From

BRAIN INJURY SOURCE

Volume 4, Issue 4

Fall 2000

"CONTROVERSIES IN NEUROPSYCHOLOGY"

Editorial Message

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

REFERENCES

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.

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Preliminary Consumer Guidelines for Choosing a Well Suited

Neuropsychologist for Evaluation and Treatment of Acquired Brain Injury

Pages 36-39

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:

• 1. Should have a good assessment record (i.e., reports seem to fit patients; they seem useful; regular consumer opinions are positive regarding utility, benefit)
• 2. Should provide recommendations that appear individualized, practical, non-generic, variably creative, and useful. They usually seem helpful and often seem to work.
• 3. Should avoid psychiatric assessment instruments and norms. They should employ normative data derived on similar patients (e.g., brain injury) and not routinely rely on psychiatric norms for evaluations. Psychiatric norms, based on patients receiving psychiatric treatment, usually represent an improper comparison group, and predispose psychologists to make psychiatric diagnoses and interpretations. They should be familiar with and employ the newest instruments in assessing relevant symptoms and strive to use instruments with the best reliability and validity and most appropriate normative comparison groups (see Dr. Miller's article in this issue for discussion of psychometric issues).
• 4. Should adequately describe behavioral observations and test-taking behaviors, especially behaviors relevant to test performance (e.g., headache, sleep, fear of losing disability).
• 5. Should integrate personality data, observational data, collaborative data, test data and premorbid (pre injury) information in a sophisticated and meaningful way that makes sense to others, and presents a rich, holistic picture of a client in their particular circumstance. Tentativeness regarding diagnosis and clinical formulations should be afforded as indicated.
• 6. Should avoid reliance on test data alone, spent enough time with the client and perform a thorough interview, get collaborative data and other information from family members and others.
• 7. Should receive client feedback that routinely suggests that adequate time was spent with them and that a reasonable effort was made to understand them in terms of personality and situation (see the article by Ms. Kolakowsky-Hayner and Dr. Kreutzer in this issue for discussion of validity of patient self report).
• 8. Should generally employ an interactional and biopsychosocial assessment and treatment model that is neither simplistic nor black / white, and/or unidirectional, and that looks at all relevant factors in a reasonable fashion. They should typically generate sophisticated, interactional diagnostic formulations, consistent with the complexity of most observed situations (i.e., things are seldom black or white), known base rates (i.e., how common the symptoms are in the non affected population), and prevailing biopsychosocial models (e.g., multifactorial models that consider vulnerabilities versus black or white formulations), (see the articlez in this issue by Dr. Mittenberg and Mr. Condit as well as Dr. Greiffenstein for two such proposed models).

  Reports of Neuropsychologists should ideally:

1. Avoid dichotomous and unidirectional conclusions, such as an "it's all psychological/ psychiatric" OR "it's all biological" (e.g., Law of the Instrument, wherein a psychologist is inclined to see everything as emotionally caused, and a physician is inclined to see everything as biological) and recognize that emotional symptoms can be both a reaction to, as well as a cause, of post concussive symptoms.
2. Avoid mostly simplistic black/white, either/or conclusions ('psychiatric' OR organic/medical', 'genuine' OR 'malingering), instead recognizing mixtures and shades of gray (See the article in this issue by Dr.'s Vanderploeg and Curtiss for related discussion of malingering assessment)
3. Be free of bias or preferential tendencies with regard to inferences about psychological or organic contributions to client conditions (e.g., tendencies to see everything and everyone as psychological; or conversely, tendency to doubt psychological influences and assume everything or everyone is organic). Notably, Table 1 represents just 64 of the possibilities with regard to brain injury related diagnostic realities. Professionals who typically employ only 2 or 3 of these (e.g., true brain injury or no brain injury, or true brain injury or malingering) are probably biased.

TABLE 1: Diagnostic Realities in Assessment of Acquired Brain Injury (ABI).
Real Organic Disorder (i.e., ABI)	X	Residual Functional Impairments	X	Residual Testing Impairments
Yes Mixed Indeterminate No		Yes & Exaggerated Yes & Not Exaggerated No & Exaggerated No & Not Exaggerated		Yes & Not Exaggerated Yes & Exaggerated No & Exaggerated No & Not Exaggerated
4		4		4	=
					64

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:

• 9. Produce reports that offer logical inferences, with reasonable, easy to follow justification. The report should be clear and "sensible" to most readers, including psychologists as well as non-psychologists.
• 10. Produce reports that: a) offer strong opinions only in very clear situations and with lots of support; b) are sufficiently tentative in generating hypotheses, recognizing the limited amount of information and time spent in the typical testing and interview situation; c) recognize the inherent limitations of testing situations involving instruments of varying validity and reliability and a host of nonspecific factors affecting results, and; d) recognize that, in science and medicine, things are rarely either-or, clear cut or unidimensional.
• 11. Avoid reliance on non Ph.D.'s to spend most of the time and perform most of the billed assessment with the client. They are not adequately trained to assess, interpret or integrate test behavior with interview, test results, personality data, etc. etc. Unfortunately, many standard practices are established on, and financially dependent upon, the primary utilization of testing technicians who are usually paid a small percentage of the billed service fee.
• 12. Should collect data, formally or informally, regarding validity and predictive accuracy of diagnostic inferences and formulations, and predictions and recommendations. Psychologists are uniquely trained to evaluate the validity and utility of their work. Also, a field as new as neuropsychology is best served when it's practitioners seriously, continuously, formally, and critically evaluate the validity and utility of their work. However, we see too few examples of any meaningful efforts at such, and, instead, too much assumed competence. When those most able to evaluate the utility of their work do not try to, consumers should ask why these practitioner are not collecting validation data (being true scientist-practitioners) need to refine their ability to help patients (becoming better clinicians), why they do not accept the same accountability of plumbers and mechanics for the results of their work and justifying their fees.

