Neuropsychologist
On behalf of Hersenletsel-uitleg we asked Mariska den Hartog a number of questions to give an idea of what a neuropsychologist can do for people with brain injury and their loved ones.
Mariska is a GZ/neuropsychologist with her own practice. She provides treatment via video calling.
Table of contents (you can go directly to a question via the link)
1. Explanation about the study to become a neuropsychologist and the career
2. Explanation about the choice of the practice name
3. Explanation about the difference between a neurologist, clinical neuropsychologist and a GZ psychologist
4. Explanation about the goal(s) of treatment with a neuropsychologist
5. Explanation about when a referral is made to a neuropsychologist and who makes the referral. Is a referral necessary?
6. Explanation of the problems that clients encounter
7. Explanation of the types of brain injuries people come to the practice with
8. Explanation of what makes the profession valuable
9. Answering the question of whether it is a difficult profession and how Mariska makes that easier
10. Explanation about the possibility of treatment via video calling and when that is not possible. Whether video calling treatments are
reimbursed. Whether people who are abroad can also use it.
12. Explanation of the conditions that someone must meet to receive reimbursement for a Neuropsychological examination
13. Question about help for partners or children of someone with brain injury
Questions
1. You started your own practice last year. Can you tell us something about your studies and career so far?
I studied Neuropsychology (‘Cognitive Functional Disorders’) at Utrecht University.
After that, I worked as a neuropsychologist at Maastricht University and the associated psychiatric hospital PMS Vijverdal, where I obtained my PhD in neuropsychology.
When I had obtained my PhD, the Vesalius brain injury clinic was set up in Den Dolder. It is now an established practice, but was innovative at the time! I was allowed to contribute to the treatment team as a neuropsychologist and I experienced this as a particularly interesting workplace, where I was able to make a good contribution to care and where I was also able to learn a great deal from all the clients and colleagues!
Later, I completed the healthcare training in psychiatry.
In this training, you learn to treat your psychological and psychiatric problems in a targeted manner.
I have never been able to choose between treating and teaching and I have often combined the two.
For example, together with a group of colleagues at the Hogeschool Utrecht, I was allowed to set up the BMH training course, focused on acute care (ambulance, emergency care and anesthesia).
Here I had the opportunity to share the knowledge I had acquired with upcoming professionals (including brain injury, communication, reassurance, emotions, neurology, psychiatry and research). These professionals all deal with people with non-congenital brain injury, which in turn helps people with NAH.
In recent years I have worked at Jenny Palm's Hersenletsel practice - we knew each other well from Vesalius.
After she retired, I set up Neuron brain injury practice, which later became neuronpsychology, where I provide short-term treatment within basic mental health care.
2. Can you tell us something about the choice of the practice name?
The name of the practice 'Neuron psychology', www.neuronpsychologie.nl is derived from the word 'neuron': a nerve cell. This is a building block in our body where all kinds of information is processed.
There are billions of neurons in the brain, which is why people always think that neurons are nerve cells in the brain. That is true, but in fact they are everywhere in the body and form one large network. And that could be very interesting for future developments.
Now that I work in my own practice, I can make more time to keep up with interesting scientific developments and do something with them in practice.
An example is that we now know that there is a layer of neurons in the intestines that communicate with the neurons in the brain.
That is very interesting, because it means that there can be more angles to influence the brain than we thought!
Another great development within my practice is the innovative treatment for post-concussion syndrome PCS: the long-term disabling complaints that can occur after a concussion.
3. What is the difference between a clinical neuropsychologist and a health care psychologist?
Actually, there are three different groups that are important.
The first is the neuropsychologist. You are a neuropsychologist if you have successfully completed the university education for this. You are then a basic psychologist, with a lot of knowledge of the brain. These basic neuropsychologists are also very good at conducting neuropsychological examination.
If you want to specialize further, the basic neuropsychologist will have to follow the two year training to become a health care psychologist. It is a work-study program, in which you learn under supervision to perform broad psychological treatments well.
You will then also receive a BIG registration (BIG is a registration in the Netherlands for Individual Healthcare Professions). Most people then call themselves a health care/neuropsychologist.
After this, you can specialize even further to Clinical Neuropsychologist. This is a four year training in which you learn even more specifically to treat people with brain damage well.
In addition, you also learn to manage a department and to set up scientific research and publish the results.
