BRAIN INJURY SOURCE
Volume 4, Issue 4
"CONTROVERSIES IN NEUROPSYCHOLOGY"
This special issue intends to highlight major controversies in the clinical / applied practice of neuropsychology as it relates to assessment and neurorehabilitation following acquired brain injury. Importantly, the last decade has witnessed phenomenal growth in neuropsychology as a scientific and applied discipline. Clinical neuropsychology, as a specialty devoted to understanding brain behavior relationships, is in a unique position to integrate and apply recent developments in the clinical neurosciences with behavioral and medical knowledge to provide useful rehabilitation services. However, as must be expected of all young and developing fields, neuropsychology is experiencing growing pains.
In order to advance as a science, we believe it to be in this field's best interest to promote open self-examination. Several authors who served to inspire this effort share this perspective. Dr. Carl Dodrill's 1997 article, "Myths of Neuropsychololgy", represented an important step by examining several widely held assumptions that under critical inspection appear to be myths and offering suggestions for remediation. Dr. Jerry Sweet, in his 1999 edited textbook, "Forensic Neuropsychology: Fundamentals and Practice", has more recently followed in this tradition with a critical examination of the practice of neuropsychology as applied in the courts that defined a model for the objective scientific practice of neuropsychology that extends beyond the courts.
The current special issue addressees several controversial issues, The authors were selected based on their ability to critically address these issues. Our intention, again, is critical self-examination in the service of advancing the utility of applied neuropsychology to rehabilitation following acquired brain injury. We do this hopefully without squeamishness about challenging the established professional guild, as we have no intention of modeling denial to our consumers.
Simply, our judgments about ourselves are not enough. Rather, we believe that, through collaboration with our patients, their families, and their other rehabilitation service providers, we can elaborate controversies and mobilize opinion with the goal of coalescence of ideas to promote increased utility of services provided to persons with acquired brain injury.
Michael F. Martelli, Ph.D.
Nathan D. Zasler, MD
Dodrill, C.B. Myths of Neuropsychology. The Clinical Neuropsychologist, 1997, 11, 1, 1-17.
Martelli, M.F. (2000). Book Review of J.J. Sweet (ed.) Forensic Neuropsychology: Fundamentals and Practice (Exxton, PA: Swets & Zeitlinger. 1999). Journal of Head Trauma Rehabilitation, 15, 4, 1073-1075.
Sweet, J.J. (Ed.). Forensic Neuropsychology: Fundamentals and Practice. Exxton, PA: Swets & Zeitlinger; 1999.
Zasler, N.D. and Martelli, M.F. (1998). Assessing Mild Traumatic Brain Injury. The AMA Guides Newsletter, November / December, 1-5.
Preliminary Consumer Guidelines for Choosing a Well Suited
Neuropsychologist for Evaluation and Treatment of Acquired Brain Injury
Michael F. Martelli, Ph.D., Nathan D. Zasler, M.D. and Frank F. LeFever, Ph.D.
Few guidelines are available to consumers for evaluating the utility of neuropsychologists in the evaluation and treatment of brain injury. In the field of clinical neuropsychology, board certification is offered as the recommended and clearest evidence of competence. However, as Dr. Lees-Haley aptly points out in this issue, board certification is problematic on several grounds. In addition, recent guidelines issued through The Houston Conference on Specialty Education and Training in Clinical Neuropsychology can and have been strongly criticized for neglect of treatment and rehabilitation related issues.
Recently, the first and second authors generated a list of competency guidelines offered as evidence of competence related to practice of forensic neuropsychology in the area of brain injury (Martelli, Zasler and Grayson, 1999). However, these guidelines were limited to criteria primarily relevant to assessment in medicolegal evaluations. The intention of the current paper is to provide a set of clinically relevant and useful guidelines, intended to assist consumers in choosing well suited rehabilitation neuropsychologist. They are based in large part on a critical evaluation regarding what is useful versus not, based on years of input from our regular consumers, namely, Occupational, Speech and Physical Therapists, Nurses, Physicians, Psychologists and Neuropsychologists, and patients and family members.
These are suggested guidelines for identifying the most "useful" rehabilitation oriented neuropsychologists. The best suited rehabilitation practitioner:
Reports of Neuropsychologists should ideally:
TABLE 1: Diagnostic Realities in Assessment of Acquired Brain Injury (ABI).
|Real Organic Disorder (i.e., ABI)||
|Residual Functional Impairments||
|Residual Testing Impairments
Further, psychologists who do an unusually large amount of medicolegal work, or who prefer to do so, should be critically evaluated. Courts and attorneys usually prefer black/white opinions and eschew practitioners with less simplistic diagnostic and conceptual viewpoints. Practitioners can be subtly reinforced while garnering much higher reimbursements (vs. standard clinical fees) by employing a more dichotomous and simplistic (and easier) adversarial ethic versus a scientific (more laborious) ethic in their opinions which are solicited (and paid for) by attorneys.
Further, professionals, like others, have not only biases, but also personal styles more suited for some settings than others. Based on observations of local practitioners, both informal and formal surveys conducted as part of an ethics review project and review of social psychology literature, the following inferences are tentatively offered.
