Brain Injury Professional, vol. 1 Issue 2

vol. 1 issue 2

Controversies

in neuropsychology

4 Guest Editor’s Message 5 Chairman’s Message 34 Professional Appointments 38 Conferences

north american brain injury society

contents

departments

vol. 1 issue 2, 2004

6 Forensic Neuropsychology: Still controversial after all these years

by Paul R. Lees-Haley, Ph.D., ABPP and David D. Fox, Ph.D.

features

12 A Professional Awakening: Discovering the Biased Beliefs of Clinical Neuropsychologists.

by Lloyd I. Cripe, PhD

16 MMPI-2: Caveats, Cautions, and Considerations

by Graeme J. Senior, Ph.D and Lucille A. Douglas, Ph.D

20 Neurofeedback: Cutting Edge Technology That Retrains the Brain

by D. Corydon Hammond, Ph.D., ABEN/ECNS, QEEG-D

24 Preliminary Consumer Guidelines for Choosing a Neuropsychologist for Evaluation and Treatment after Acquired Brain Injury

by Michael F. Martelli, Ph.D, Nathan D. Zasler, MD and Patricia R. Babin, PhD

28 Conflicts and Controversies After Brain Injury: Struggling to be me

by Scott Howard, MS

32 Forensic Neuropsychology: Things are Getting Better all the Time. A Reply to Drs. Less-Haley and Fox

by Keith Nicholson, Ph.D.

chairman Robert D. Voogt, PhD treasurer Bruce H. Stern, Esq. family liason Julian MacQueen executive vice president Michael P. Pietrzak, MD, FACEP executive director/administration Margaret J. Roberts executive director/operations J. Charles Haynes, JD communications manager Brandy Buzinski marketing manager Joyce Parker graphic designer Nikolai Alexeev administrative assistant Benjamin Morgan administrative assistant Bonnie Haynes

brain injury professional publisher Charles W. Haynes publisher J. Charles Haynes, JD executive editor Donald G. Stein, PhD editor in chief Nathan Zasler, MD design and layout Nikolai Alexeev advertising sales Joyce Parker

editorial inquiries Managing Editor Brain Injury Professional PO Box 131401 Houston, TX 77219-1401 Tel 713.526.6900 Fax 713.526.7787 Website: www.nabis.org

advertising inquiries Joyce Parker Brain Injury Professional HDI Publishers PO Box 131401 Houston, TX 77219-1401 Tel 713.526.6900 Fax 713.526.7787

national office North American Brain Injury Society PO Box 1804 Alexandria, VA 22313 Tel 703.683.8400 Fax 703.683.8996 Website: www.nabis.org

Brain Injury Professional is a quarterly publication published jointly by the North American Brain Injury Society and HDI Publishers. © 2004 NABIS/HDI Publishers. All rights reserved. No part of this publication may be reproduced in whole or in part in any way without the written permission from the publisher. For reprint requests, please contact, Managing Editor, Brain Injury Professional, PO Box 131401, Houston, TX 772191400, Tel 713.526.6900, Fax 713.526.7787, e-mail mail@hdipub.com

33 Controversy Does Not Equal Failure: Baby and Bath Successfully Separated. Reply to Keith Nicholson

by David D. Fox, Ph.D. and Paul Lees-Haley, Ph.D. BRAIN INJURY PROFESSIONAL

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guest editor’s message

I am honored to edit this special issue of Brain Injury Professional intended to highlight some of the major controversies in the practice of neuropsychology in assessment and rehabilitation following brain injury. The authors represent a group of talented critical thinkers who offer a richly representative sample of controversial positions.

The goal of this issue is critical selfexamination in the service of advancing the utility of neuropsyMichael F. Martelli, Ph.D. chology to rehabilitation following brain injury. In order to advance as a science, we share the opinion that it is in the best interest of neuropsychology to promote open self-examination (Dodrill, 1997; Zasler and Martelli, 1998; Sweet, 1999; Martelli and Zasler, 2000, 2001).

Dr.'s Lees-Haley and Fox launch this issue with an irreverently witty but sober overview of forensic neuropsychology. This is a field characterized by rampant disagreement and perpetual controversy where even the most fundamental concepts and tools and terms are the subject of intense debate. In an enjoyably readable critical review, they characterize almost every important controversy. They conclude that this is an incipient discipline in great need of modesty, descriptive research, base rates and norms for tests and real behavior, and establishing greater consensus in order to make neuropsychology a science that better serves consumers.

Dr. Cripe follows with his professional awakening regarding biases in the common practice of neuropsychologists engaged in personal injury litigation. He uses an illustrative story of clinical supervision to elaborate on his perceptions of prominent biases and articulate a list of these biases inferred from reviewing reports, research papers, discussions, presentations and sworn testimonies of neuropsychologists. Finally, he offers a list of inspirational quotations aimed at checking our biases in promotion of doing our best and at the very least, doing no harm.

Dr.'s Senior and Douglas report on their research and experience that reveals caveats, cautions, and concerns regarding use of the MMPI-2, the most popular measure of psychosocial functioning in assessing personal injury claimants. Impressive evidence from 3,857 personal injury claimants from Australia and the USA indicates misclassification rates approaching 40% when using standard interpre-

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tive procedures of the MMPI, especially in the case of brain injury.

Problems regarding the use of validity scales, inferences regarding symptom severity based upon scale elevations, reliance upon correlates, and use in formulating diagnoses from traditional and diagnosis specific scales are delineated.

Dr. Hammond reviews a considerable body of experimental research on the effective use of EEG biofeedback for uncontrolled epilepsy in humans, and a growing body of literature documenting improvements in persons with ADHD. Seizure disorders and problems with attention and impulse control are frequently seen after brain injury and EEG biofeedback is now being applied to TBI and stroke. Although better outcome studies are needed, there are reports of cases and of series of cases and at least one randomized controlled trial that offer very encouraging results.

In the paper by Dr.'s Martelli, Zasler and Babin, clinical experience and feedback and input from consumers are integrated with relevant professional standards and literature in critically evaluating the utility of psychology and neuropsychology services. A set of preliminary but relevant and clinically useful guidelines are offered to assist consumers in evaluating and choosing well suited rehabilitation psychologists and neuropsychologists for specialty evaluation and treatment services following brain injury.

In the concluding paper, a clinical psychology intern shares his personal struggles following a severe TBI at age 20. Scott Howard courageously describes his experience as a survivor whose persistence over 10 years has culminated in successful graduate school training.

His unique qualifications allow illuminating descriptions that address conflicting interests between rehabilitation, the legal system and the community he returned to. His observations will hopefully help professionals appreciate the emotional impact and everyday challenge faced by survivors who are "struggling to be me".

Michael F. Martelli, Ph.D. REFERENCES Dodrill CB., Myths of Neuropsychology. The Clinical Neuropsychologist. 11(1): 1-17, 1997.

Martelli MF. & Zasler ND., Controversies in Neuropsychology (Special Issue). Brain Injury Source. 4(4), 2000.

Martelli MF. & Zasler ND., Controversies in Neuropsychology (Special Issue). NeuroRehabilitation: An interdisciplinary journal. 16(4), 2001.

Sweet JJ. (Ed.): Forensic Neuropsychology: Fundamentals and Practice. Exxton, PA: Swets & Zeitlinger; 1999.

Zasler, N.D. and Martelli, M.F., Assessing Mild Traumatic Brain Injury. The AMA Guides Newsletter. November / December: 1-5, 1998.

chairman’s message

The message is being written as I fly home from the NABIS medical-legal conference in Beaver Creek, Colorado. The speakers and audience said that this was one of the finest conferences they attended on this subject. Professionals from all over the country came together for three intense days of study. The social highlight on a snowy evening was a wine tasting sponsored by Michael Bee, along with Mik Pietrzak. There was a lot of discussion regarding neuropsychological testing, malingering and the current status of neuropsychology. Therefore, this periodical is dedicated to exploring the dilemmas and conflicts in neuropsychology today. A thank you to all the authors is in order.

As the chair, I would like to tell you a little bit about NABIS which is a thriving organization. NABIS began in May, 2003, and was inspired by professionals attending our International Brain Injury Association's conference in Stockholm, Sweden. They expressed a desire for the formation of a society that would meet the needs of clinical and legal professionals working in the field of brain injury. NABIS continues to grow in membership, and sponsors like Tony Gamboa, and Michael Bee have joined the Chairman's Council through their recent contributions. Thank you for your support.

As a multidisciplinary society, NABIS serves as a platform for exchange between the range of professional disciplines involved in the care and treatment of brain injury. The principle mission of NABIS is to move brain injury forward in the areas of basic science, clinical care, research, policy or litigation. As evidenced by the quality of our 2003 conference in Amelia Island, Florida, the September 2004 conference in Beaver Creek, Colorado, as well as the brain injury conference in Napa Valley in October, 2004, it is obvious that NABIS is here to stay. We have to our credit this cutting edge publication, as well as the upcoming national scientific conference scheduled for June 2005, in Washington, DC. Congressman Pascrell has attended our strategic planning meeting in Washington, DC, to seek our assistance to help the cause of brain injury. Our membership is quickly growing, as are our contributors. NABIS is a credible and dynamic society now and will grow even stronger in the future. If you have not done so already, please consider visiting www.nabis.org and becoming a member now.

Robert D. Voogt, Ph.D., C.R.C. Chairman and President

BRAIN INJURY PROFESSIONAL

5

Forensic Neuropsychology:

Still Controversial After All These Years

by Paul R. Lees-Haley, Ph.D., ABPP and David D. Fox, Ph.D. Within the field of psychology, neuropsychology has come to be virtually synonymous with disagreement and controversy. While our knowledge of neuropsychology has grown enormously in the past 40 years, the areas of disagreement seemed to have increased proportionally. Even the most fundamental concepts and tools and terms are the subject of intense debate. Old controversies go on year after year without resolution. What is the cause of persistent postconcussive syndrome? What percent of mild TBI patients develop PPCS? Is the Halstead-Reitan battery more reliable and valid than any other, or is it an outdated antique that includes pointless tests that don’t measure anything useful? Should we have a set and fixed battery of procedures or should tests be selected based on the clinical question at hand? What is the best IQ test for English-speaking adults, or is IQ “meaningless” and not worth including in a neuropsychological battery? Which neurotoxicological studies use high quality scientific methodology and reach sound scientific conclusions, and which studies are “junk science?” How many mild brain injury plaintiffs are malingering, and do we dare admit it? Are actuarial or clinical methods superior in dealing with individual brain injury case evaluations? Are substantial numbers of postconcussive complaints iatrogenic effects of contact with lawyers and irresponsible clinicians?

Attorneys shake their heads and comment that neuropsychology is “smoke and mirrors” by experts who “almost seem to make it up as they go along.” Their complaint is overstated but an objective reader will feel some sympathy for their reaction if one considers what lawyers and judges encounter as they try to understand our views in depositions and trials. For example… There is no generally accepted battery of tests used by more than a minority of neuropsychologists. Expressions like “frontal lobe syndrome” and “executive functioning” are so diffusely and variably defined from one text to the next, and from one expert’s deposition to the next, that an expert could appear to explain anything with them. These expressions are no more precise 6

BRAIN INJURY PROFESSIONAL

than loose Freudian terms that can be warped and turned to justify any view.

But some experts claim that their definitions of these terms are generally accepted and that they are measured with generally accepted procedures.

Although we all use these terms, there is no generally accepted definition of mild traumatic brain injury (MTBI) or postconcussive syndrome (PCS) or the complaints associated with these terms. As noted in recent reviews, even the highest quality empirical research studies use different definitions of MTBI (e.g., see Binder, Rohling & Larrabee, 1997; Binder, 1997; & Satz, Zauch, McCleary, Light, Asarnow, & Becker, 1997). Different professional interest groups propose different definitions of mild head injury. Experts give different answers in depositions when asked to define MTBI. Some experts ignore a century of unresolved controversy and testify that their definition of postconcussive syndrome is generally accepted. The concept has still not been accepted as a diagnosis in the DSM, the diagnostic manual most widely referenced by testifying experts in psychology, psychiatry, and neuropsychology. There also are no generally accepted definitions of moderate and severe brain injury.

There is no generally accepted definition of impairment. One widely used practice is to refer to percentile levels but different percentile definitions are used from one expert to the next. Some experts use the lowest 2% as defining impairment, and others use the lowest 16%. Performance levels characterized as impaired in test manuals also vary from one test to the next, often with no logical or empirical basis. Even the general use of percentiles to define impairment is controversial and they are often applied in a fashion that ignores the pre-injury level of the patient and testing confounds. For that matter, there is little agreement as to how to estimate premorbid functioning and new methods are proposed every year.

