Journal Identification = NRP Article Identification = 0633 Date: June 16, 2021 Time: 3:59 pm
doi:10.1684/nrp.2021.0633
REVUE DE NEUROPSYCHOLOGIE
NEUROSCIENCES COGNITIVES ET CLINIQUES
56
Point of view
Rev Neuropsychol
2020 ; 12 (S1) : 56-8
The relationship to the other
in memory consultations:
what remains of our paradigms? * La relation à l’autre
dans les consultations mémoire : que reste-t-il de nos paradigmes ?
Pascale Gerardin1, Aline Rahnema1, Thérèse Rivasseau-Jonveaux2
1Psychologist specialized in neuropsychology, Memory Research Resource Center of Lorraine, Geriatrics.
Brabois Hospital. CHRU Nancy.
54500 Vandœuvre-les-Nancy, France
<p.gerardin@chru-nancy.fr>
2Neurologist. Research Resource Center of Lorraine, Brabois Hospital, Morvan Alley, CHRU Nancy, 54500 Vandœuvre-les-Nancy, France
To cite this article: Gerardin P, Rah- nema A, Rivasseau-Jonveaux T. The relationship to the other in memory consul- tations: what remains of our paradigms?
Rev Neuropsychol 2020;12(S1):56-8 doi:10.1684/nrp.2021.0633
Our practices are subject to pandemic experience
The brutal and sudden arrival of the COVID-19 pan- demic, quickly upset most of our certainties in many areas.
Scientific knowledge was built on a day-to-day basis, con- currently with the virus spread, the human tragedy that it imposed, there and the struggle to adapt to health measures.
Subjected almost instantaneously to the regulated protective and containment measures, professional activities had to be significantly adapted, and sometimes this occurred with no regards to their specific nature, to the target population, or to the trajectory of care of people in the hospital field.
One important consequence of these measures was the cancellation of outpatient care activities, day hospitaliza- tions, external clinics, counselling and follow-up consul- tations. Health professionals, physicians, and neuropsy- chologists, were simultaneously adapting to confinement and re-thinking their practice, starting teleconsultations and telephone follow-ups, while experiencing –together with patients– increasing levels of uncertainty, fear and anxiety.
In the context of public health emergency, it was neces- sary both to comply with institutional and political bodies, and to adapt practice, moving very fast from well-known procedures and approaches, to the “unknown”, while living with the uncertainty that it generates.
∗This article is an English language translation of the following article: Gerardin P, Rahnema A, Jonveaux TR. La relation à l’autre dans les consultations mémoire : que reste-t-il de nos paradigmes ?Rev Neuropsychol2020 ; 12 (2) : 175-7. doi:10.1684/nrp.2020.0563.
Correspondence:
P. Gerardin
Even if, as Philippe Alain and his team[1]point out, dig- ital techniques have made particularly spectacular progress in recent decades, the real validity of digital technologies could be questioned due to the lack of a model or precise previous theoretical references at the neuropsychological level.
We accepted the challenge of adapting ourselves, to what seemed an almost impossible mission, given the extent to which our activities are framed by the relationship to the Other –patients and caregivers– whether in regard to collecting and administrating data on disorders’ history, or analyzing complaint expression in its gestural, behavioral emotional and affective dimensions.
Thus, in the so-called “standard” practice, the amount and richness of these data sources, and their analysis within a clinical perspective, help to enroll the person in a course of care. The neuropsychological assessment is carried out in this continuum either to contribute to the diagnosis or to evaluate the disorders afterwards.
The sudden changes and novelty of the context raised a number of questions: about the means available to formu- late a diagnosis and develop monitoring approaches, about new data collection techniques, in the absence of face-to- face observation and interactions, which are so important at the cognitive and psychological levels, and about prac- tice adaptations to remote interactions, which significantly affect relational styles. How to conceive beyond all the pre- requisites essential for the interview and the evaluation, the setting in confidence of the person or this adhesion and his investment?
All of the essential elements having determined and sus- tained these interactions, –both implicitly and explicitly–
over the years of exercise, had to be reconsidered in a quasi-experimental dimension.
Journal Identification = NRP Article Identification = 0633 Date: June 16, 2021 Time: 3:59 pm
REVUE DE NEUROPSYCHOLOGIE
NEUROSCIENCES COGNITIVES ET CLINIQUES
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Point of view
Importantly, there is a clear contradiction between the concept of “social distancing ”and the very nature of the relationship that engages a clinical professional and the person who receives care. Thus, given that the termbarrier refers to the concepts of obstacle and prohibition of pas- sage, while bringing to mind the idea of making something difficult (Larousse), the requirement of social distancing, in the context of a caregiving relationship, represents a paradoxical injunction to the prerequisites of a relationship based on closeness and trust. How to get people to describe their disorders and at the same time protect themselves from them through physical distancing? More specifically, how to carry out a neuropsychological assessment while taking into consideration the potential bias that these barriers may introduce to a methodology that is essentially based on going back and forth around paper/pencil supports, as widely recalled at the last SNLF forum in December 2019[2].
As a de facto resistance, it was necessary to go beyond these simple but patent representations, in order to bring to light, a change of paradigm. In other words, it is less a question of disrupting the relationship modes than a com- plete modification of the standard consultation “scripts”
[3] at the cognitive -representation level. In other words, more than the relationship itself, the changes concern the principles of the relationship, and their operating and prag- matic modes. The question is whether remote consultation, teleconsultation, or maintenance of support to caregivers by telephone exchange can represent an opening to oth- ers, which allows taking into account the complaint and the disturbances, the diagnosed pathology or the dif- ficulties and experiences inherent to this very specific context.
