Neuropsychological Interventions: Clinical Research and Practice

Jonathan M. Silver, M.D.

BOOK REVIEW EDITOR

It has been a long time since the term cognitive remediation had to be explained and defended within the field of rehabilitation. Cognitive remediation has joined the field and is practiced by a multitude of professionals. Many of those professionals have been trained in neuropsychology, cognitive psychology, and learning theory as part of their academic training in clinical neuropsychology, special education, speech pathology, or occupational therapy programs. The task of translating academic knowledge into clinical intervention has been primarily the domain of professional apprenticeship: externships, internships, postdoctoral training programs, and on-the-job training. Only recently has a literature been growing that can accompany that training,^1–3 a literature that focuses on practical, hands-on approaches to neurorehabilitation that are research based. Dr. Eslinger has edited a volume that will be a valuable addition to that literature.

This collection of articles is much more than a “how-to” book. Clearly, Dr. Eslinger has directed the contributors to provide literature reviews and theoretical formulations in addition to descriptions of interventions and the context in which interventions occur. In addition, it seems that he has emphasized the relevance of interventions to everyday life functioning of individuals with brain injury. The result is a jewel of a book for the experienced clinician and an important text for those entering the field of neuropsychological rehabilitation.

Fourteen chapters by 22 authors cover evaluation, research in the rehabilitation context, and a broad range of topics concerning intervention. Approaches are presented not only to the usual foci of neuropsychological intervention (visual perception, memory, learning, and attention), but also to deficits in areas of more complex, everyday activity such as executive and social and emotional functioning. Almost all of the chapters are sophisticated presentations that are both thoughtful and thought-provoking.

The first part of the book deals with research relevant to the field and theoretical and methodological issues of interventions. In the most compelling chapter, authors Thomas Berquist and James Malec clarify the difference between a traditional neuropsychological assessment and one designed to answer rehabilitation issues. They first distinguish between cognitive impairment (a deficit in function), cognitive disability (how the impairment affects an activity), and handicap (how the disability affects social functioning), then note that “in postacute brain injury rehabilitation settings, neuropsychologists are asked to describe the effects of brain injury in terms of disability and handicap rather than impaired mental function alone.” The issue then becomes how to provide “environmental validity” to neuropsychological assessments. The authors advise expanding the concept of evaluation to include the cognitive, emotional, personality, environmental, and interpersonal factors that can cause an impairment to become a disability or a handicap. They provide two case studies that illustrate the importance of a comprehensive assessment.

John Whyte's chapter, on pharmacological treatment of cognitive impairments, follows Drs. Berquist and Malec's lead in developing a thoughtful and sophisticated way of conceptualizing disability. Dr. Whyte does not merely discuss drugs and their actions; rather, his approach is a social psychological one:

Dr. Whyte points to the current limited impact of medications on improving attention and cognitive abilities in everyday life—partially because drugs act on a cellular level, far removed from the complexity of cognition and social behavior. He offers various conceptual models and methodological approaches to future research.

The major section of the book presents models of intervention for neuropsychological impairments. Its eight chapters concern rehabilitation of the following areas: attention, learning and memory, visuoperceptual ability, language, apraxia, executive functioning, social disturbances and emotional processing. Each chapter presents theoretical models, an overview of relevant research, and a discussion of interventions and their impact on daily behavior. All are useful and interesting to clinicians who want guidance in offering neuropsychological treatment.

Some of the chapters are superb. For example, Elizabeth and Martha Glisky's chapter on learning and memory impairments is lucid and wise and reflects both a sound theoretical background and solid clinical experience. They begin by clearly stating the clinical challenge: “Memory is not a unitary concept…it can break down in a variety of ways. Thus, the notion of a single therapy for memory impairment is untenable.” In terms of treatment, they point to “the need to consider the functional consequences of memory impairment and direct our rehabilitation techniques toward eliminating or alleviating real problems in everyday life.” The chapter discusses and critiques different models of rehabilitation in terms of potential impact on everyday functioning and analyzes methods of assessment and intervention.

Because of my own research interests, I specially appreciated Grattan and Ghahramanlou's chapter on rehabilitation of neurologically based social disturbances. The authors maintain that social impairments are multidetermined by premorbid personality, changes in affect and cognition secondary to the cerebral impairment, and the individual's perception of the brain injury and the reaction to it. As most rehabilitation clinicians know, impairment of social behavior is one of the most damaging sequelae of acquired brain injury. The authors note that “the social difficulties often present a more serious barrier to adjustment, adaptation and rehabilitation than physical, sensory or cognitive disturbances.” Problems such as disinhibition, impulsivity, concrete and/or rigid thinking, and adynamia contribute to the reduction in ability to deal effectively with social interactions because they cause changes in the social aspects of self-regulation, self-awareness, sensitivity and problem solving. The chapter presents in tabular form a good survey of empirical studies that investigate the amelioration of various deficits that cause reduction in social behavior. In a clear, concise way, it examines how a wide variety of techniques can improve aspects of social functioning. For instance, when discussing disturbances in self-regulation (deficits in the management of initiation, inhibition, intensity, and duration of social interactions), descriptions of stress inoculation training, behavioral management, and cognitive restructuring are presented along with the research evidence for each method.

In the concluding “Future Directions,” Dr. Eslinger summarizes the 13 chapters and points to the need for “scientific, empirical evidence to support provision of specific interventions and management approaches. For neuropsychological impairments, it is still an early time for such analysis, but there is increasing convergence of such evidence from these chapters, recent books, articles, and even an evidence-based analysis of cognitive rehabilitation.”

Rarely am I as excited about a book as I was reading Neuropsychological Interventions. It provides a needed resource for clinicians and researchers in the field. It also is a fine textbook for training young clinicians; I have already given the Bergquist and Malec chapter on assessment to my interns, and I gave a copy of the Grattan and Ghahramanlou chapter to my colleagues who are studying problem-solving in persons with acquired brain injury. This is not to say that every chapter is equally impressive. Overall, however, Neuropsychological Interventions is an excellent addition to the field of neurorehabilitation.