Detailed descriptive statistics are not available for most tests or in most research reports. As a result, we cannot easily determine the shape of the

distribution of scores for most tests, for relevant populations (if at all), and that have on the reliability of the battery? on those occasions when we can figure it out, there are usually no generally And once we obtain test data, how do we interpret it? What scores are accepted sources that we can point to as authoritative. Thus the meaning normal and which are abnormal, and which norms provide the best basis of a particular percentile for a particular test is not always clear. For examfor such a conclusion? Should age, education and gender corrections be ple, the implications of a score on a normally distributed test are different used or are they not applicable to brain injury cases? In the most active than one with a truncated distribution with a crowded floor or ceiling. international neuropsychology listserv, Dr. David Loring’s group out of Nonetheless, neuropsychologists routinely look at a score and conclude the Medical College of Georgia, a participant recently referred to “the genthat its ranked position tells us whether the patient lost something that eral dumbing down of clinical neuropsychology” and characterized the matters, without having data on the range, clustering of scores, absolute trend toward demographic correction as a “lemming-like urge to age and distances between ranks, or shape of the distribution. To compound the education correct every bit of quantitative data.” problem, there has not been sufficient research to demonstrate that our In forensic cases the patient is often tested repeatedly. How do we deal basic concepts (e.g., attention, abstract reasoning) are actually normally with possible practice effects? When interpreting test scores, how much of distributed in the population. Without establishing the a priori assumption a difference does it take to make a difference? Some experts emphasize the of the shape of a trait’s distribution, how can meaningful tests be develstatistically significant differences between test-retest group means without oped and compared with each other? mentioning the small absolute test-retest differences and the high test-retest What do neuropsychological tests test? In the tradition of St. Augusscore correlations for many of the tests commonly used in forensic matters. tine, what it is we measure we do not know.

They also blur similar tests; for example, Some experts claim tests provide a basis for say- NABIS welcomes your comments about this although the short category test, booklet foring whether the patient has a brain injury. Oth- and other articles in Brain Injury Professional. mat, appears to have less of a practice effect ers say the tests are functional measures, or outproblem than the longer versions, this may not come measures, that do not substantiate an Post your thoughts on one of our forums by be volunteered in the expert’s testimony (on the opinion of how that condition arose. Some visiting www.forum.nabis.org or email: other hand, the vulnerability of the category experts talk glibly about domains of function- mail@nabis.org. test to practice would also be relevant to voluning. Many use terms such as attention, verbal See page 32 for a discussion of this article. teer). Some experts testify that practice effects memory, recent memory, working memory, explain improved scores, without adding qualiabstract reasoning, etc. as if they were unitary concepts. Calling a hodgefications, e.g., pointing out the novelty and learning involved with some podge of measures a “domain,” they lump results of several tests together as tests, in contrast to other tests where practice is unlikely to lead to if they measured the same thing. But they do not. And we do not have improved performance. Some experts testify about practice effects without generally accepted definitions of fundamental concepts like attention, conqualifying their opinions based on the nature of the injury or patient charcentration or various forms of memory. From one research study to the acteristics. They testify as if it were irrelevant that one plaintiff was a next, substantially different definitions and measures are employed. Some young, intelligent, energetic individual with a mild brain injury, and experts testify as if each domain operated in a specific site in the brain, and another was someone with below average pre-injury occupational and eduimply that by knowing the test scores they can localize the lesion to that cational achievement and a severe brain injury. Although there is a growing site. Although there are elements of truth to the localization argument, body of literature on the subject, disentangling the relevant factors associatmostly associated with sensory motor functions, this testimony far exceeds ed with practice effects remains a series of empirical questions, so such genthe state of the art. As Dr. Bill Black noted, “Do we really have a clear eral testimony is overinterpretation of the literature. understanding of what specific brain function we are assessing by adminisOther significant psychometric issues plague many of our neuropsytering a particular test? I think that the reality of brain-behavior relationchological procedures. Psychologists know that test scores do not represent ships is far more complex than even the new group of experts suggest” points so much as bands of confidence. Often these confidence intervals (personal communication, June 2000). Perhaps this lack of established are so large that specific scores are meaningless for the forensic decision at validity reflects the paucity of accepted neuropsychological theory. Other hand. Although there has been some reluctant acceptance of the use of than occasional brief papers, there really has not been a comprehensive theconfidence intervals, there is ample reason to believe that the reliability ory of brain functioning expounded since Luria. In a similar vein, why has estimates used to generate these estimates are themselves variable. As recogneuropsychology ignored the vast research and theory generated by cogninized in the Standards for Educational and Psychological Testing, tests do tive psychologists? not possess a specified reliability coefficient in the form of an inherent A related problem is the empirical basis for many neuropsychological property, analogous to weight or size. Each test’s reliability will vary by the tests. Commonly, tests are used that have been validated solely by statistical population, level of functioning and other variables. In our experience such significance tests between mismatched groups that bear no resemblance to considerations are virtually always ignored in neuropsychological reports. actual individuals for whom clinical distinctions need to be made. ValidaNumerous aspects of differential diagnosis remain controversial. We often tion of suggested cutoffs with other populations is rarely reported and see syndromes identified as diagnoses in expert reports. For example, under often ignored when they are weak. The inherent problem of using signifithe diagnosis section of the report we see terms such as postconcussive syncance tests to validate tests has reached sufficient prominence to be disdrome or frontal lobe syndrome. But these are not diagnoses. Syndromes are cussed repeatedly in prominent psychological journals. There is still miniloose collections of phenomena that appear to occur together but are not mal attention paid to Bayesian methodology to describe probability of a understood well enough to permit a real diagnosis. Unlike mental disorders, condition (brain damage, functional impairment) being present based on which are defined in the DSM, syndromes have not generally agreed upon various predictors. Despite the recommendation of nearly 50 years ago, the definitions. Another problem is the source of information used for differential empirical accuracy of successive hypothesis testing has largely been relegatdiagnosis. We see reports from experts who render causation opinions based ed to clinical lore rather than reproducible scrutiny. on interviews and testing alone, without considering records. We have seen There is no agreement even as to whether all neuropsychologists cases in which the expert claimed the MMPI profile showed the injury was should use a fixed standard battery. At least one professional group (Coalicaused by an MVA and cases where the expert said a common and nonspeciftion of Clinical Practitioners in Neuropsychology) has drafted a proposal ic pattern of neuropsychological test scores showed that the cause of the to describe which test batteries have established validity but some of their impairment was toxic exposure. Although the DSM is the most widely used leaders have a financial interest in the batteries that “made the grade.” authority for defining mental diagnoses, it too has its critics, including those Most everyone agrees that test procedures that are supported by research who regard it as something of a joke produced by political consensus for the constitute the gold standard. But with what populations? To answer which financial advantage of making every variation in human behavior a diagnosquestions? If additional tests are included (for example, the Rey Auditory able medical disorder tracking the latest guidelines for insurance coverage. We Verbal Learning Test to the Halstead-Reitan Battery) how are such data have seen the same expert in different cases cite the same test score pattern as integrated into a fixed battery that is alleged to be a validated approach? “classic” examples of different syndromes that suited the needs of the attorney When tests are added or omitted from “fixed” batteries, what impact does who retained him.

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As with many clinical enterprises, clinical neuropsychologists often give inappropriate weight to patients they have seen in developing hypothetical relationships between test scores and some objective criterion. The non-neuropsychology literature has well established that this use of anecdotal clinical experience is fertile ground for illusory correlations. Ignoring the research literature in favor of clinical experience may be emotionally persuasive but it makes bad science and practice.

Assuming we somehow agree on how to test the patient and define the brain injury and related emotional distress, how do we provide the most effective treatment? Some experts provide cognitive rehabilitation and related emotional therapies virtually wholesale but (as in other fields of psychology and psychiatry) it is not at all clear what works. Salazar et al. (2000) noted that “…most rehabilitation strategies have not been subjected to the degree of scientific scrutiny for effectiveness and cost-efficiency that is expected of other medical therapies… Thus, the question remains whether interdisciplinary cognitive TBI rehabilitation as currently practiced is an effective and cost-efficient method of returning TBI patients to their maximum potential” (p.

3075). And psychology’s efforts to study how best to help patients cope with stressful life events is in outright disarray. Somerfield and McCrae went so far as to say, “…the quantity of research on stress and coping is not matched by its quality. In fact… the study of human adaptational processes is in crisis: Two decades of concentrated research have yielded relatively little of either clinical or theoretical value” (p. 620).

Neuropsychology has been going through its adolescence during a time when managed care has crushed clinical incomes and the legal profession has been cultivating a business opportunity. Cynics have begun to refer to neuropsychology as a “pawn” or “handmaiden” of the legal profession. And in truth, involvement with lawyers has compromised the intellectual integrity of the field. This is not to saddle lawyers with responsibility for neuropsychologists’ conduct. A complex incentive system has evolved in American society comprising plaintiff attorneys, defense attorneys, insurers, neuropsychologists and other experts, and patients (claimants, plaintiffs, applicants, etc.). Thoughtful people know that absurd allegations are leading to elaborate, expensive, unnecessary work but the system is so rewarding to the players involved that it is difficult to reform.

Who is qualified to call themselves a neuropsychologist? Attempts have been made to describe necessary training in neuropsychology (e.g., Houston Conference) but much listserve bandwidth has been spent challenging or defending these suggested guidelines. The overwhelming majority of the senior members of the profession never had the opportunity to receive the training described by the Houston Conference. Are luminary psychologists who were trained before there was post-doctoral training no longer neuropsychologists?

When it comes to professional credibility there is no accepted standard. What is the role of board-certifying bodies, such as the American Board of Clinical Neuropsychology (ABCN)? Are these organizations truly befriending consumers, or are they misleading them for political and financial gain? Literature circulated by ABCN diplomates equates ABCN certification with medical board certification – a highly misleading comparison that should not be made to consumers. And other boards give even more misleading impressions to the public. There is no evidence that board-certified experts are any better diagnosticians or therapists and a lot of evidence suggesting that experts with more experience and more training are not really producing at a higher level than lower paid personnel. There is significant concern on the validity and reliability of the board-certification procedures of even the best known boards (e.g., see Rohling, Lees-Haley, Langhinrichsen-Rohling, & Williamson, 2003).

The source of the published ethics used by most neuropsychologists – the American Psychological Association – for years has circulated advertisements by quacks about frivolous, dubious or downright bogus therapies.

Some of us feel that APA values fashionable political correctness and making money for psychologists more than quality science and consumer welfare. Thus there are serious questions about the source of the standards most psychological experts profess to follow. However, as long as we do profess to follow these standards, we should do so reasonably consistently.

But neuropsychology experts use experimental tests in forensic evaluations, including tests with no manuals or no competent validation studies and woefully inadequate norms. They use tests designed for other purposes than the case at hand.

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Some neuropsychological experts interpret virtually all their clinical observations in terms of brain injury with no realistic perspective. As Dr. David Hartman aptly noted, “neuropsychologists who have taken very narrow training in a neuropsychology graduate program followed by a neuropsychology internship are in the position of the individual who, having only a hammer, identifies everything as a nail... in a recent case example an individual who showed psychotic, obsessive-compulsive symptomatology was diagnosed by four separate neuropsychologists as brain-damaged. It was apparent that these clinicians had never actually seen a psychotic individual and diagnosed acute psychosis as brain damage due to a minor bump on the head without change in mental status… The people who saw this woman mistook the extreme variability of neuropsychological test results inherent in an acutely psychotic individual and thought it was severe head injury from a minor bump on the head. They apparently weren’t aware that acutely disturbed schizophrenics don’t exactly look ruler flat on neuropsych test results” (personal communication, June 22, 2000).

Judging from expert reports, depositions, and comments on the Internet neuropsychology listservs, one can find a neuropsychologist who believes there is a neuropsychological test or pattern of scores that is sensitive to virtually anything. The application of “neuropsychology for everything” is so broad as to be meaningless. If it measures everything it measures nothing. One expert referred to forensic neuropsychology as the art of practicing a science that does not yet exist (Faust, 1991).

In some courts there is controversy over whether neuropsychologists should be permitted to testify on causation of brain damage. Most neuropsychologists agree that this should be permitted but there is heated debate on how to do it. For example, some experts are willing to testify that impairment is due to brain damage based on test data alone and other experts require a detailed history before reaching this conclusion. Once there is agreement that there is cognitive impairment, the methodology for determining its cause is controversial. Some experts will tender such opinions based on the self report of the plaintiff; others feel this is naïve or even preposterous.

