry from the Cbt. Thinking about depression. But this is part of the narrative which is central to our profession. Right. So everybody has
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Vaughan Bell: psychological distress.
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Vaughan Bell: And actually, the psychiatric diagnosis are arbitrary distinction between you know, mental wellness and mental health may be useful, regardless. But you know, I think.
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Vaughan Bell: You know, saying it's an arbitrary distinction would probably be
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Vaughan Bell: something most people would agree with and therefore the same way we can understand
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Vaughan Bell: stress and distress in everyday life. We can apply usefully to people who have
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Vaughan Bell: mark difficulties, mental health problems.
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Vaughan Bell: We do not have that same sort of narrative or understanding
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Vaughan Bell: for neurological neurop, psychiatric and neuroplogical problems. Despite the fact that if you
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Vaughan Bell: have a good understanding, you'll understand a head. Injury lies on the spectrum that seizures lie on a spectrum, that metabolic difficulties lie on a spectrum, that the impact of drugs and alcohol lies on the spectrum
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Vaughan Bell: and you know, actually a lot of
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Vaughan Bell: what we think of and conceptualizing clinical psychology as neurological disorders
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Vaughan Bell: also lie on a spectrum. And that same approach, that same understanding that allows you to work with some one who has severe TBI. After road traffic accident is also useful
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Vaughan Bell: for someone, for example, who's in mental health services and has experienced domestic violence.
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Ingram Wright: But I suppose I I was
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Ingram Wright: wondering whether this is a question of emphasis when it comes to treating individuals, so
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Ingram Wright: I often find myself in my
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Ingram Wright: paediatric practice seeing a family who have a child who's had a traumatic brain injury.
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Ingram Wright: You know, thinking about
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Ingram Wright: the time I'm using my skills as a clinical psychologist to understand the impact of trauma on the family, on their perceptions of the child's development
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Ingram Wright: on their concerns
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Ingram Wright: emergent behavior. That might well, Harold, something that they've heard could turn into something much more sinister later on. To offer reassurance, to offer Psycho education to offer
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Ingram Wright: guidance to that family in terms of framing their concerns, but very much about understanding a family who've experienced trauma, and I was struck by what you were saying about
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Ingram Wright: professional stamps we might adopt around formulation and
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Ingram Wright: the views on on biological explanations. Is it just a question of emphasis that in in some cases, if I, seeing a young person with epilepsy and
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Ingram Wright: and depression, sometimes it's about growing up with a chronic condition and understanding that you get left out at the football team because there are concerns about you getting a bump on the head, perhaps erroneously, and you're socially excluded. And
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Ingram Wright: there's a whole. There's a story there, right? And it it. It isn't harmful necessarily to emphasize that story in some cases. But where the story is about carbazopene and your measles, temporal structures, and your regulatory function.
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Ingram Wright: It's also important not to disregard that story in some cases, but it may well be that we can deliver services that that that does reflect a rather false dichotomy. But it's a dichotomy that's sensitive to the fact that balance will sometimes be on one side
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and sometimes on another. Is that is that a reasonable approach? Do you think?
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Vaughan Bell: II think it's entirely reasonable? You know I'm not. I'm not saying that we should destroy the structure of our services, that they they're for a good reason, and they evolve over time.
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Vaughan Bell: And
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Vaughan Bell: but you know, if you, if you talk to folks
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Vaughan Bell: who have neurological difficulties or mental health difficulties. And if you look at the studies on unmet needs.
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Vaughan Bell: yet they will. It's very, very clear, for actually people's needs and not needs are not being met
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Vaughan Bell: by a lot of the services. And this is not through lack of willing. This is not through, you know, kind of, you know, it's it's just the way services are structured or training is structured. And and actually the way.
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Vaughan Bell: So
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profession has evolved in terms of understanding some of these difficulties, which means that
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Vaughan Bell: actually. some of the services do sideline some of the problems that people have. And you know it's not that people are kind of. you know, putting their fingers in their ears and things like this. They're often at a loss to how to support someone. And if you've ever worked in.
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Vaughan Bell: you know, mental health services with someone with a neurological difficulty, or you've worked in the the, You know neurological services for. And you've had the experience of trying to find someone a service that will accept someone support them in a more integrated way. It can be very difficult or frustrating.
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Vaughan Bell: but I think, as professionals. what we can do is think about how well our own profession.
