Module 3: Diverse skills and roles

3.7 Clinical psychology

Clinical Psychologists are a key profession working with PDoC patients. This can sometime surprise people. They wonder what this profession can offer individuals who have no or minimal awareness. After all, a great deal of the training for clinical psychologists is about working with conversation and interaction.

  1. Write a list of ideas about what a psychologist can offer when assigned to work in a centre caring for PDoC patients.
  2. Then listen to Dr Sarah Crawford as she introduces one core aspect of what she can offer as a Consultant Clinical Neuropsychologist – was this something you’d included in your list?
  3. Then work your way through the rest of the unit. Did your list cover everything raised here? Did it highlight something extra? 

So, one key role, highlighted by Sarah is ensuring that when people can’t speak for themselves their voice is heard in decisions about them. That can involve the skill of psychologists in looking at the decision-making process around the patient, and supporting people to speak for the patient, conveying what they know, for example, about what the person was like and what would be important to them in the circumstances. Psychologists have a crucial part to play in supporting best interests decisions-making; this is something we address at length in our course on “Law, Ethics and Best Interests’.

Clinical psychologists can also work directly with patients, with families, and with the MDT.

Working with patients

Clinical psychologists can help to assess behaviours (e.g. eye and hand movements, for example, or crying and laughing). They have a lot of training in thinking about and interpreting behaviour. They can use this to contribute to MDT discussions of a patient’s level of consciousness (and might be involved in doing test such as WHIM). They might also help to interpret or intervene if the patient appears withdrawn or there are concerns they are ‘depressed’.

Sarah emphasises the important of never leaping to conclusions. She highlights the need to avoid assuming intentionality eg if a patient is ‘smearing”- this could just be wandering hands. She also cautions against applying emotional labels to people with PDoC (eg because they are crying). Such behaviours have to be properly investigated before assuming that they indicate a patient’s consciousness intention or a ‘reaction’.

If called to see a patient who is regularly tearful for example, she will try to assess how often this occurs and whether there appear to be any triggers. She’ll do this through talking to family and staff, observing the patient herself and sometimes by asking for records to be kept or trying to systematically test what is going on. Such assessments may then inform decisions about pain relief or trying anti-depressants.

Combining observations of current behaviour with knowledge of what the person was like before their brain injury is important for making best interest decision about any intervention. Listen to Sarah below reflect on what to do, for example if a patient (perhaps in MCS+) is consistently pulling out tubes or refusing medication. (Again, this is something we just touch on here but explore further in out ‘Law, Ethics and Best Interests’ course).

Working with families

Clinical psychologists have a crucial role to play in supporting families. There is a large psychological literature about families highlighting burden, distress and complex grief. We engage in depth with such issues in our course on “Communicating with Families”. Here we simply want to highlight how clinical psychologists with experience in this field see their own role.

Sarah Crawford starts by emphasising how families may react badly to being referred to see her – and underlines the need to avoid pathologising the family.

Below listen to another clip from Sarah and one from another very experienced clinical psychologist, Dr Alistair Teagar. Alistair is a Consultant Clinical Neuropsychologist working in acute neuro-rehabilitation.

Here they reflect on issues such as working with families around family dynamics, reactions to clinical prognosis and the trauma of ‘ambiguous loss’ (the person they knew is ‘gone’ and yet still here).

Finally listen to how Alistair Teagar highlights his role in supporting family engagement – especially before and after meetings.

Supporting the team

The final role highlighted by clinical psychologists involved in PDoC care related to the support they could give the team and their own role in the MDT.

Given psychologists’ skill sets, and the way they work with patients, families, teams and systems, it is perhaps not surprising that clinical psychologists can have a key role to play when it comes to some of the difficult but essential decisions facing clinical teams: such as whether to continue or discontinue life-sustaining treatment. Clinical psychologists in some units have carved out key roles for themselves in this area; you’ll learn more about that if you go on to do our “Law, Ethics and Best Interests Course” – which talks about the role played by every member of the team in always ensuring that treatment is only given where it is in the best interests of the patient, and is never simply provided by default.

Post a comment below

We’ve given a general overview of roles here, but if you are a psychologist – is there anything else you’d want to highlight about your work, especially for new psychologists coming to work with PDoC patients, or to colleagues from other professional training backgrounds? 

Advanced Learning

If you’d like to do further reading about clinical psychology here are some papers for discussion

Crawford S, Beaumont JG. Psychological needs of patients in low awareness states, their families, and health professionals. Neuropsychol Rehabil. 2005 Jul-Sep;15(3-4):548-55. doi: 10.1080/09602010543000082. PMID: 16350995.

Kitzinger, C, Kitzinger, J. Grief, anger and despair in relatives of severely brain injured patients: Responding without pathologising. Clin Rehabil 2014; 28(7): 627631.

Li YH, Xu ZP. Psychological crisis intervention for the family members of patients in a vegetative state. Clinics (Sao Paulo). 2012;67(4):341-345. doi:10.6061/clinics/2012(04)07.