Self-report data are so prominently unreliable that concerns about their validity were the subject of a front-page story in the APA Monitor in January 1997. There was a related prominent story in the January issue of the APS Observer (Rowe, 1997), following up on the November, 1996 symposium on these problems sponsored by the National Institute of Health.

Yet some experts rely on histories with such blind faith that they apparently never consider the possibility that the patient might tell a fib or simply not be very good at diagnostic self assessment and describing his or her own cognitive and emotional history.

The use of self-report data is fraught with controversy. As Carl Dodrill noted, “…a significant amount of conflict in the forensic setting is due to differences in the degree to which neuropsychologists accept patient report as valid. I believe that this is a huge source of difficulty” (Dodrill, personal communication, June 20, 2000). An abundance of research in the past ten years attests to the fact that people in litigation bring a response bias to forensic assessment. Despite the overwhelming evidence that symptom invalidity is so common that it needs to be ruled out as an explanation for the data in each individual forensic case, some experts’ reports are repetitions of the patient’s claims and conclusions without critical analysis.

These are not expert opinions; they are echoes with the misleading blessing of a Ph.D. Failure to critically analyze self report data is not an acceptable difference of professional opinion; lack of scientific skepticism is incompetence. Curiously, the same expert who will swallow whole and uncritically an absurd history reported by a plaintiff or defendant will express intense skepticism for the work of a colleague retained by opposing counsel, and imply that the colleague is a cynic for being skeptical.

Attorneys challenge us to state the basis for our opinions and some of them are smart enough to insist on facts and reasoning instead of being buffaloed by big words and credentials. Because patients rarely ask us to explain our reasoning or cite research that supports the statements we make, attorneys offer us an important opportunity for intellectual growth.

Some experts act as if everything causes concussions and concussions last forever. Even when all the facts are against them, such experts persist in reaching the conclusion that the plaintiff is brain damaged and the injury has serious repercussions on the plaintiff’s life. No initial evidence of injury, perfectly normal tests scores and return to work with good perfor-

mance are mere nuisance details between these experts and the conclusion that the plaintiff is impaired by a brain injury. These experts persist in diagnosing brain injury regardless of contrary evidence. One of the solutions plaintiff attorneys love to promote in these cases is the use of collateral sources – friendly witnesses who will testify that the plaintiff is different than before. This practice has a host of reliability problems. Relying on loved ones in an adversarial setting makes no more sense than relying on the views of personal enemies – this practice is an open invitation to unreliability. Lawsuits are analogous to competitive sports – people take sides.

We have seen cases in which a board-certified neuropsychologist administered a battery of tests that showed normal functioning but disregarded his own battery when immediate family members (interested parties) said the patient was different and suffering impairments that were quite serious.

Laypersons know better than to send letters of recommendation from their mother and sister with their job application, but board-certified neuropsychologists accept statements by family members solicited by lawyers in adversarial lawsuits as if they were gold standards of scientific measurement. If family opinions trump expert testing, why waste the consumer’s time and money on neuropsychological testing? Why not go directly to the family and spare the poor patient the neuropsychology bills?

Malingering is a topic of debate that elevates neuropsychologists’ blood pressure even higher than the PPCS arguments. Despite research exposing the fallacy of subjective evaluations of honesty, some experts continue to rely on intuition, subjective clinical judgment and speculation, and claim they can rule out malingering based on clinical judgment (“the patient appeared sincere”) without studying relationships between test scores and tests of malingering and historical data. Some experts do not even administer malingering tests. We still see testimony like this: “When you’ve been doing this work as long as I have, you can tell whether people are telling the truth or malingering”). As the late Jay Ziskin was fond of pointing out, “if you were fooled, how would you know?” And can we really read minds, or tell what is intentional and what is unconscious? Some neuropsychologists speciously emphasize the “grave implications” of a diagnosis of malingering, and talk about how cautious one should be about reaching such a conclusion. One has to ask whether these same experts accept frivolous diagnoses and conclusions about schizophrenia, bipolar disorder, major depression, disability, sanity, competence, and other issues with important and life-altering implications for the patient. Of course experts should be careful with differential diagnosis but to single out malingering as if it were more important than other diagnoses is misleading. In a forensic neuropsychology case, the standard of care requires ruling out malingering as an explanation for the observed complaints.

Expert statements about the handling of test materials and raw test data are often wholly contradictory. Most of us feel that attorneys should not have unrestricted access to tests and their answers, but the American Psychological Association sells a book containing the items and answers of the most widely used test in the profession to attorneys, and actively markets the book (while simultaneously supplying psychologists with statements to help them resist disclosure of test materials to attorneys). Some psychologists feel that they should not give their raw data to lawyers, even under a protective order, but others turn it over readily. Despite the most recent APA standards there is no generally accepted definition of raw data. Some experts provide details on scores in their reports while others consider scores to be part of the raw data they feel they should not include in reports. There is no generally accepted definition of who is “qualified” to receive tests and raw test data. Experts tell judges that psychological tests are not sold to anyone but psychologists but this claim is so blatantly false that one wonders why more psychologists are not charged with perjury. Some experts view raw data as part of the report.

One has to wonder if part of the resistance to disclosure of raw data is self protection, rather than consumer protection, because disclosure of the raw data so frequently leads to the discovery that the expert made errors. For example, attorneys find so many errors in simple arithmetic in neuropsychologists’ raw test data that one nationally recognized catastrophic injury attorney, Ric Gass, of Milwaukee, refers to neuropsychologists as “notoriously poor mathematicians” (Gass, 2000, p. 6).

Although the better quality scientific literature clearly indicates the improbability of significant lasting consequences following a mild brain injury, some experts routinely assume they have found exceptions based on self report, even in silly accidents. For example, some repeatedly purport to

have found evidence of serious brain injury because the individual, in hindsight, reports feeling dazed or confused after a low speed motor vehicle accident or bump on the head.

Given the irreconcilable differences between neuropsychologists concerning standards of practice, one wonders how a jury could ever conclude that someone was guilty of malpractice in this field. It would be like finding a jellyfish guilty of not maintaining its shape. How can we possibly protect consumers in a context so devoid of structure? In order to protect consumers, we must develop reasonable standards that we can agree on and then follow those standards. Where can we start?

SOLUTIONS Proposing solutions to current controversies in neuropsychology is almost like suggesting “solutions for modern society” or “solutions for enduring problems in philosophy” – vast to the point of absurdity. However, reviewers appropriately often ask writers who express criticisms to propose solutions. In that spirit we will suggest what we believe are a few priorities that should receive more attention if we are going to make neuropsychology a science that serves consumers to the best of its ability.

The most profound scientific need in neuropsychology is fundamental descriptive research to discover what reality is in the world of things neuropsychological. This basic research need is not only for base rates and norms for our tests, which are extremely important, but real world, naturalistic descriptive research that discovers how people behave in naturalistic settings. How do they behave in their daily lives when engaging in the activities we refer to as attending, remembering, concentrating, reasoning, learning, forming abstract concepts and making abstract inferences, etc.?

How do random adults and children behave, as well as those with a history of neurological insult? Although descriptive research is emerging concerning base rates of neuropsychological phenomena, Reitan remains correct in his observation that neuropsychologists do not know what is normal (Reitan, 1992). Fundamental ecological research is needed as much today as it was when Roger Barker recommended it decades ago (e.g., see Barker, 1968). But it is under-funded hard work to slog through the behavioral jungles like Charles Darwin, recording raw facts and spending years thinking about them.

A second current need arises from the fact that the intellectual independence of the field is under siege. One solution is to spend less time minimizing our conflicts and acting as if the discipline has achieved a reasonable basis in scientific fact and theory, and more time establishing consensus through vehicles such as professional position papers by leading organizations such as the National Academy of Neuropsychology – position papers based on science, not on political negotiations in the fashion of psychiatrists writing DSM criteria. Setting forth state of the art position papers will provide guidance to young neuropsychologists and to consumers and provide challenges to researchers to advance the field. Another solution is development of new business arenas whereby neuropsychologists can obtain funding and recognize incentives consistent with practicing quality science and unbiased patient care. We sorely need new business development that is not in the stranglehold of lawyers. Lawyers are advocates, not truth seekers. We also need to do a better job at creating products and services that consumers find valuable, so that we escape dependence on insurance companies and HMO’s. Their view of what is reasonable and necessary is not consistent with long term basic research needs or experimentation with new treatment protocols. If we can develop alternative funding sources, possibly attention can be focused on severely brain-injured patients – professional attention that presently is being diverted into circular controversies over trivial injuries.

Is forensic neuropsychology a science that does not yet exist? Perhaps.

But an alternative view is that it is an incipient discipline with a great need for research at a time when our claims concerning what we know now should perhaps be more modest. The list of uncontroversial “established facts” that are generally accepted in this field is relatively short.

ABOUT THE AUTHORS Dr. Paul Lees-Haley is the author or co-author of 200 publications. He is a Phi Beta Kappa, Phi Kappa Phi, Woodrow Wilson Fellow and the recipient of the National Academy of Neuropsychology Nelson Butters Award for research contributions to clinical neuropsychology.

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Dr. David Fox has specialized in psychological assessment and neuropsychology for more than 20 years in the Los Angeles area. Author of more than a dozen professional articles, he is also on the Adjunct Faculty of Pepperdine University's Graduate School of Education and Psychology.

Earlier versions of this paper were published in Brain Injury Source and NeuroRehabilitation. Address correspondence to: Paul R. Lees-Haley, Ph.D., ABPP, 2915 Bob Wallace Ave., Huntsville, AL 35805.

Email paul@lees-haley.com.

ACKNOWLEDGEMENTS Thank you to Jerry Sweet, David Loring, Larry Cohen, Don Liddy, David Hartman, Marty Rohling, Jacobus Donders, Bill Black, Hal Smith, Brad Axelrod, Greg Lee, Manfred Greiffenstein, Carl Dodrill, Fernando Melendez, Barry Crown, David Bush, and Fiona Bardenhagen for their suggestions concerning the content of this article. Any errors or omissions in this article are solely the responsibility of the authors.

REFERENCES Substantial portions of this article appeared in Lees-Haley, PR. & Fox, DD., Isn't everything in forensic neuropsychology controversial? NeuroRehabilitation. 16(4), 2001. Special Issue: Controversies in neuropsychology. pp. 267- 273.

1. Adams, KM, A normative festival: How does the ensemble play together? Journal of Clinical & Experimental Neuropsychology. 22(2): 299-302, 2000.

2. American Educational Research Association, American Psychological Association, and National Council on Measurement in Education. Standards for educational and psychological testing. Washington, DC: American Psychological Association, 1985, 2000.

3. American Psychological Association, Ethical principles of psychologists and code of conduct. American Psychologist. 47: 1597-1611, 1992.

4. Barker RG., Ecological psychology: Concepts and methods for studying the environment of human behavior.

Stanford, CA, Stanford University Press, 1968.

5. Binder LM. Rohling ML. & Larrabee GJ., A review of mild head trauma. Part I: Meta-analytic review of neuropsychological studies. Journal of Clinical and Experimental Neuropsychology. 19: 421-431, 1997.

6. Binder LM. A review of mild head trauma. Part II: Clinical implications. Journal of Clinical and Experimental Neuropsychology. 19: 432-457, 1997.

Tangram Behavioral Program

7. Faust D., Forensic neuropsychology: The art of practicing a science that does not yet exist. Neuropsychology Review. 2: 205-231, 1991.

8. Gass JR., Lawyer tips. Hippocrates’ Lantern. 7: 5-6, 2000.

San Marcos, Texas

9. Reitan R., Clinical neuropsychology: We’ve arrived but do we want to stay? Paper presented to the American Psychological Association, Washington, D.C, 1992.

10. Rohling ML. Lees-Haley PR. Langhinrichsen-Rohling J. and Williamson DJ., A Statistical Analysis of Board Certification in Clinical Neuropsychology. Archives of Clinical Neuropsychology. 18: 331-352, 2003.

For over twenty years, the Tangram Behavioral Program has served individuals with acquired brain injury, mental illness, and behavioral disorders, offering:

11. Rowe PM., The science of self report. APS Observer. 10: 3-38, 1967.

• Emergency placements

12. Salazar AM. Warden DL. Schwab K. Spector J. Braverman S. Walter J. Cole R. Rosner M. M. Martin EM. Ecklund J. & Ellenbogen RG., Cognitive rehabilitation for traumatic brain injury: A randomized trial. JAMA. 283: 3075-3081, 2000.

• Behavioral stabilization

13. Satz P. Zauch K. McCleary C. Light R.,Asarnow R. & Becker D., Mild head injury in children and adolescents: A review of studies (1970-1995). Psychological Bulletin. 122: 107-131, 1997.