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Vaughan Bell: in terms of the understanding, the training and the way we conceptualize problems
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Vaughan Bell: actually allows us
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Vaughan Bell: to support people ourselves.
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Vaughan Bell: regardless of what? Of what service we work in.
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Cliodhna Carroll: And I think there's something is in there and what you're saying, phone about resources, that it's, you know, it's a knowledge resource. It's an information resource in terms of training. But I guess I'm thinking as you're talking about. You know, colleagues, that work in mental health services where you know. Maybe they've you know, they have somebody who comes along with mental health difficulties. And they're thinking this person is cognitive difficulties, all doing
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Cliodhna Carroll: a cognitive assessment and a and actually the resources to do a cognitive assessment aren't in the test covered, or there's bits that have been there for over 20 years. And
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Cliodhna Carroll: there's something, isn't there, about the resource available within mental health services, to actually be able to consider someone's cognitive difficulties, or how to manage that, or adapt adapt the therapy.
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Cliodhna Carroll: and to to support
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Vaughan Bell: to an extent.
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I have to say. But I think this is one area, the specific example you mentioned cleaner.
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Vaughan Bell: where someone, a clinical psychologist working in mental health services has concerns about cognition, and is, you know, thinks that an assessment might be best where I don't necessarily think
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Vaughan Bell: it's always down to resources. Sometimes it's down to confidence and training. And and, you know, actual.
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Vaughan Bell: helpful framing of something straightforward, like a cognitive assessment
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Vaughan Bell: in in at the doctoral level. So, for example, II frequently, and contacted by clinical psychologists, qualified clinical psychologists and and
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Vaughan Bell: trainees, who. doing a cognitive assessment.
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And
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Vaughan Bell: one of the first questions I always ask is.
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Vaughan Bell: what problem are you trying to solve?
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Vaughan Bell: And it is amazing
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Vaughan Bell: to me
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Vaughan Bell: how often people struggle to answer that question. So why? Why, what? What problem will your cognitive assessments solve? And you know, people sometimes go wanna find out where they have cognitive difficulties.
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Vaughan Bell: And also from what you told me. You probably don't need to do an assessment to assess that it's very clear that they do
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Vaughan Bell: so. Wh. What would be the? And actually, it's a there are lots of different problems you can solve by doing a thorough cognitive assessment. Sometimes it can be a
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Vaughan Bell: to what extent the person self reported difficulties in memory, and so on, supported by
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Vaughan Bell: you know, neuro psychological problems, to what extent? And there are other more complex ones.
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Vaughan Bell: to what extent might different things be causing these cognitive problems, and so on and so forth.
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Vaughan Bell: But the fact that we
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Vaughan Bell: train on clinical, a most clinical psychologist, I would say, leave clinical training. having had the experience of physically delivering the test.
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Vaughan Bell: calculating the results.
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but with
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Vaughan Bell: often little understanding of
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Vaughan Bell: what that assessment is useful, for what problems it can solve.
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Vaughan Bell: and to a certain extent the ability to formulate. And you know, if you formulation is is a never ending skill that you develop over time, and it would. So you can't expect everybody to.
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Vaughan Bell: you know, be able to perfectly formulate the kind of cognitive trajectory of someone who's had lifelong epilepsy and alcohol problems and things like that. It gets kind of, you know, that requires a lot of background knowledge that isn't gonna be taught.
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Vaughan Bell: And that's not such a bad thing.
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Vaughan Bell: but being able to formulate reasonably kind of standard stuff like, to what extent do the numbers
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Vaughan Bell: that have come out of this test. Reflect the likelihood of them having neuroplogical difficulties which are adequately measured by this assessment.
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And so I don't think it is always
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Vaughan Bell: an issue of resources
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Vaughan Bell: to a to an extent. I think it's often an issue of how neuropology is taught and incorporated into clinical psychology training. Considering that clinical psychologists are the only profession
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Vaughan Bell: who can do these sorts of cognitive assessments.
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Fact that you know most clinical psychologists.
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Vaughan Bell: And this is not purely my judgment when I do training. Frequently clinical psychologists mentioned to me. I just don't feel confident doing it. I haven't done one for years. I avoid doing them. I mean, it's you know. No, no one would lead clinical psychology to use the same example.
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Vaughan Bell: not feeling very confident, doing straightforward risk assessments.