Actually, there are already relatively few neuropsychologists. Of course, there are even fewer health care/neuropsychologists and the number of Clinical Neuropsychologists is really very small.
4. What is the goal or what can be the goals of treatment by a neuropsychologist?
A neuropsychologist (and all other specialisms) focuses on all kinds of problems of people with all kinds of brain damage.
A neuropsychologist cannot determine whether there is a brain damage, or what it looks like in the brain.
For this, research will have to be done by a neurologist, in which imaging research in the form of a brain scan is certainly important.
A neuropsychologist generally focuses on the cognitive, emotional and behavioural consequences of brain damage.
We are focused on explaining what is going on, to provide tools to improve functioning. Furthermore, as a healthcare psychologist / neuropsychologist and Clinical Neuropsychologist, to tackle all kinds of additional psychological problems.
Together with the client and their environment, because brain damage affects the entire system around someone.
With brain injury, it is precisely the ever-present invisible consequences that are particularly disabling. Think of rapidly occurring severe fatigue, significantly increased sensitivity to stimuli, tinnitus (ringing in the ears), cognitive problems, emotional disturbances, etc. etc. They limit the resilience enormously, but you cannot just see them.
Recognizing this is of enormous importance. Often the problem may also be improved somewhat. But keeping an eye on permanent limitations, so that chronic overload is reduced, is just as important during treatment with a neuropsychologist.
5. When do you come into the picture? When is a referral made to a neuropsychologist and who makes the referral? Is a referral necessary?
After a brain injury, people usually first end up in hospital. Neuropsychologists generally also work in a neurology department. This is sometimes followed by a rehabilitation period, in which neuropsychologists are also involved.
Once home, people still regularly encounter the invisible consequences of the brain injury. It is precisely because of the invisible consequences that people are often overtaxed by their environment and by themselves.
They can then receive first-line help from occupational therapists who specialize in brain injury, who often help them to adjust the load to their resilience.
Neuropsychologists can also help to adjust the load to their resilience and can also explain well what is going on.
Sometimes problems also arise in processing everything that has happened, or people develop other psychological problems. In that case, a GZ/neuropsychologist or a Clinical Neuropsychologist may come into the picture. They often work in mental health care.
It appears to be quite difficult for clients to find their way to professionals.
The brain injury teams help people find the right care. With a bit of luck, the Breinlijn pilot will soon be launched nationwide and they will also become an important source of information.
In order to qualify for reimbursement of psychological treatment by the health insurer, a referral letter from the general practitioner or medical specialist (e.g. rehabilitation physician or neurologist) is always required. You can also be helped without a referral, but then the health insurer will not reimburse the treatment.
6. What kind of problems do clients encounter?
People who are treated by a neuropsychologist mainly encounter the invisible consequences of brain damage. For example, enormous mental fatigue, severe sensitivity to stimuli (light, sound, crowds), cognitive problems (e.g. memory, planning, dealing with changes), a short fuse, increased emotionality or a flattening of it, impulsiveness or difficulty in taking action.
People are quickly overtaxed by this, both by their environment and by themselves. This often leads to exhaustion, gloom, anxiety, problems with processing everything that has happened, etc. Of course, in such a situation, problems generally also arise in work, family and relationships. It is all quite a lot.
7. What types of brain injury do you see in your practice?
We actually see all types of non-congenital brain injury. A large part consists of CVAs (cerebral infarctions and hemorrhages),
traumatic brain injury, tumors, infections in the brain, poisoning, oxygen deficiency, for example as a result of successful resuscitation outside the hospital. In that case too, there is brain injury and this is a situation for which insufficient attention is yet paid. etc. etc.
Within my practice I also specifically focus on people with post-concussion syndrome (PCS), the long-term consequences that sometimes arise after a concussion. This group of patients is still not treated sufficiently in the Netherlands. In my experience, the problem can be treated very well by GZ/neuropsychologists or Clinical Neuropsychologists, preferably in combination with an occupational therapist or physiotherapist.
8. What is the most valuable thing about your profession?
For clients and their environment, the most valuable thing is always the recognition and acknowledgement of the problems they encounter that are so incomprehensible to them.
For me, the most valuable thing is to help people take a step forward in their lives and to help them immediately regain a bit of their autonomy, which simply makes their lives a bit nicer and more fun. That makes me happy too!