• Residential rehabilitation

• Transitions to less restrictive environments, and • When necessary, long term supported living services

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14. Somerfield MR. & McCrae RR., Stress and coping research. American Psychologist. 55, 620-625.

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15. Williams AD., Challenging neuropsychological testing in brain injury cases. Hippocrates’ Lantern . 7: 1-6, 2000.

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A ProfessionAl AwAkening

Discovering the Biased Beliefs of Clinical neuropsychologists

by Lloyd I. Cripe, Ph.D. The young North American clinical neuropsychologist was bright, dedicated and armed with the best possible professional training and credentials.

She was a newly board credentialed clinician who studied every patient she encountered from an eclectic humanistic perspective using a comprehensive assessment approach that combined all possible avenues of information, both quantitative and qualitative, to best understand the complicated neurobehavioral problems of persons suffering the hard realities of brain disorders. Records were reviewed, patients and family members interviewed, a thorough history of the patient obtained, behaviors and mental processes were directly observed, appropriate behavioral neurology tasks and standardized tests administered, observations made during the testing, appropriate normative standards applied, and all of the information was careful integrated and analyzed to determine the patient’s neuropsychological problems, their impact upon adaptive functioning, and the most practical recommendations for treatment. It was hard mental work that required long hours, but it was rewarding when the patient was understood and the interventions led to better outcomes.

When she started her professional practice, she never intended to see patients that were embroiled in medical-legal battles, but it was inevitable.

Many patients seen by neuropsychologists have acquired brain problems because of accidents, especially motor vehicle accidents. The accidents are often caused by someone or something, so there are typically questions of legal liability and damages connected to their cases. This means that attorneys become involved representing either the injured person (plaintiff) or the liable person (defendant). She soon discovered that a practicing neuropsychologist gets involved with medical-legal cases in this culture whether they want to or not.

She examined her first personal injury litigation patient in the private practice established right after her board certification. It was a man in his early 40’s who suffered a mild head injury in a motor vehicle accident with brief loss of consciousness a year-and-a-half earlier but was still experiencing cognitive and emotional problems. He was referred by himself and his attorney. He was struggling to continue with his employment. He had no significant medical or psychiatric problems prior to the injury. He was puzzled about his problems and needed some help.

She carefully studied the patient using her typical comprehensive evaluation approach adding tests sensitive to rate of information processing, attention processes and memory, knowing these are common potential 12

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problem areas for mild head injured patients. The evaluation revealed mild deficits consistent with the persistent sequella of a mild closed head injury. His psychological symptom inventory, the MMPI, was elevated on scales 1, 2, and 3. She concluded the profile had been affected by his endorsement of symptoms consistent with his head injury sequella and that there was no clinical evidence that he had a psychiatric disorder of thought or affect although he was understandably mildly stressed and discouraged over his acquired problems. He had returned to his previous work, but was struggling to function as well as he had prior to injury. She concluded in her report that he had persistent neurobehavioral problems that needed treatment by a cognitive therapist associated with a local brain injury program. She also concluded that the injury was the marker in time for the onset of the problems and that the etiology was a mild head injury. The cause was the motor vehicle accident.

Shortly after she completed her report, the defense attorney requested that the patient be seen by another neuropsychologist who mainly saw patients referred by defense attorneys. The patient was reluctant, but consented and showed-up on time for the evaluation. A report was issued a couple of weeks later concluding that the patient was probably malingering and there was no evidence of any problems associated with the injury. It further concluded that the patient was probably depressed and this best accounted for any cognitive inefficiencies he might have. There was concern expressed that he had used some marijuana in his early twenties and had once told his family physician that he was having some marital problems. It was stated that he probably had longstanding pre-existing problems that added to his current consternation. Questions of malingering were raised because he performed weakly on one of several tests of effort obtaining a score of 80 correct out of a possible 100 items. Concerns were expressed about secondary gains because the person was experiencing financial stressors and stood to make monetary gains from the law suit.

When the young neuropsychologist read the defense expert’s report, she was numb with disbelief. Had the defense oriented neuropsychologist seen the wrong patient? The identifying information was the same. It must have been the same patient, but she had not seen anything like what was described in the report. How could their opinions be so different?

The more she thought about it, the more unbelievable it seemed. At first she even questioned herself, but realized that she had seen what she had seen and reported it accurately. Her emotions changed into frustra-

tion. She decided to give herself some thinking time.

Eventually, she decided to contact a most trusted and highly experienced mentor-colleague to get some help thinking this through carefully.

Why had two persons of the same profession studied the same phenomenon but drawn such discrepant conclusions? The patient was further puzzled and now caught in a crossfire of opposite opinions.

Her mentor was nearing retirement, but still professionally active and energetic. He had spent over thirty years in the profession practicing, teaching and researching clinical neuropsychology. He had a special interest in neurologic disorders that have milder effects upon mental operations and how they impact adaptation. He had written a lot about the subject of mild head injury and the challenges of assessing their problems. He had seen thousand’s of persons with mild brain problems and carefully studied how their minds and adaptation were affected by the misfortune of disease and trauma. As her clinical supervisor in her postdoctoral fellowship, he had been the primary influence and molder of her clinical thinking and development. She deeply respected him.

Upon arriving at his office, they exchanged greetings, updated each other regarding their personal lives and engaged in some chit-chat about the current political happenings. He suddenly shifted the conversation and attentively asked, “What brings you my way?”

She then explained in detail what had happened with her case. She showed him the two reports, which he carefully read in silence. It seemed to her that he was taking forever and she finally asked, “How could this happen? How could we see the same patient and end up seeing things so differently? I need your help to understand this and decide what to do.”

He slowly looked up from the reports and shared the following thoughts: As psychologists, we know that we are all driven by conscious and unconscious biased beliefs. These implicit and explicit leanings, predilections, and prejudices are deeply rooted in our mental systems. They strongly influence our perceptions, thoughts, emotions, judgments and actions. Although they have a strong influence upon us, we often lack a full awareness of them, but they are implicit in our behavior. These biases are of course formed intentionally and unintentionally throughout our lives based upon our informal and formal learning experiences, but they are especially the products of our various informal and formal educational experiences during the formative years. Over the years, they build upon each layer by layer permeating how we see ourselves, others and the world in general in the various domains of our lives.

These biases also significantly affect our professional work. No matter how committed we are to the ideal of objectivity, everything we do clinically is profoundly affected by these biases. How we approach a patient, interact with them, select procedures, make observations, attend, not attend, reject, analyze the information, draw conclusions and write our findings are all strongly affected by these biases. In the final analysis, no matter how objective we attempt to be, we are really quite subjective.

It is challenging to become aware of our own biases. They are powerful rules that drive and guide our behaviors, but often operate out of our awareness. They are manifested implicitly and explicitly in what we say and do.

With a dedicated commitment to self-understanding, it is possible to become aware of these biases, but it is difficult. It is of course easier to see them in others than to see them in ourselves. Usually the greatest awareness occurs by taking the risk of looking deeply within ourselves and soliciting trusted others to honestly observe and confidentially share their observations with us.

This requires a deliberate vigilant spiritual and psychotherapeutic journey dedicated to discovering these biases and then learning how to avoid their entrapments. Few are willing to make such an effort.

When I started my clinical career, I had no intention of consulting in medical-legal cases. My motivations were to be the best possible clinician I could be and do something worthwhile for humanity while earning an adequate living. Regardless, as a clinical neuropsychologist practicing in North America, patients were encountered with different types of brain injuries from accidents, usually motor vehicle accidents. Because of the laws of this country, accidents typically involve potential issues of legal liability and damages. Therefore, the injured patients encountered in clinical practice are often involved in personal injury litigation. This leads to involvement with attorneys and legal proceedings.

Over time, more and more medical-legal cases were referred for neuropsychological evaluation. Initially, the referrals came from both plaintiff and defense attorneys, but gradually shifted more and more to referrals from plaintiff cases. Many of the cases involved mild head injuries with all

the challenges and controversies associated with them. These cases allowed observation of the professional products of clinical neuropsychologists working for either plaintiff or defense attorneys.

You see, clinical neuropsychologists consulting in medical-legal cases are highly selected by the counsel that hires them. In other words, it is not by accident that a defense or plaintiff attorney selects a particular expert.

Both plaintiff and defense attorneys are heavily invested in their missions.

The plaintiff attorney is representing a person who has allegedly been injured and damaged. Someone is potentially liable for the injuries. Ideally, the solicited clinical expert helps understand the client, clarify what the problems are, determines the etiology and cause, explains the impact upon the person’s adaptation, and recommends the necessary treatments for the best possible management and adaptation. The hope is that the expert will accurately represent all of this and bolster the case in the direction of a winning outcome. Secretly the plaintiff attorney wishes that the experts will find the person impaired, credibly communicate and convince, whomever necessary, that their client is terribly harmed. This will hopefully build a strong case and greater rewards.

The defense attorney is defending someone’s money, usually an insurance company’s assets, and ideally wants to defend the client from any liability or damages that the plaintiff is claiming. Ideally, the solicited clinical expert will determine that the accident did not cause any damages and that any problems the person claims is probably due to other factors than the accident itself. This will help free the client from any financial obligation.

As many forces as possible are brought together by the defense attorney to bolster the theory that their client is not responsible and the claims are unjustified. The neuropsychologist chosen to aid this cause is very carefully selected. This will hopefully protect his client’s money and bring in more for himself.

Strong forces emanate from each of these camps trying to rally and martial the various players in favor of their missions. It takes a strong commitment to professional ethics to not be sucked into the vortices of these forces. The plaintiff consultant has to work hard to be an advocate of the clinical truth of the patient rather than an advocate of the plaintiff or the legal outcome. The defense consultant has to work hard to be an advocate of the clinical truth of the patient and behave fairly rather than become an advocate of the theory of the defense who is promoting the notion that the injury has caused no harm. Conscious effort must be applied to avoid becoming an adversary of the plaintiff.

The roles of the plaintiff and defense attorneys mandate what clinician roles will prove most beneficial to them. This need dictates their selection of experts. Plaintiff attorneys benefit more from patient-centered clinicians. This paints more of a human suffering face on the presentation.

Defense attorneys benefit more from data-centered technical clinicians.

This paints more of a scientific face on the matter and divorces it from the emotion of human suffering making it more an issue of numbers.

A clinical neuropsychologist with a science-clinician perspective that is patient-centered, concerned about the doctor-patient relationship, sees the patient as the client, studies patients equally in an open manner using both qualitative and quantitative methods, takes whatever time necessary to study the person, utilities all the best available clinical tools, recognizes the need for more information than test scores, knows the limitations of test data in understanding complicated brain-mind problems, considers all sources of information as viable data, uses all information, utilizes statistical and clinical experience comparisons, and considers the best possible interventions for the patient is more often a desirable consultant for the purposes of a plaintiff attorney but undesirable for the purposes of the defense attorney.

A clinical neuropsychologist that is not as concerned about the doctorpatient relationship, relies more upon group test data than clinical case study, uses a briefer evaluation process, is more focused upon research, test data and statistics than upon qualitative clinical patient analysis is often a more desirable consultant for the purposes of a defense attorney. To summarize: A neuropsychologist who cares most about patients is more valuable to a plaintiff attorney. A neuropsychologist who cares more about data than patients is more valuable to a defense attorney. A neuropsychologist who cares about both patients and data is ideal, but doesn’t fit very well with the intended polarizations.

Fortunately, despite the polarizations, there are in the medical-legal arena many balanced neuropsychologists who approach each case in a dedicated professional manner applying the best methods and skills available whether consulting for either plaintiff or defense cases. They appreciate the BRAIN INJURY PROFESSIONAL

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QUOTATIONS Only in quiet waters do things mirror themselves undistorted. Only in a quiet mind is adequate perception of the world. Hans Margolius When the subject is highly controversial…one can not hope to tell the truth. One can only show how one came to hold whatever opinion one does hold. One can only give one’s audience the chance of drawing their own conclusions as they observe the limitations, the prejudices, the idiosyncrasies. Virginia Woolf Science is nothing but developed perception, interpreted intent, common sense rounded out and minutely articulated. George Santayanna It is only about things that do not interest one that one can give really unbiased opinions, which is no doubt the reason why an unbiased opinion is always valueless. Oscar Wilde When a thing ceases to be a subject of controversy, it ceases to be a subject of interest. William Hazlitt The ultimate measure of a man is not where he stands in moments of comfort and convenience, but where he stands at times of challenge and controversy. Martin Luther King, Jr. Education is a method whereby one acquires a higher grade of prejudices.