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Ingram Wright: And I wondered, Vaughan, because I have a similar experience, having conversations with people who've
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Ingram Wright: conducted a cognitive assessment. And often there's an array of numbers, and I'll say, what do these numbers tell me? And I'll say, well, the numbers on the road not gonna tell you anything right? So what was the what was the question that you thought these numbers were were answering. I wondered if the bit that's often missing in terms of people's thinking is actually being able to consider cognition
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Ingram Wright: right. It's not so much the assessment. But what do you know about someone's cognition?
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Ingram Wright: What do what do you know about their memory or their attentional functioning, their general levels of ability? And I think that the way that training has become somewhat dichotomized in terms of clinical psychology and neuroplogy has been that cognition has fallen out. So we think of neuroplogy as being testing. And we think of clinical psychology as being very mental health focused.
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Ingram Wright: And yet that kind of
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Ingram Wright: that sort of bread and butter, being able to ask people questions about their cognitive strengths and weaknesses is something that's not necessarily very well
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Ingram Wright: founded in our repertoire as clinical psychology. So would you agree with that? So I often
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Ingram Wright: try to emphasize it in having these conversations. How might you ask someone about their memory in a way that
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Ingram Wright: reflects the underlying architecture of our memory systems. What W. How might someone describe having a poor memory in a W in a way that would peak your interest about them, possibly having a memory disorder.
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Ingram Wright: because I think one of the things that's very difficult without any training is to know what's the threshold for doing an assessment. And so.
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Ingram Wright: as you pointed out that in some people that the extent and breadth of cognitive impairment might be evident from speaking to someone about their everyday difficulties. And so there is correspondingly limited value in doing an assessment. If all you're trying to do is to demonstrate that what they're saying is valid. I mean, there might be some value in that. But
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Ingram Wright: but we can. We can learn a lot from talking to people, can't we about the cognition, about the content experience? Yeah, and not just through their answers. Ex. Exactly how you know how you mentioned how people answer the question.
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and
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Vaughan Bell: because, as as we know, you know, one of the one of our kind of important foundational facts is that people subjective
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Vaughan Bell: cognitive complaints are not a good guide to actually how their cognition is. And so that doesn't mean we ignore people. We take people seriously. But what it means is, we can't just ask people.
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Vaughan Bell: how's your memory?
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Vaughan Bell: Yeah, it's fine, great problem solved.
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Vaughan Bell: And so, yeah, actually, you know how people
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answer.
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Vaughan Bell: how we talk to people about these things. What other information we need
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Vaughan Bell: to, you know other people's opinions, and you know, Abs absolutely
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Vaughan Bell: crucial.
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Vaughan Bell: And to understand that, for example, we need to have a good understanding, for example, of how different sorts of difficulties can impact
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Vaughan Bell: on your experience and knowledge of your own memory.
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Vaughan Bell: And and yeah, that's that's a real
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Vaughan Bell: kind of crucial skill.
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Vaughan Bell: right in terms of, particularly in terms of different sorts of neurological difficulties. And it's not necessarily the case that that
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Vaughan Bell: you need to have an in-depth knowledge, but it also applies to psychiatric difficulties. We know that, for example, in older people
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Vaughan Bell: subjective memory complaints are a better guide to some one having depression than they are to some one having
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Vaughan Bell: neuroplogical difficulties with their memory.
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Vaughan Bell: And this sort of thing pops up a lot, and the and the more you you kind of. You know, investigate this
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Vaughan Bell: the more you understand that there's an important and essential interaction between people's mood stress trauma, you know, and so and so on, and cognition.
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Vaughan Bell: and it goes in both directions.
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Vaughan Bell: And our job is not to, you know, have a memory thermometer.
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Vaughan Bell: blood test. Psychology is my friend who he calls it right? You you just get a bunch of numbers out.
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Vaughan Bell: Actually.
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Vaughan Bell: what psychologists should be doing is understanding all of this complexity
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Vaughan Bell: and helping someone solve a problem
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Vaughan Bell: that's causing them difficulties.
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Ingram Wright: It's a lot easier for us to
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Ingram Wright: teach people how to do a blood test right? It's a lot
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Ingram Wright: or time efficient. We can teach someone how to do a memory test the list learning test. You know, those skills are relatively, straightforwardly acquired, aren't they? It's much more difficult to do the kind of thing that you're describing, which is to
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Ingram Wright: have a background in understanding memory systems and understanding how people report subjective experience and how that's fraught with all kinds of
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Ingram Wright: biases, I suppose. But
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Ingram Wright: we need to be able to cut through that and and and come to a formulation which includes cognition in some way, but that that requires
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Ingram Wright: quite detailed and subtle and sophisticated training, doesn't it. I suppose that's what you're suggesting. We need right?