Towards a change of scripts more than of relationship modes
In the event of a consultation script change, what lessons can we learn from the initial consultations or support dis- cussions undertaken in this way?
The usual consultation script and its course involves the intervention of several professionals. From the ambulance attendant to the administration, the consultation nurse, the neuropsychologist and the doctor, everything helps to welcome and explicitly include the person in a care jour- ney. The various successive receptions are all structures to remind the person of his troubles and/or his complaint that will contribute to a possible diagnosis. The succession of the different protagonists allows an elaboration of the care process.
However, teleconsultation favors and imposes a sin- gle referent interlocutor, limiting the plurality of views and approaches and effectively reducing the argument of the legitimacy of the consultation, a valuable argument when the person presents an anosognosia.
How to relate to each other is also a new paradigm.
From a standing welcoming position with a gesture that inspire security and confidence, the body language of the sitting position presupposes other models. When formal postures in a dedicated office, arranged for this purpose, in order of reception and evaluation must give way to a more informal, less conventional reception, the relational reception is different. It begins at the opening of the con- nection or with verbal expression in an immediacy that can confuse or surprise, as the images or voices are expressive;
there is no possible exhaust lines, such as the ones made possible by reading time of the request letter, or viewing the patient’s record on the computer. In this new situation, the interaction begins without this whole panel of precautions and remedies, just as the end of consultation ends quickly, with an abrupt conversation end, without the usual con- duct that accompanies the person’s departure. Indeed, it is often at the door, that the words of banal conversation, the wishes for the holidays to come for example, allow to leave one another in a space of conviviality and to free themselves from the weight of the symptoms expressed or the diagnosis revealed. It is also sometimes in these moments, more infor- mally, that essential elements concerning the disorders can be said, or a behavior can be observed on the step of the door. All these data, which may seem innocuous, condition both the care of the person but also his adherence to his support, it is in this sense that they are decisive.
Apart from these consultations beginning and end- ing times, the course of the consultation also changes.
For the physician, the clinical examination cannot be of the same nature in the absence of direct observation.
Often placed between the interview and the summary time/explanations/conclusions, direct examination makes it possible to support and confirm or refute the first hypotheti- cal assumptions, within a hypothetical-deductive approach.
It is often a second breath, in the form of feedback with intuitions around cognitive and medical references, where observation takes precedence over interactions and where the doctor is more focused on the patient than on his sur- roundings.
For the neuropsychologist, the interview and the collec- tion of the personal history, the complaint and its analysis, the awareness of the disorders and their repercussions will lead to the psychometric phase, and the choice and use of tests, guided by the interview. Testing requires confidence- building conditions or sustained encouragement at times.
The quality of the investment in the proposed investigation determines the quality of the performance analysis and thus the contribution to the diagnosis.
All these paradigms are reversed in teleconsultation with a space-time in favor of an elaboration “on the spot” with a particular attention on modes of vigilance so that the patient remains in the exchange. The choice of tests and testing is also a critical issue, given the poverty of the tools available and, moreover, the validity in this context of those available.
The test of the pandemic is undoubtedly the opportunity to open up reflections and research on this essential topic, to
Journal Identification = NRP Article Identification = 0633 Date: June 16, 2021 Time: 3:59 pm
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practitioners/clinicians practice[4, 5]. It is also an unprece- dented opportunity to validate new practices.
The place of the entourage
The role of the environment requires to be understood, as regulating the postures and expressions of each other may be easier in a dedicated space-time, such as a consultation office. The distinction between the one requesting consul- tation and/or the one complaining and presenting disorders is made more complex.
Teleconsultation also imposes new rules that could ben- efit those who welcome consultation in their intimate setting and familiar landmarks; in addition to the consultation, the comings and goings of relatives in their usual roles and activities can be observed. But it is difficult or impossible to ensure full confidentiality of the exchange as in a closed- door office setting. For example, throughout a patient’s first consultation, her spouse can enter, glimpse behind her, go about her business, and so on.
In some cases, spouses find it difficult to leave the ground to the patient who presents the symptoms and who is at the center of the intervention, while in some other cases it is the patient who does not want to provide the spouse with space to share with caregiver an opinion on these difficul- ties. In some other cases, the absence of hospital contextual benchmarks reduces adherence to the clinical process, and may promote the expression of anosognosia or refusal, both of which limit information exchanges, thus preventing care.
Concurrently, the need to focus on helping caregiver became quickly apparent. This was quickly addressed, by
relying upon many local and national initiatives on distant psychological interventions, and by elaboration and dis- tribution of specific documents or guides. This support is organized with the purpose of maintaining ties and some- how preserving an attentive and available presence. This may have allowed for closer contact with some families, as we noted.
Finally
These few reflections show how the sudden experi- ence of the pandemic reveals the fragility of our previous paradigms in this context. Even when if we aspire to return to previous practice conditions the unprecedented char- acter of this event has put at risk certain certainties and assurances.
However, this experience allows us to embark on possi- ble new avenues of neuropsychological consultations and assessments, while maintaining the relational modes on which the tangible trust relationship that binds us to the patient is based. These are only the premises, but the route of teleconsultations is initiated without departing from the fundamentals of interactions. These remain to be developed and configured in new intervention frame- works, representing both a real challenge and an ideal, as well as an exciting project for the months and years to come.
Conflict of interest None.
References
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