Laurence J. Peter A great many people think they are thinking when they are really rearranging their prejudices. William James Only as you know yourself can your brain serve you as a sharp and efficient tool. Know your own failings, passions, and prejudices so you can separate them from what you see. Bernard M. Baruch It is never too late to give up our prejudices. Henry David Thoreau Everyone is a prisoner of his own experiences. No one can eliminate prejudices – just recognize them. Edward R. Murrow When dealing with people, let us remember we are not dealing with creatures of logic. We are dealing with creatures of emotion, creatures bustling with prejudices and motivated by pride and vanity. Dale Carnegie I believe I have no prejudices whatsoever. All I need to know is that a man is a member of the human race. That’s bad enough for me. Mark Twain I don’t like principles. I prefer prejudices. Oscar Wilde I’m free of all prejudices. I hate everyone equally. W.C. Fields There is nothing respecting which a man may be so long unconscious as of the extent and strength of his prejudices. Francis Jeffrey From their experience or from the recorded experience of others (history), men learn only what their passions and their metaphysical prejudices allow them to learn. Aldous Huxley Those who don’t like thinking should at least rearrange their prejudices from time to time. Luther Burbank The mind is no match with the heart in persuasion; constitutionality is no match with compassion. Everett Dirksen

strengths and weaknesses of the trade and themselves. They recognize the complexity of brain-mind problems and the challenges of trying to assess these complicated problems with our limited technology. They know this is not rocket science, it is more complicated than that. They handle each patient carefully and respectfully. They are competent and ethical. They are honest and cannot be bought. They know that ultimately, the understanding of brain-mind problems is a complicated subjective matter – often a gray matter. They are a credit to themselves and our profession.

All of the players involved in the medical legal process have biased beliefs. The plaintiff, the plaintiff’s family and friends, the plaintiff’s attorney, the plaintiff’s experts, the defendant, the defense attorney, the defense experts, the jurors and even the judge bring biased beliefs to the case.

Books could be written on all the different players and their biases. No one is exempt. Try some time to write down all the potential different biased beliefs each of these persons might have regarding just the topic of 14

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mild head injuries. I once did it and ended up with long lists under each player. I discovered how challenging it is to present the realities of a mild head injury case in the medical-legal setting.

Because you have encountered a medical-legal defense oriented clinical neuropsychologist, you need to understand their biased beliefs.

In every region there are neuropsychologists who mainly see patients referred by defense attorneys. They don’t really see the person as a patient.

They see the attorney as their client. The patient is mandated to appear for an evaluation. It is called an independent medical evaluation, but isn’t really independent. This just a convenient illusion. The examiner relies upon a lot of other information than what is independently collected and has no special objectivity. The patient doesn’t really want to go to the evaluation, but they have to go. They go reluctantly with trepidation, anxiety and resentment.

They often know the reputation of the examiner and see the evaluation as a potential setup. They do not trust the doctor and the doctor doesn’t trust them. This undermines the very foundation of the clinical examination because the doctor-patient relationship that is essential for open communication and understanding is missing. This makes it difficult to get the necessary information for an accurate diagnosis of something as complicated as the mind. The examiner often approaches the interview with a template of interrogating questions intentionally and unintentionally designed to elicit information that fit biases rather than understand the reality of the person’s experience. Tests that are insensitive to the patients problems are often selected to prove that nothing is really statistically wrong with the person’s functioning. Tests of effort are given without warning under the false pretense of being an important measure of their problems. The cutoffs on these tests are set very high so that any performance less than perfect is an indication that the person isn’t really trying. If the person doesn’t pass the stringent effort tests, it is concluded that the person is probably consciously manipulating or even malingering. If the person passes the effort tests and shows any weakness on the neuropsychological tests, the problems are reasoned away as caused by factors other than the injury. The records and history are combed in detail to find whatever item from the past on which to blame pre-existing factors rather than connect the deficits to the injury. The correlations are often weak. Psychological symptom inventories like the MMPI are given and elevations on the profiles are used to blame “emotional factors” for the persons complaints and cognitive problems. Reports are written that are heavy on record reviews and light on the person’s history, the course of their problems and the nature of their problems. Tests are analyzed by group data using norms that conveniently show that the person is functioning within the “normal range.” The broad range of normal overlooks the possibility that the person might have previously been in the higher level of normal prior to injury. This conveniently washes out normal variability. The reports usually conclude that the person is either some sort of manipulator or has no problems related to the injury. Any cognitive problems they have are probably due to either longstanding pre-existing factors or so-called emotional factors.

You see, defense oriented neuropsychologists unwittingly operate on a set of biased beliefs which can be inferred from their writings (e.g. reports, research papers) and oral testimonies (e.g. discussions, presentations, sworn testimonies). They include the following: 1. (a) A person cannot be significantly injured by a mild head injury.

They should be able to snap out of it in a few weeks. (b) If they don’t snap out of it, they are weak persons and whatever problems they have are due to pre-existing issues or litigation hopes.

2. The person referred by a defense attorney is not the patient or client.

3. The defense attorney is the client.

4. Therefore, I don’t have to treat the person like a patient.

5. How the patient gets referred to you doesn’t affect the evaluation.

6. The doctor-patient relationship isn’t all that important in an “objective” examination.

7. How I behave in the examination has little to no impact upon the examination.

8. Only the patient can manipulate the examination and its results.

9. What the patient says, self-report, cannot be trusted and isn’t all that important in “objectively” determining what is really wrong with them.

10. Record review is crucial and a lot of effort should be put into it.

11. What is written in records is reliable, especially the parts that get my attention.

12. If you look long and hard, you can always find something in the history, other than the injury, to blame the problems on.

13. All the treating people in this case have not had the privilege of seeing

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all the information I have, therefore I know more about this persons problems.

The plaintiff, plaintiff attorney, plaintiff experts and the treating doctors have either been deceived or duped into believing what they do about this person.

I am the only one that can keep my head straight in all of this.

My opinion is the only objective one.

Money is the main thing that motivates people, especially in litigation.

Most people, except me, will sell their souls for some bucks.

(Secondary) gains mean everything and all the (secondary) losses mean nothing.

Tests are based on sound science and the test data is the only objective part of the examination.

Test scores are the only solid reality, regardless of how well they fit the patient’s experience and presentation.

If the person fails an effort test, especially my favorite one, none of the other information can be trusted and the other tests mean nothing.

In the person fails an effort test, it is a sign of intentional manipulation and probably malingering.

If the person does okay on the effort tests and shows any weaknesses on the neuropsychological tests, it can best be explained by “other factors” than injury, especially “emotional factors.”

Although self-report is useless, there are two exceptions: (1) the self-report of the patient on the MMPI; and (2) my interpretation of this case.

Elevations on the MMPI are dead ringer indicators of “emotional factors” complicating the case.

Elevations on the MMPI explain the cause of any problems on the neuropsychological tests although there is little correlation between the two.

The scientific research about of all of this is well developed and this is the main thing I base my opinions upon.

The last chapter has been written on all of this matter and I am confident that I know what it says.

He smiled at her and said, “There you have my biased beliefs about why you did not see what your defense oriented colleague saw. You don’t have

the same biased beliefs. You have your own, but I know they are not as skeptical and cynical.”

She asked, “Aren’t you going to give me some references to backup your assertions?”

He firmly replied, “No, I am not going to give you any references to support my experience. You can search my work if you wish. Psychologists use too many damn references as an obsessive defense against uncertainty and insecurity. This promotes their false sense of grandiosity and avoids the risk of creative thinking. Besides, unwittingly the references are selected by their particular biases and only give the illusion that they are relying on solid facts outside of themselves. We all know you can generally find a study in psychology that proves or disproves almost anything. I just want you to think about this for yourself uncluttered by a false sense of security and examine your own biases.”

With that he bid her goodbye and handed her a list of quotations (Page 18). She continues to think on these things, exploring her own biases and confidently practicing her profession with mindfulness and compassion. She is dedicated to doing her best and at the very least, doing no harm.

ABOUT THE AUTHOR Lloyd I. Cripe, PhD, ABPP, ABPN is a practicing Clinical Neuropsychologist in Carlsborg, Washington. He received his doctoral degree in 1974 from the University of Minnesota with training in counseling and clinical psychology. He completed a postdoctoral fellowship in 1981 in clinical neuropsychology with the Army Medical Department. He is board certified in clinical neuropsychology with the American Board of Professional Psychology and the American Board of Clinical Neuropsychology. He is a Fellow of the National Academy of Neuropsychology. He is a highly experienced clinician and educator in clinical neuropsychology. He has trained postdoctoral fellows and lends ongoing supervision/consultation to neuropsychology clinicians. He has special interests in the training of neuropsychologists, the neuropsychological evaluation process, the evaluation of personality and emotions in persons with neurologic disorders, and mild closed head injury. His private practice specializes in the evaluation and diagnosis of brain dysfunction, its causes and its adaptive consequences. He consults with medical and legal professionals throughout the country. He is an active contributor to local, national and international clinical neuropsychology professional organizations. Email the author: lcripe@olypen.com.

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15

MMPI 2: Caveats, Cautions, and Considerations

by Graeme J. Senior, Ph.D. and Lucille A. Douglas, Ph.D. Introduction The second edition of the Minnesota Multiphasic Personality Inventory (MMPI-2) is widely utilized to assess psychosocial maladjustment and is finding increasing popularity in settings outside of the primarily psychiatric context in which it was developed. This is particularly the case in the medicolegal setting where the MMPI-2 is the most popular measure of psychosocial functioning in assessing personal injury claimants (Ben-Porath, Graham, Hall, Hirschman, & Zaragoza, 1995).

Our research and experience in using the MMPI-2 to assess personal injury claimants has provided us with an opportunity to formally evaluate some of the caveats, cautions, and concerns in this well-standardised measure that boasts more than 10000 publications since its original development (Senior & Douglas, 2004). For those who are unfamiliar with or do not routinely employ the MMPI-2, we hope that the limitations addressed here with regard to this specific psychological test will illustrate the more general and pervasive difficulties encountered when applying decision-making rules to the observation of human behavior and their influence upon description, diagnosis, and treatment of patients.

It is not our contention that the interpretative guidelines established over the last sixty years for the MMPI and MMPI-2 have no empirical basis.

Rather, we believe that the validity of any interpretative guideline must be evaluated before being applied. Only in this way can we become aware of those circumstances in which cherished guidelines are unable to perform in the way we expect. What follows is an examination of four issues that impact substantially upon MMPI-2 interpretation when assessing personal injury claimants and more generally when assessing those with reported neuropathology. These issues relate to: concerns regarding the use of validity scales; inferences regarding disorder or symptom severity based upon MMPI2 scale elevations; concerns regarding reliance upon correlates; and the use of the MMPI-2 in formulating diagnoses.

MMPI-2 Personal Injury Claimant Sample For the purposes of this study a sample of 3857 MMPI-2 protocols of personal injury claimants was compiled from two forensic psychological practices in Australia and the United States of America. Protocols with more than 10 omitted items or with VRIN or TRIN T-Scores of 80 or more were excluded, leaving a total of 2838 cases (1391 males, 1447 females) The mean age of the sample was 35.9 years (SD = 13.8) with an average of 11.8 years of education (SD = 4.2). The diagnostic composition of this sample is summarised in Table 1. The “Others” group included ADHD, Bereavement, Bipolar Disorder, CFS, Cognitive Disorder, Dementia, Dissociative Disorder, Dysthymia, Factitious Disorder, OCD, Phobia, Schizophrenia, Sleep Disorder, and Whiplash. The “Malingering” group consisted of those cases for whom strong evidence of exaggeration or malingering existed based primarily upon surveillance information, drug testing, and cognitive measures indicating exaggeration of deficit or insufficient effort.

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BRAIN INJURY PROFESSIONAL

How Valid Are the Infrequency Scales?

It is uncertain as to when endorsing items that are infrequently reported by most people came to be adopted as suggesting symptom exaggeration or malingering. However by the mid 1940’s, Meehl and Hathaway (1946) were proposing that the F scale “was a very good device for identifying the intentional faking that could be set up in an experimental situation” (p. 537).

Much research has been conducted supporting the sensitivity of the Infrequency family of scales, Infrequency (F), Back Infrequency (Fb), and Infrequency-Psychopathology (Fp) in both the MMPI and MMPI-2. In the context of the MMPI-2, sensitivity evaluates the likelihood of a scale elevation in a known group or condition. Unfortunately, as clinicians we are seldom assured of the status of our patients, and are usually administering psychological tests to address this very issue. It is not the sensitivity of the Infrequency scales that concerns us here, but rather the specificity or more appropriately for the clinician, the positive predictive power. In the clinical setting, this is where the test score is known, and the group membership is being inferred.