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Vaughan Bell: And and do you know what though? That's that's what we get. Alright. We get detailed and nuanced training about a whole range of things. It's just interesting that it rarely involves
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Vaughan Bell: neuros psychology. It's always a different part of the syllabus. And and it's still the case that a lot of on neurosycology training, even on a clinical psychology level, is taught as if it is about a different population
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Vaughan Bell: of people and and a lot of the, you know, training documents
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Vaughan Bell: for clinical neurop psychology are still very clear that this is about neurological patients.
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Vaughan Bell: And so from both sides. I think we is a a case of just coming to an understanding that
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Vaughan Bell: actually, this is not an optional specialization.
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Vaughan Bell: There may be some optional and specialized things, but of course there is in in everything. I mean, there's much to learn about Ptsd and trauma that you don't learn on
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training and won't learn in other services.
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Vaughan Bell: And yet nobody, you know. Nobody goes through training going. Wow! You know this trauma thing. It's just not for me. It's a bit too complex, and I don't think it's relevant.
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Vaughan Bell: You know, don't see myself doing it.
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Vaughan Bell: And yet that is the attitude we've often had for for you know, neuro psychological approaches
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Ingram Wright: you touched on the I mean early on that sort of service structure. I think what you were saying is that we don't need necessarily the revolution in the way that services are structured. You're not saying we need to dismantle
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Ingram Wright: neuro rehab services. We need to pull neuropology out of neurosciences centers where it does exist
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Ingram Wright: and place it somewhere else. So it's kind of more accessible. But we do need to think about the
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Ingram Wright: lack of accessibility of some of our services to those with mental health problems is that
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Vaughan Bell: doesn't have to be a dismantling. Necessarily, these could be.
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Ingram Wright: they're challenging. But they could be subtle tweaks, couldn't they? To the the training and the disposition of various services to accommodate individuals with mental health histories?
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Vaughan Bell: Absolutely. And you know if we think of trauma informed care. And of course there are debates about trauma informed care, and I kind of have mixed mixed feelings about it. I've never met anybody who doesn't think they're doing, trauma informed care, interestingly enough, despite the fact that clearly there must be some, you know, additional knowledge and and
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and kind of framing involved. But
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Vaughan Bell: I really like the idea that
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Vaughan Bell: some additional knowledge, training, understanding of the impact of trauma is understood as no, you don't have to work in a trauma clinic.
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Vaughan Bell: You can inform your work wherever you work with an understanding of trauma.
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Vaughan Bell: and if we had neuropologically informed care.
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Vaughan Bell: I think that would be a better model
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Vaughan Bell: than
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Vaughan Bell: trying to either make everybody a neuro psychologist or to, you know, make people feel
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Vaughan Bell: slightly inadequate because they're not a neuropologist
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Vaughan Bell: actually, neuropologically informed. Care is probably what we should be.
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Vaughan Bell: you know, aiming for
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Vaughan Bell: just because it's you know, important and helpful and is accessible.
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Vaughan Bell: To clinical psychologists wherever they work.
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Ingram Wright: Well, and it's been a it's been a real pleasure talking to you. II would anybody, I mean, I'm sure that anybody listening would be interested in pursuing these ideas further. Hearing about what you've said, and we'll make sure the link to your lecture is is is out with alongside this podcast but I just really wanted to thank you for speaking so openly and about what is actually quite a difficult and challenging area, I think.
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Ingram Wright: for all of us, and I guess, particularly if you're
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Ingram Wright: working their Vaughan and acting as a an advocate for for change. It's like strikes me there's a sort of campaigning voice in there somewhere, is there?
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Vaughan Bell: Yeah, you know, and and part of that campaigning voice is not to wag my finger. It's to invite people in. you know, and I hope a lot of what I'm doing is trying to
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Vaughan Bell: convince
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Vaughan Bell: psychologists who would not previously think of themselves as a neuropology person just to go. Do you know what this is? This is important? This will help me and help the folks I work with, and is not more intimidating, difficult, abstract than anything else I do
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Ingram Wright: thank you for.
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Cliodhna Carroll: Thank you.
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Vaughan Bell: Thank you. Folks very kind of you.