Practitioners with skeptical or suspicious behavioral traits and compulsive tendencies seem inclined to show diagnostic preferences more compatible with defense attorney interests and are more predisposed to defense related medicolegal involvements. Those with histrionic or hypochondriacal and sympathetic personality traits are more inclined to diagnostic preferences compatible with becoming a plaintiff's expert. Persons with tendencies toward social finesse and flexible morals, in contrast, seem more inclined to be identified by reputation as attorney's experts (i.e., agree with the retaining side, whether defense or plaintiff). Importantly, involvement in specialization then results in continued reinforcement of selected traits, which can further reinforce biases. Notably, protection against this can be obtained by insisting on a practitioner with a local reputation for being fair, objective and a "straight shooter." It should be emphasized, for example, that a reputed "plaintiff" inclined neuropsychologist will probably be more likely to diagnose significant brain injury and potentially assist with procuring a higher settlement. However, diagnosing a brain injury when chronic pain is the real source of problems and making strong statements about permanent disabling impairments produces inaccurate expectancies, incorrect treatment and unnecessary prolongation or even permanence of distress.
Good neuropsychologists should also:
With regard to shopping, the best suited rehabilitation neuropsychologists will usually:
Given any uncertainty, it seems prudent to maintain skepticism, and critically scrutinize recommended guidelines in the following cases:
Finally, Dr. Lees-Haley' article in this issue offers some excellent complimentary recommendations to consumers that not only also assist with finding the most helpful neuropsychologist, but also using them to a consumer's best advantage. These guidelines are highly recommended reading.
In this paper, an attempt is made to offer a set of preliminary consumer guidelines for evaluating and choosing well suited rehabilitation neuropsychologists for specialty evaluation and treatment services for persons with brain injury. The intention of the article is to reflect the needs of consumers, based on a critical evaluation regarding what is useful, based on years of input from the regular consumers of neuropsychology. We hope that these guidelines, even though preliminary, are clinically relevant and useful. In the future, we hope to provide guidelines with a greater emphasis on rehabilitation treatment services.
Hannay, H. J., Bieliauskas, L. A., Crosson, B. A., Hammeke, T. A., Hamsher, K. deS., & Koffler, S. P. (1998). Proceedings: The Houston Conference on Specialty Education and Training in Clinical Neuropsychology. Archives of Clinical Neuropsychology, [in press]. Copyright by the National Academy of Neuropsychology.
Martelli, M.F., Zasler, N.D. & Grayson, R. (1999). Ethical considerations in medicolegal evaluation of neurologic injury and impairment. NeuroRehabilitation: An interdisciplinary journal, 13, 1, 45-66.
Biographical Sketches of Authors
Michael F. Martelli, PhD is the director of Rehabilitation Neuropsychology for Concussion Care Centre of Virginia, Pinnacle Rehabilitation and Tree of Life and has 15 years of experience in rehabilitation psychology and neuropsychology with specialization in practical, holistic assessment and treatment services primarily in the areas of rehabilitation of neurologic and chronic pain disorders. He is the commissioner of psychology for the National Association of Disability Evaluating Professionals, has appointments in the Departments of Psychology, Psychiatry and Rehabilitation Counseling at Medical College of Virginia / Virginia Commonwealth University, serves on several brain injury related boards, is the current President of the Brain Injury Association of Virginia and has lectured and published widely in numerous areas relating to disability, rehabilitation and neuropsychology. He has produced a Habit Retraining model and methodology for neurologic rehabilitation for which some impressive outcome data are being collected.
Nathan D. Zasler, MD, FAAPM&R, FAADEP, CIME, DAAPM is an internationally respected specialist in brain injury care and rehabilitation. He is Medical Director of the Concussion Care Centre of Virginia and the medical consultant to Pinnacle Rehabilitation. Dr. Zasler is also CEO and medical director of Tree of Life, a living assistance and transitional rehabilitation program for persons with acquired brain injury. He is board certified in Physical Medicine and Rehabilitation and fellowship trained in brain injury. He is a fellow of the American Academy of Disability Evaluating Physicians, a board certified independent medical examiner and a diplomate of the American Academy of Pain Management. Dr. Zasler has lectured and written extensively on rehabilitation issues. He is on numerous journal editorial boards and is editor in chief of the international scientific publication "NeuroRehabilitation: An Interdisciplinary Journal", as well as, the "International Neurotrauma Letter". He was recently been named, as of 2001, the new co-editor of the international journal, "Brain Injury". His main areas of clinical and research interest include neuromedical issues in acquired brain injury and chronic pain rehabilitation including headache.
F. Frank LeFever, Ph.D was introduced to neuropsychology by Hans-Lukas Teuber, who urged him to enter that new field. He did, after a detour doing rain surgery on rats, analyzing the effect of their executive functions using an elaborate operant conditioning procedure (B.F. Skinner was his thesis mentor's thesis mentor) for his Ph.D. (1973, New York University), studying Behavior Therapy with Joseph Wolpe, and teaching college students before his clinical internship, postdoctoral specialization in human neuropsychology, and clinical practice with rehabilitation patients (TBI, Stroke, MS, etc.) at Helen Hayes Hospital (1977 to present). He regularly presents research and case studies to the International Neuropsychological Society and to the Society for Neuroscience. As president of the New York Psychology Group he organizes many conferences promoting integration of neurosciences and clinical neuropsychology, and has dealt with professional practice issues as president of the Neuropsychology Division of the New York State Psychological Association.
Address Correspondence to the first author at:
Concussion Care Centre of Virginia
10120 West Broad Street, Suites G & H
Glen Allen, Virginia 23060