9. Is it a tough job or not and how do you make it easier for yourself?
I have to admit that it is indeed a tough job in general. At the same time, in most treatments I am working with someone to help them move forward one way or another. That gives me energy.
To be honest, I also regularly laugh a bit with the client. There is simply room for humor in difficult situations. I also keep a close eye on my own mental health, including by guarding my boundaries, relaxing sufficiently and asking for support from colleagues where necessary.
10. We understand that people can request a consultation with you via video calling. That is genuine use of modern developments and a huge helping hand to people who cannot travel far. Is it being used? For example, can people from Belgium also use this option or is it not reimbursed by a health insurer?
Many treatments can also take place via video calling and I do that too. There are a small number of treatments where that is not yet convenient (for example when giving EMDR - the patient has to be in the room for that), but actually it is always possible.
It is precisely because of the invisible consequences of brain damage that people are often so tired from traveling. Then you still have to start the treatment. I don't think that is very convenient. The energy can be better spent. Not everyone feels like video calling. Still, once people have tried it, they usually like it very much.
Treatment via the internet is simply reimbursed by the insurer. They are actually a huge supporter of all forms of e-health!
Because I am known for my effective treatment method for post-concussion syndrome, Dutch people living abroad know where to find me for that. It depends on the insurance of those Dutch people abroad whether they get reimbursed or not. They should always ask their insurer themselves.
11. We still have two important questions that we hear a lot from our supporters.
Is it true that not all brain injuries can be made visible with a structural scan such as MRI and CT scan?
Certainly! An MRI scan is a very sensitive scan, which measures ‘holes in the brain’ from half a millimeter. That is extremely small. At the same time, we know very well (especially from animal experiments) that, for example, mild traumatic brain injury causes damage at the cellular level. And that is many times smaller than what an MRI can measure. So you cannot make that visible with an MRI.
There are also certain diseases in the brain (particularly some ‘white matter diseases’), which are not directly visible on a scan. In that case, people have had all kinds of symptoms that point to the disease for a long time, without it being visible on a scan at that stage.
12. Is it true that not everyone is reimbursed for a neuropsychological examination by their health insurer and what are the conditions that someone must meet to be reimbursed for a neuropsychological examination?
Yes, that is also true. Within the current health insurance laws, strict rules apply for reimbursement of a neuropsychological examination and other diagnostic examination. At the moment, it is mainly possible within institutions, such as when you are admitted to a hospital, during treatment in a rehabilitation center and within specialist mental health care.
Within basic mental health care, where I also work, health insurers do not reimburse a neuropsychological examination. Some practices do offer this, but then people have to pay for it themselves.
13 The last question is whether you can also treat a partner or others from the family, without the brain injury victim being treated. If so, is that reimbursed?
It is certainly very important to include a partner or the family in the treatment. The brain injury generally has a major impact on the entire family, even if it is only in the head of one family member.
The most obvious thing is for the family members to come along occasionally. Of course, you discuss this with each other first and the client must agree to this. You then all see each other together, and the client is also present. Then it also falls under the reimbursed treatment time and there are no additional costs.
Partners of clients can also receive treatment themselves. Some observations must be made in this regard.
It is important that the partners do not have the same therapist.
The therapist will then too easily end up in a very difficult position due to his/her very strict professional confidentiality, in which he/she will become trapped.
A therapist will therefore not quickly proceed to treat a family member when the client is already receiving treatment.
It is important for the professional ethical regulations of the therapist that the two treatments are separated, because the client and partner have a different therapist.
This of course applies equally to children.
Children up to the age of 18 are also subject to different healthcare legislation than adults: the healthcare legislation for youth care. In principle, they can only go to specialists trained for this purpose. And whether the treatment is reimbursed depends on the contracts that the youth care worker has concluded with the municipality in which the child lives.
The treatment of the partner is often not reimbursed by the health insurer. It usually concerns the diagnosis called ‘adjustment problems’: justified major difficulty in adjusting to the such unpleasant and drastic changes due to the brain injury of the loved one.
Unfortunately, this has not been reimbursed by the health insurer for years, not even with a referral. If the partner’s problems have become serious enough that, for example, a depression or anxiety disorder can be diagnosed in the meantime, treatment is only reimbursed by the health insurer. A very distressing situation.
Mariska
www.neuronpsychologie.nl
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