The F scales will be of considerable use if they are sensitive to symptom exaggeration or “faking bad”, as long as they are insensitive to legitimate or

Table 1. Frequency of Diagnostic Groups in the Personal Injury Claimant Sample Diagnose

N

%

Normal

316

11.1

TBI

299

10.5

Adjustment Disorder

284

10.0

Chronic Pain

284

10.0

Somatoform Disorder

243

8.6

Others

214

7.5

Nil Diagnosis

199

7.0

Depression

192

6.8

PTSD

164

5.8

Diagnosis Unavailable

135

4.8

Substance Abuse

110

3.9

Medical Conditions

92

3.2

Anxiety

88

3.1

Malingering

79

2.8

Personality Disorders

58

2.0

Learning Disability

47

1.7

Panic Disorder

34

1.2

2838

100.0

Total

accurate reporting of symptoms. This is a critical issue in the medicolegal arena where serious concerns regarding the high base rates of malingering must be offset against the reduction or denial of compensation which may occur as the result of a false assertion of exaggeration. The 2001 revision of the MMPI-2 manual clarifies the roles of the respective Infrequency scales. F evaluates atypical or discrepant responding within the first 361 items, while Fb evaluates the second half of the test starting with item 281. The Psychopathology F scale draws its item content from both halves of the test and differs from the normative based standards of F and Fb in that its items were endorsed by less than 20% of a sample of psychiatric inpatients. The implications of their respective item content is that Fb can be compared to F to examine potential changes in response bias between the first and second halves of the test. The role of Fp is to aid in discriminating between severe psychopathology and exaggeration when elevations in F or Fb are encountered.

The implicit assumption is that an elevated F in the presence of an unelevated Fp (T<90) is indicative of severe psychopathology, and an elevated F in the presence of an elevated Fp suggests exaggeration. Table 2 shows the distribution of elevations in Infrequency scales which are associated with symptom exaggeration or “faking bad”. The Infrequency scales are much more sensitive to symptom exaggeration or malingering than they are to other conditions or disorders. However, when positive predictive power is considered, the outcome is less favorable. For example, of the 79 malingerers in the sample, a criterion of F>110 identified 18 or 22.8% of that group, by far the highest detection rate of any group. However, in using this criterion in order to identify those 18 malingerers, 96 other individuals would also be identified as exaggerators, indicating a positive predictive power of 0.15. In other words, only 15% of those who produced F scores of 110 or higher were from the malingering group. Similarly, the criterion in which Fb is greater than or equal to 110 and exceeds the F scale by 30 points or more, identifies only 2.5% or 2 of the malingerers, with the remaining 176 cases coming from other diagnostic groups. This indicates a positive predictive power of 0.01.

Only 1% of those cases in the sample which met the Fb criterion came from the malingering group. Fp fares somewhat better in that 21.5% or 17 malingerers met this criterion, again substantially more than any other group. However, this constitutes only 17% of those individuals who met this criterion with the remaining 82 cases coming from other groups.

We recognize that using such a conservative definition of malingering has resulted in a group size that substantially underestimates the base rates of exaggeration in the medicolegal setting. It is not our contention that there could be no individuals who were motivated to misrepresent or exaggerate their level of psychosocial impairment in any of the other diagnostic groups.

Rather, that any heuristic or algorithm designed to identify such individuals must, at the very least, be able to identify those individuals who have been verified as malingerers through other objective means.

A multiple regression approach was also utilized to evaluate the Infrequency scales. All Basic and Content scales were entered into a stepwise multiple regression. For each Infrequency scale, the solution retained was that combination of scales and subscales that accounted for the greatest amount of variance without introducing multicollinearity.

Table 2. Comparison of Different Criteria for "Faking Bad" on the MMPI-2 Fp >90 Percentage of Cases That Meet Criterion Diagnostic Groups

F>90

F>110

Fb>110

Fb>110 Fb-F >30

Fp>90

Adjustment Disorder

3.9

1.1

1.8

0.7

0.7

Anxiety Disorder

9.1

3.4

2.3

0.0

0.0

Depression

14.1

4.7

7.8

0.0

3.6

Learning Disability

10.6

4.3

8.5

0.0

4.3

Malingerers

41.8

22.8

26.9

2.5

21.5

Medical

3.3

1.1

2.2

1.1

1.1

Others

13.1

5.6

7.9

1.9

6.1

Pain

7.4

3.5

6.0

2.1

1.8

Panic

17.6

2.9

11.8

2.9

2.9

Personality Disorder

12.1

3.4

8.6

1.7

0.0

PTSD

15.9

4.3

9.8

1.8

3.7

Somatoform Disorder

9.5

3.3

3.7

0.4

2.1

Substance Abuse

19.1

7.3

13.6

0.9

8.2

TBI

7.7

3.0

5.0

0.3

3.0

In the personal injury claimant sample, 82% of the variance of the F scale can be accounted for by seven scales reflecting social alienation (Sc1), psychotic symptomatology (BIZ1), emotional alienation (Sc2), acknowledgement of substance abuse (AAS), physical concerns (Hs), constrained (R), and cognitive difficulties (Sc3). 89% of the variance in Fb was accounted for by seven scales reflecting emotional alienation (Sc2), schizotypal characteristics (BIZ2), suicidal ideation (DEP4), generalized fearfulness (FRS1), acknowledgement of substance abuse (AAS), low treatment motivation (TRT1), and social alienation (Sc1).

In contrast, MMPI-2 scales and subscales account for a comparatively small amount of the variance of Fp, only 54% reflecting social alienation (Sc1), psychotic symptomatology (BIZ1), emotional alienation (Sc2), acknowledgement of substance abuse (AAS), physical concerns (Hs), constrained (R), cognitive difficulties (Sc3), addiction potential (APS), familial alienation (FAM2), self-deprecation (DEP3), explosive behavior (ANG1), and generalized fearfulness (FRS1). Predictably, given that Fp draws its item content from the entire test, a combination of those measures contributing to F and Fb were retained.

Those clinical scales which account for such a high amount of variance in F and Fb do not appear to be atypical or discrepant, and could well be present in individuals with a variety of conditions. Additionally, while there is some sharing of content (social and emotional alienation, and substance abuse), F seems to be most related to psychological disturbance (e.g. psychotic symptoms, cognitive problems), while Fb seems to be more associated with psychological distress (e.g. suicidal ideation and generalized fearfulness).

These different patterns of association are most likely due to the distribution of item content across the MMPI-2, but this does not alter the fundamental concern that an individual who acknowledges his feelings of social alienation, reports thoughts of suicide, and acknowledges his substance abuse may be potentially misinterpreted as exaggerating his symptoms or malingering.

Scale Elevation and Symptom Severity A number of studies have raised concerns regarding the poor relationship between magnitude of MMPI-2 scale elevation and severity of reported symptoms (Gass, Russell, & Hamilton, 1990; Gass et al., 1992). In medicolegal evaluations this is an important concern as the discrepancy between MMPI-2 scale elevations and evidence drawn from objective psychological tests and behavioural observation are cited in reports as reflecting inconsistency. We have seen this issue employed by clinicians as justification for a diagnosis of malingering based upon the DSM-IV criterion “marked discrepancy between the person’s claimed stress or disability and the objective findings”. (p. 739, DSM-IV). For example, a claimant may report on the MMPI-2 that they experience difficulties with memory and concentration but does not demonstrate impaired performance on cognitive tests of memory or attention. This failure to support the claimant’s self-report may be misconstrued as symptom exaggeration or malingering.

Even a cursory examination of the MMPI-2 reveals the flaw in the assumptions underlying such an inference. Elevation on MMPI-2 scales are a product of increasing raw score totals. Each item on a scale contributes a score of 1 if it is endorsed in the direction associated with the construct the scale is designed to assess (e.g. saying “True” to a question regarding memory difficulties) and 0 if it does not (saying “False”). This means that higher raw scores reflect endorsement of MORE symptoms, not greater symptom severity.

We have examined this issue with regard to the MMPI-2 and two selfreport measures in which claimants indicated the severity of reported symptoms, the Problem Checklist (PCL) and the degree to which their difficulties detrimentally impact upon their daily functioning, the Competency Rating Scale (CRS). Five subscales have been developed for the PCL measuring cognitive problems, emotional difficulties, anger, executive dysfunction and physical problems. Four subscales have been developed for the CRS evaluating poor memory, activities of daily living, social impairment, and emotional dyscontrol (Dawes, Senior, & Douglas, 2003).

Multiple regression was used to examine the relationship between MMPI-2 Basic and Content scales and subscales and the PCL and CRS in a sample of 114 personal injury claimant (73 males, 41 females) cases where both measures had been administered. The mean age of the sample was 38.9 (SD = 11.5) with an average of 11.5 years of education (SD = 2.4). Diagnoses included in this sample were TBI (40.4%), Chronic pain (17.5%), depression (10.5%), PTSD (4.4%), Chronic fatigue (4.4%), Adjustment disorder (3.5%). The remaining 19.3% consisted of cases with anxiety, arteriovenous malformation, electric shock, epilepsy, learning disability, migraine, myocardial infarction, panic disorder, substance abuse, and undetermined diagnosis. The solution retained in each regression accounted for BRAIN INJURY PROFESSIONAL

17

the greatest amount of variance without introducing multicollinearity.

While the item content of the MMPI-2 scales were consistent with those of the PCL and CRS, only a small number of scales significantly predicted PCL and CRS scores (see Table 3). The adjusted r2 values indicate that for most PCL and CRS scales no more than one-quarter to one-third of the variance can be accounted for by MMPI-2 scales. This suggests that elevations on MMPI-2 scales are poor predictors of the severity of symptoms or degree of impairment in daily functioning as measured by the PCL and CRS. Utilizing Scale Correlates There is a great emphasis in the MMPI-2 literature placed on the wealth of evidence regarding behavioral correlates and the MMPI-2. While correlation certainly indicates the presence of a statistically significant relationship between variables, this does not directly translate into clinical utility. Strong associations among MMPI-2 scales can be utilized in a hypothesis-testing approach but must be evaluated in terms of not only supporting a clinical inference but also in a disconfirmatory role.

The incremental validity of DEP with regard to D is well-established (Ben-Porath, Butcher, & Graham, 1991). In this personal injury claimant sample D and DEP correlate 0.723. We utilize this redundancy in scales in an active hypothesis-testing approach in which the Basic scales serve to generate hypotheses and the Content scales are utilized to evaluate them. An elevation in D raises the question of depression, while a corresponding elevation in DEP confirms it. Table 4 illustrates the level of concordance or agreement between D and DEP scales as well as between anxiety-related measures such as Pt and ANX. In the majority of conditions, D and DEP are both elevated in 60% to 80% of cases. Depending on the diagnosis this indicates that disagreement, in which DEP fails to confirm an inference of depression, occurs in approximately 20% to 40% of protocols. This base rate is sufficiently high to rule out any interpretative guideline that suggests that elevations in D alone indicate depression-related symptoms. Similarly, PT and ANX are correlated 0.77 in this personal injury claimant sample. While the concordance is generally higher for PT and ANX, approximately 65% to 95%, there is still disagreement in 5% to 35% of cases.

Where related Basic and Content scales do not correspond, alternative explanations must be considered along with further hypothesis testing. If we do not actively test our scale-based inferences in each MMPI-2 protocol, we become vulnerable to contradicting the self-reports of our clients in favor of behavioral correlations established through group data. As has been illustrated high correlations do not preclude dissociations between related variables.

tation settings (Jacobucci, 1993).

Discriminant analyses were conducted using Basic Scales, Content Scales and each of the specific scales with groups of individuals with PTSD (N = 164) and TBI (N = 299). These groups were chosen because of their relative frequency in the sample, the existence of specific MMPI-2 scales developed for their assessment, and the clarity of their respective psychiatric and neurological etiologies.

The diagnostic accuracy of the discriminant analyses are displayed in Table 5. The misclassification rates vary from 1 in 2 to 1 in 4 cases, with a mean of 39%. Thus, on average 1 in 3 cases would be incorrectly classified.

The specific scales perform no better than combinations of Basic or Content scales suggesting little has been gained in terms of classification accuracy by their development.

Nor is this high error rate restricted to the more recently developed scales as is illustrated in Table 6 with regards to discriminating Depression (N = 192) and TBI groups. Here again the misclassification rate has a mean of 33% where 1 in every 3 cases was classified incorrectly.