Formal data collection is preferable, and might include a structured Continuous Quality Improvement (CQI) program with continued extended follow-up efforts to assess validity and predictive accuracy longitudinally, with mechanism for modifying practice based on validity data. For example, are other causes of lower test scores (e.g., chronic pain, sleep disturbance, psychological disturbance) being adequately considered in the differential diagnosis of brain injuries? Are predictions of ability or inability to benefit from treatment supported? Do predictions about work and other areas of functioning hold true? Do patients respond to prescribed recommendations? Do diagnostic patterns fit expected base rates?. To be most useful to patients while serving advancement of the field of neuropsychology, programs and practitioners should: (i) employ naturalistic, ecologically valid criterion variables (i.e., real world predictor variables versus simplistic models and methods, such as comparing of diagnostic and prognostic statements with available cookbooks that are questionably and marginally useful in terms of association with the diagnoses or real life variables being predicted – see Dr. Sbordone's excellent article on ecological validity in this issue) and (ii) allow independent inspection of their "track record", and afford open, clear discussion re: efforts, results, and positive effects on service provision (e.g., changes in assessment methods, diagnostic formulations, recommendations, treatment interventions, etc.).

At a minimum, informal data collection is essential, and would be reflected in efforts to solicit, from patients, referral sources, informal follow up information regarding treatment outcome, etc. Data regarding track record should be available; changes in professional practice should be evident from these practices, and easy to discuss. Importantly, no one would hire a plumber or auto mechanic (i) if the correlation's between their tests and actual problems were as nebulous, and (ii) there was as much disagreement among practitioners about diagnoses or treatment, or (iii) there was no assurance that the problem (e.g., toilet overflowing) would be repaired.

Should any one settle for a neuropsychologist who makes predictions when they may never be held responsible for the accuracy of their diagnoses, ability to fix problems, or even follow up?

If there is no realistic expectation that the "toilet overflow" can be repaired, shouldn't the practitioner be expected to make extra effort to explain why, and to suggest practical alternative strategies for compensating for the problem?

• 13. Good neuropsychologists provides balanced or reasonable amount of treatment services and does not perform only (or mostly) assessment duties. Not doing so limits scope of knowledge of some patients types, because follow up data for evaluation and refinement of diagnostic and prognostic inferences is not seen. Ideally, they should:
• See a significant portion of the particular patient type being assessed, in individual treatment
• Have a reputation for treating the particular patient type/ population and have a treatment record, and reputation that seems reasonable, especially in the brain injury community.
• Seem willing to treat (and does) patients regarded as "challenging" (especially if they have a reputation for getting good results in a fair amount of time)
• Show openness to new ideas, self examination of the utility of their services and genuine interest in improving services and improving the lives of the persons with whom they work.

With regard to shopping, the best suited rehabilitation neuropsychologists will usually:

• Work in specialty settings which will be differentially recognized by their name (e.g., Brain Injury Rehabilitation Services: Physical Medicine and Rehabilitation Hospital; Rehabilitation Neuropsychology; Physical Medicine and Rehabilitation Hospital / Service). Neuropsychologists working in these settings, and not part-time consultants who specialize in other areas, are usually best qualified.
• Be identified as specialists in the assessment and treatment area of the patient being referred, and not only be identified by working in a setting identified as such by name, as noted above, and reputation, but also by primary duties performed and personal identification (e.g., neuropsychologist, brain injury rehabilitation psychologist).

Given any uncertainty, it seems prudent to maintain skepticism, and critically scrutinize recommended guidelines in the following cases:

1. Psychologists who are primarily employed and associated with Psychiatry or traditional Psychology or mental health delivery services, where traditional psychiatric patients are the focus of treatment. These services will be designated as such (e.g., Psychology Service; Psychiatry Service; Psychological Assessment Clinic; etc.)
2. Part-time consultants to rehabilitation or neuropsychology programs who are employed and primarily associated with traditional psychological assessment and treatment services
3. Psychologists who perform primarily assessment versus treatment, including psychologists associated with agencies or departments labeled as assessment specialty services (e.g., Psychological Assessment Service)
4. Psychologists associated with traditional agencies (e.g., Psychological Assessment Center in a Psychiatry Department; Psychiatry Service) who purport to also provide neurologic, rehabilitation (in addition to psychiatric evaluation) when formal agencies specializing in such services exist locally. This would be especially true in the case of psychologists who do not work in a setting that affords working relationships and dialogue with equally qualified professionals in the same specialty area - absence of alternate ideas, challenges, feedback, and so on, foster stagnation versus facilitate development and professional growth.
5. Psychologists who seem defensive or resentful in response to these inquiries, or who offer purported diplomates or credentials in lieu of the suggested experience and credentials recommended herein.

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.

CONCLUSION

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.

REFERENCES

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