The classification errors are even larger when applying the common clinical heuristic of T-scores greater than or equal to 65 indicating clinically significant elevations (see Table 7). Note that each scale reveals clinical sensitivity in that individuals with conditions associated with particular scales have a high probability of elevating that scale. Unfortunately, scale elevations are just as likely to occur in the presence of other clinical conditions as well.

Accuracy of discrimination between psychiatric (PTSD, Depression) and neurological (TBI) cases is insufficient to justify a discriminative role for the MMPI-2. While MMPI-2 scales demonstrate sensitivity, they lack the clinical specificity necessary for diagnostic purposes. Additionally, their classification accuracy does not increase beyond that of the Basic or Content scales.

Table 3. MMPI-2 Predictors of PCL and CRS Scales Name

MMPI-2 Predictors

Adj. r2

D1, FAM2 (-), Sc6

.376

D4, FAM2 (-), ANX (-), Sc6, TRT2, R

.339

ANG1, D4, FAM2 (-)

.228

D1

.348

D4, Pd1 (-), Sc6

.254

Hy4, ASP2 (-), LSE1 (-), WRK

.330

D1

.280

1: Poor Memory

D4, Hs

.211

2: Daily Activities

Hs, Mf

.169

SOD1, SOD2

.326

D1, Hy3 (-)

.416

Problem Checklist 1: Cognitive 2: Anger 3: Emotional 4: Executive Dysfunction 5: Physical Competency Rating Scale

The Role of the MMPI-2 in Diagnosis “The use of the MMPI-2 approach to personality and clinical appraisal is an alternative approach to psychiatric diagnosis – one that provides a summary of symptoms and problems from the patient’s self-reported perspective.

MMPI-based diagnostic descriptions are more specific and are based on more empirical research than are DSM-based psychiatric categories.” (p.158, Pope, Butcher, & Seelen, 2000) The MMPI was originally developed in the context of psychiatric diagnosis. Increasingly, the MMPI and MMPI-2 have been employed with populations that differ from those utilised in their scale construction. This concern has led to the development of new measures designed to be sensitive to a wider variety of conditions such as Post-Traumatic Stress Disorder (PTSD) and Traumatic Brain Injury (TBI).

Putting aside the question of exactly which empirically validated system of diagnosis the MMPI-2 does represent, the continued presence of diagnostic considerations in the computer-based interpretative systems such as the Caldwell Report developed by Alex Caldwell, the MMPI-2 Adult Interpretative System developed by Roger Greene, and the Minnesota Report developed by James Butcher (for examples of these reports see Friedman, Lewak, Nichols, & Webb, 2001 or Greene, 2002) provide some credence to our continued concerns regarding clinical diagnoses made using the MMPI-2 (see Senior & Douglas, 2001). Nowhere is this practice more perilous than in the evaluation of claimants who have sustained brain injuries.

The personal injury claimant sample was examined to determine the degree to which individuals with primarily psychiatric or neurological complaints can be discriminated using Basic scales, Content scales, and scales developed specifically for this purpose. The specific scales examined were: PK – (Post-Traumatic Stress Disorder-Keane) – this scale was developed for the evaluation of PTSD (Keane, Malloy, & Fairbank, 1984); TBIf – (Traumatic Brain Injury in a forensic setting). This scale was developed for the evaluation of traumatic brain injury in the personal injury claimant setting (Senior, Lothrop, & Deacon, 1999); and CII – (Cerebral Impairment Index) - this scale was developed to assess self-reports of TBI cases in clinical and rehabili18

BRAIN INJURY PROFESSIONAL

3: Social Impairment 4: Emotional Dyscontrol

Note: (-) indicates negative loading in the regression, ANG1 = Explosive Behavior, ANX = Anxiety, ASP2 = Antisocial Behaviors, D1 = Subjective Depression, D4 = Mental Dullness, FAM2 = Familial Alienation, Hs = Hypochondriasis, Hy3 = Lassitude-Malaise, Hy4 = Somatic Complaints, LSE1 = Self-doubt, Mf = Masculinity-femininity, Pd1 = Familial Discord, R = Repression, Sc6 = Bizarre Sensory Experiences, SOD1 = Introversion, SOD2 = Shyness, TRT2 = Inability to Disclose, WRK = Negative Work Indicators

Table 4. Correspondence between Basic and Content Scale Elevations Percentage of Cases with T-Scores > 65

Diagnoses

D

DEP

Concordance

Pt

ANX

Concordance

Adjustment Disorder

82.7

52.8

60.9%

62.0

60.2

80.6%

Anxiety Disorder

86.4

54.5

59.1%

71.6

71.6

84.1%

Depression

89.6

70.8

76.1%

83.9

71.4

81.3%

Learning Disability

59.6

34.0

50.0%

42.6

39.3

70.0%

Malingerer

93.7

67.1

71.6%

86.1

67.1

76.4%

Medical

63.0

27.2

43.2%

41.3

35.9

70.9%

Others

71.0

45.8

61.8%

57.9

46.7

72.7%

Pain

69.7

46.5

63.1%

52.5

50.4

79.0%

Panic

82.4

58.8

71.4%

70.6

64.7

83.3%

Personality Disorder

67.2

51.7

71.9%

65.5

53.4

71.1%

PTSD

79.3

69.5

81.4%

75.0

74.4

93.5%

Somatoform Disorder

82.3

35.8

43.0%

62.1

43.2

61.0%

Substance Abuse

80.0

65.5

78.3%

70.0

70.0

90.9%

TBI

66.9

46.8

64.4%

54.5

50.8

76.7%

Accordingly, we believe the MMPI-2 should not be employed for diagnostic purposes and should be restricted to the descriptive role for which its item content and response characteristics are well-suited.

Conclusions Before interpreting elevated F scales as indicative of symptom exaggeration or “faking bad”, consider the likelihood that a specific pattern of accurate or legitimate endorsements may be producing the elevation. This is best accomplished through comparison of the individual’s presentation on the MMPI-2 with other sources of information such as clinical interview, history, and other psychological test findings.

Do not assume that greater scale elevations are indicative of more severe symptoms or conditions. At best, high scale elevations suggest that more of the items associated with the underlying construct have been endorsed, i.e. increases in DEP signal more depressive symptoms not more severe depression. Once the presence of symptoms has been determined, we recommend the use of specific measures designed to evaluate symptom severity such as the Beck Depression Inventory for depression, Trauma Symptom Inventory for trauma-related symptoms, or the Pain Patient Profile for pain.

Utilize highly correlated scales for both confirmatory and disconfirmatory roles. Avoid the tendency to blindly accept an interpretative guideline based upon a single scale no matter the authoritative source. As a self-report inventory the MMPI-2 provides insight into a respondent’s attitudes, beliefs, interests, symptoms, and behaviors. These insights will be best achieved through systematic examination of the patterns of responses generated on the individual’s MMPI-2 and not the imposition of general descriptors based

Table 5. Diagnostic accuracy of discriminant analyses of MMPI-2 scales for PTSD and TBI Groups % Accurately Classified PTSD

TBI

Basic scales

67.1

68.7

Content scales

67.7

75.6

PK

63.4

61.5

TBIf

59.1

49.8

CII

56.1

52.5

Variables

Table 6. Diagnostic accuracy of discriminant analyses of MMPI-2 scales for Depression and TBI Groups % Accurately Classified Depression

TBI

Basic scales

69.1

69.5

Content scales

69.8

71.6

D

63.4

61.5

DEP

62.5

66.2

Variables

Table 7. Percentage of Cases with Elevations on Specific MMPI-2 Scales

upon behavioral correlates derived from group studies.

Do not render MMPI-2 based diagnoses. Recognize that the contribution that the MMPI-2 makes is to provide a rich description of the patient/client as they wish to be perceived. The MMPI-2 may generate results that are consistent with or challenge proposed diagnoses, but the test’s ability to discriminate amongst diagnostic groups is insufficient to justify any diagnostic role.

In particular, be cautious when using scales specifically developed to identify a particular diagnostic group. While their sensitivity is virtually assured, the lack of specificity with regard to other salient clinical groups is inadequate.

REFERENCES 1. American Psychiatric Association: Diagnostic and statistical manual of mental disorders: DSMIV-TR (4th ed. Text Revision). Washington, DC: American Psychiatric Association, 2000.

2. Ben-Porath YS. Butcher JN. & Graham JR., Contribution of the MMPI-2 content scales to the differential diagnosis of schizophrenia and major depression. Psychological Assessment.

3(4): 634-640, 1991.

3. Ben-Porath YS. Graham JR. Hall GCN. Hirschman RD. & Zaragoza MS.: Forensic applications of the MMPI-2. Thousand Oaks, CA: Sage, 1995 4. Cavallo MM. Kay T. & Ezrachi O., Problems and changes after traumatic brain injury: Differing perceptions within and between families. Brain Injury. 6(4): 327-335, 1992.

5. Dawes SE. Senior GJ. & Douglas LA., Efficacy and base rates of the problem checklist (PC) and competency ratings (CR) of the Head Injury Family Interview (HIFI) in assessing personal injury claimants. Archives of Clinical Neuropsychology. 18(6): 789, 2003.

6. Friedman AF. Lewak R. Nichols DS. & Webb JT.: Psychological assessment with the MMPI2. Mahwah, NJ: Lawrence Erlbaum Associates, 2001.

7. Gass C. Burda PC. Starkey TW. & Dominguez F., MMPI interpretation of psychiatric inpatients: Caution in making inferences about concentration and memory. Journal of Clinical Psychology. 48(4): 493-499, 1992.

8. Gass C. Russell E.W. & Hamilton R.A., Accuracy of MMPI-based inferences regarding memory and concentration in closed-head-trauma patients. Psychological Assessment. 2(2): 175178, 1990.

9. Greene RL.: The MMPI-2: An interpretative manual. (2nd ed.). Boston, MA: Allyn and Bacon, 2000.

10. Jacobucci GD.: Cerebral impairment: A new content scale for the MMPI-2. Master of Arts Thesis, Simon Fraser University, 1993.

11. Keane TM. Malloy PF. & Fairbank JA., Empirical development of an MMPI scale for the assessment of combat-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology. 52(5): 888-891, 1984.

12. Meehl PE. & Hathaway SR., The K factor as a suppressor variable in the Minnesota multiphasic personality inventory. Journal of Applied Psychology. 30: 525-564, 1946.

13. Pope KS. Butcher JN. & Seelen, J.: The MMPI, MMPI-2, & MMPI-A in court. A practical guide for expert witnesses and attorneys. (2nd Ed.). Washington, D.C.: American Psychological Association, 2000.

14. Prigatano G. Fordyce D. Zeiner H. Roueche J. Pepping M. & Wood B.C.: Neuropsychological Rehabilitation After Brain Injury. Baltimore, Md: Johns Hopkins, 1986.

15. Senior GJ., & Douglas, L.A. (2001). Misconceptions and misuse of the MMPI-2 in assessing personal injury claimants. Neurorehabilitation, 16, 203-213.

16. Senior, G.J., & Douglas, L.A., Straw men in the Land of Oz: A reply to Butcher and BenPorath (2004). Australian Psychologist. 39(1): 51-56, 2004.

17. Senior G. Lothrop P. & Deacon S. TBI(f): An MMPI-2 scale for assessing traumatic brain injury in a forensic setting. Poster presented at the 19th Annual Conference of the National Academy of Neuropsychology, San Antonio, Texas, USA. 10-13 November, 1999.

Percentage of Cases with T-Scores > 65

Diagnoses

TBI(f)_t

CII

PK

D

DEP

Adjustment Disorder

81

69

51

82.7

52.8

Anxiety Disorder

82

82

61

86.4

54.5

Depression

89

84

66

89.6

70.8

Learning Disability

78

70

54

59.6

34.0

Malingerer

98

95

72

93.7

67.1

Medical

77

71

28

63.0

27.2

Others

69

64

45

71.0

45.8

Pain

71

62

42

69.7

46.5

Panic

82

82

53

82.4

58.8

Personality Disorder

67

67

53

67.2

51.7

PTSD

80

78

71

79.3

69.5

Somatoform Disorder

86

84

40

82.3

35.8

Substance Abuse

74

68

66

80.0

65.5

TBI

80

75

50

65.9

46.8

ABOUT THE AUTHOR Graeme J. Senior, Ph.D. is a senior lecturer in the Department of Psychology at the University of Southern Queensland in Australia. The current focus of his research and clinical work is in the areas of forensic, clinical, and neuropsychological assessment. Much of the consultancy and clinical work he does is specific to addressing medicolegal issues with psychological test data aimed at developing more robust methods of psychological test data interpretation in personal injury claimants. He has been conducting a program of normative studies over the last eight plus years along with the construction of a co-operative database of medicolegal and clinical cognitive and psychosocial cases. These data will contribute to establishing Australian norms for many of the most commonly administered cognitive tasks, and establishing Australian medicolegal base-rate data for these same tests as well as the MMPI-2. Dr. Senior and his Honours, Masters and Doctoral level students have produced a large number of presentations and a very impressive website on these topics: http://www.usq.edu.au/users/senior/.

Lucille A. Douglas, Ph.D. is a Clinical Psychologist in private practice. She received her Ph.D. in Clinical Psychology from Long Island University, New York in 1992. Her practice, Assessment Services in Psychology, is in Brisbane, Australia, and specializes in medicolegal assessments of personal injury claimants. The focus of her clinical research is in developing more effective tools and decisionmaking models in the detection of neuropathology.

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NEUROFEEDBACK: Cutting Edge Technology That Retrains the Brain

by D. Corydon Hammond, Ph.D., ABEN/ECNS, QEEG-D What is Neurofeedback Neurofeedback is EEG biofeedback or brainwave training. Neurofeedback training usually begins with a quantitative EEG (QEEG) assessment. A large body of research exists on the abnormal EEG and QEEG patterns associated with various medical and psychiatric disorders (Hughes & John, 1999). The assessment for neurofeedback training may consist of anywhere from 2 to 19 electrodes being placed on the head at standardized electrode sites to gather EEG data. This data is then usually compared statistically to a normative database, providing scientifically objective information on how the patient's functional brain activity differs from age appropriate norms. QEEG is an accepted procedure for evaluating head trauma in the military and V.A. hospital system. Data from the QEEG guides the neurofeedback treatment process wherein we retrain the brain.

An example of part of a QEEG brain map is seen in Figure 1. The patient was riding on a motorcycle with her husband. Despite wearing a helmet, she suffered a serious head injury when the front tire blew out. In the map, the color green represents areas of normal EEG activity while the color red represents a 3-Z-score or greater deviation from norms. The patient hit her head in the left posterior area, suffering a coup-contracoup head injury, which can be seen moving from the left posterior area to the right frontal area of the map. The map shows the very excessive slow (6-8 Hz) brainwave activity that is present.

During the neurofeedback training itself, there are usually two electrodes placed on the scalp at locations where the EEG activity is most divergent from norms. Reference and ground electrodes are placed on the earlobes. Nothing intrusive is introduced into the brain. The electrodes simply measure the ongoing brainwave activity. Ordinarily we are unable to reliably influence our brainwave activity because we lack awareness of it.

However, when we are able to see representations of our brainwave activity 20

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on a computer screen a few thousandths of a second after it occurs, it allows us to modify our brainwave patterns through operant conditioning.

The patient is placed in front of a computer screen. The computer display may be as complex as a computer/video game type of display. It may also be as simple as two bar graphs, one representing slow and inefficient brainwave activity, and the other bar graph representing efficient, beta brainwave activity. The patient concentrates on the screen. When the inappropriate activity decreases slightly and the appropriate activity increases slightly, a pleasant tone is heard. At first, changes in brainwave activity are transient. However, as sessions are repeated, and as the therapist gradually modifies the thresholds for inhibiting inappropriate activity and for reinforcing healthier brainwave activity, enduring changes are gradually conditioned.

In the remainder of this paper we will review some of the history and research in the field of neurofeedback, then discussing its application to brain injuries. As you will see, neurofeedback has been found to be effective in modifying brain function and in producing significant improvements in clinical symptoms.

History & Literature Review The field of EEG biofeedback (neurofeedback) began in the 1960's as a method of enhancing relaxation by increasing alpha brain waves. Research followed (Moore, 2000; Hammond, in press) providing experimental validation that neurofeedback could effectively reduce anxiety, whether it was generalized anxiety, phobic anxiety, or post-traumatic stress disorder.

Neurofeedback got its next boost from a chanced discovery.

Dr. Barry Sterman was conducting sleep research at UCLA in the late 1960's. Working with cats, Sterman learned that you could condition a certain brainwave pattern that he named the sensorimotor rhythm. He

Figure 1 QEEG Brain Map of a Coup-Contracoup Head Injury

believed that this was a very interesting discovery, but before pursuing this research further, he became involved in a government funded project to study the toxic effects of rocket motor propellant fuel. They used cats in this research and just as it caused toxic effects in humans, so it also caused these effects in the cats, including having grand mal epileptic seizures.

However, there was something very puzzling. While the majority of the cats experienced seizures, seizure onset was very delayed in seven cats, and three could never be induced to have a seizure. Finally they realized that the seizure-resistant cats were ones that Sterman had previously conditioned to produce more of the sensorimotor rhythm. It had increased their seizure threshold.

This serendipitous finding led to a considerable body of experimental research on the use of neurofeedback with uncontrolled epilepsy in humans. Much of this research was summarized by Sterman (2000) and documented that 82% of the most severe, uncontrolled epileptics (where often neurosurgery to remove part of the temporal lobe was the only alternative still being considered) demonstrated a significant reduction in seizure frequency, with an average of a 70% reduction in seizures. Nine studies reviewed by Sterman (2000) had control conditions which variously included non-contingent reinforcement, EMG biofeedback, an ABA crossover design, random feedback, and relaxation training with EEG electrodes. One study included both yoked non-contingent and wait-list control groups. Another controlled study (Kotchoubey et al., 2001) recently further validated the effectiveness of neurofeedback compared to medication and placebo. Some of this research (e.g., Whitsett et al., 1982) utilized pre-post sleep lab evaluations, which are important because there is more epileptiform activity in a sleep EEG than in a waking EEG. This research documented that the positive changes in EEG activity following neurofeedback training are not just a voluntary waking change associated with learning a certain mode of concentration on a computer screen. The positive changes in reduced epileptogenic activity were seen even during sleep. Sterman and Lantz (2001) demonstrated that in epileptic patients following neurofeedback training, there were neuropsychological test improvements in memory that were of a selective nature in patients with unilateral right vs. left temporal lobe lesions, which would be very difficult to interpret as non-specific.

These neurofeedback studies meet the criteria for being both an efficacious and specific treatment for uncontrolled epilepsy, which is the highest level of evidence-based support for a treatment that was established by the American Psychological Association Clinical Psychology Division task force on efficacious treatments (Chambless et al., 1998a, 1998b). Notably, a selectively biased review of neurofeedback (Lohr et al., 2001) failed to acknowledge any of this literature. The effectiveness of neurofeedback with this brain disorder certainly provides encouraging evidence about the possibilities of neurofeedback with brain injuries.

The next major area of research in neurofeedback has been with ADD/ADHD and learning disabilities. A large body of QEEG research has verified abnormal brainwave activity in persons with ADD/ADHD (e.g., Baving et al., 1999; Bresnahan et al., 1999; Chabot & Serfontein, 1996; Chabot et al., 1996, 1999; Clarke et al., 1998; Clarke, Barry, McCarthy, & Selikowitz, 2001a, 2001b; DeFrance et al., 1996; Lazzaro et al., 1998; Mann et al., 1992; Matsuura et al., 1993; Monastra et al, 1999, 2001; Suffin & Emory, 1995). Brain injury patients typically share some common problems with individuals with ADD/ADHD, including difficulties maintaining attention and with impulse control.

The first ADD/ADHD neurofeedback study was published by Lubar and Shouse (1976). In a case study with an ABA reversal design, it was shown that attentiveness and oppositional behaviors improved when slow brainwave activity was inhibited and efficient beta brainwave activity was reinforced. However, when these training contingencies were reversed, the improvements deteriorated, and then subsequently improved again when they reinstituted appropriate training. Thompson and Thompson (1998) reported on successful improvements in 111 ADD/ADHD patients and Kaiser and Othmer (2000) reported on a series of 186 ADHD cases.

Lubar (1995) published a 10-year independent follow-up of 52 ADHD patients, noting change and maintenance of change in over 80% of patients. Fascinatingly, every ADD/ADHD or learning disability study that has evaluated IQ pre- and post-treatment has found IQ increases following neurofeedback training. These improvements have ranged from an average of 9 IQ points improvement (Linden et al., 1996) in one study, to an average 12 IQ point improvement in another study (Thompson & Thompson, 1998), to a mean of 19 IQ points (Tansey, 1990), and even up to an average increase of 23 IQ points in still another study (Othmer, Othmer & Kaiser, 1999).

Rossiter and LaVaque (1995) compared the effects of EEG biofeedback with stimulant medication (methylphenidate or dextroamphetamine) on a continuous performance test (Test of Variables of Attention (TOVA)) and a standardized behavioral symptom rating scale. Following pre-testing, 46 patients were divided into two groups, matched for intelligence, age, and gender and either treated with 20 thirty minute sessions of neurofeedback or with stimulant medication. Neurofeedback produced comparable improvements to stimulant medication on the TOVA and on rating subscales for hyperactivity, attentional problems, and externalizing behaviors.

Linden, Habib, and Radojevic (1996) reported a controlled study where 18 ADHD children were randomly assigned to either a wait list control condition or neurofeedback. The neurofeedback treatment group received 40 45-minute sessions of training. The children receiving neurofeedback showed a significant reduction in symptoms of inattention as measured by the IOWA-Conners Behavior Rating scale, and a significant increase in IQ (9 points).

Monastra, Monastra, and George (2002) compared neurofeedback to Ritalin in the treatment of ADD/ADHD. In this study, 100 patients took part in a multi-modal treatment program that included: stimulant medication, a parenting program that included subsequent individualized parentcounseling as needed, and academic support with an Individual Education Plan or 504 Accommodation Plan. Fifty-one patients received an average of 28.7 hours of neurofeedback training (provided in 40 minute sessions) in addition to the treatments just cited, and 49 did not. Patients were examined on IQ tests, behavioral rating scales, a continuous performance test, and a QEEG assessment, and there were no significant differences on pre-treatments measures between the groups. There were no drop-outs in the study. Both groups were evaluated one year later, both while taking stimulant medication and then after medication had been discontinued for one week. Significant improvement was found in both groups while still using medication, but after a week off medication, there was relapse on behavioral and CPT measures in each of the subjects who did not receive neurofeedback training, and no improvement in EEG patterns. In contrast, patients who received neurofeedback training as part of their treatment demonstrated sustained improvement on the TOVA and on behavioral measures, as well as improvements in their EEG measures.

More recently Fuchs, Birbaumer, Lutzenberger, Gruzelier & Kaiser (2003) compared an average of 27 hours of neurofeedback training with Ritalin. Outcome measures included a test of intelligence (WISC-R), computerized tests of attention (the TOVA and the Attention Endurance Test) and the IOWA-Conners Behavior Rating Scale. Statistical analysis of the pre-treatment measures found that the groups were comparable in terms of intelligence and severity of ADHD symptoms. It was found that both EEG biofeedback and Ritalin produced significant improvements on computerized tests of attention and on behavioral rating scales, land the degree of improvement from neurofeedback was comparable with that found in patients who were treated with and still remained on Ritalin. In the area of learning disabilities, Fernandez et al. (2003) have also documented the ability of neurofeedback, in contrast to a sham placebo control condition, to produce significant improvements.

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Neurofeedback with Traumatic Brain Injury From the literature reviewed thus far, it is apparent that neurofeedback provides a potent method for improving brain function in persons with uncontrolled epilepsy and ADD/ADHD. Similar problems are frequently seen after brain injury. Neurofeedback is now being applied to a wide variety of conditions, including traumatic brain injuries and stroke. Better outcome studies need to be done in this area, but there are very encouraging reports of cases and of series of cases (e.g., Ayers, 1999; Bounias et al., 2001, 2002; Hoffman et al., 1996a, 1996b; Keller, 2001; Laibow et al., 2001; Thornton, 2001, 2002; Tinius & Tinius, 2001) and one randomized controlled trial (Schoenberger et al., 2001). In the latter study, TBI patients receiving neurotherapy (compared with a wait-list controls group) improved significantly in depression, fatigue, and other problematic symptoms, as well as some measures of cognitive functioning, including those involving working memory, immediate memory of new material, and retention of information.

One outcomes report (Ayers, 1987) with head injuries found that some of the earliest improvements from training were an increase in energy and decrease in depression, mood swings, anxiety, and anger. A decrease in sensitivity to sound/light and an increase in attention span often improved next, followed by a reduction of dizziness and headaches, and finally, an improvement in libido and less reversal of letters or words. In that report, about 60% of patients reported significant improvement in short-term memory. Fascinatingly, Ayers (1999) has reported 78% success in bringing individuals out of coma who had been in level 2 coma for more than 2 months.

Case Example. A concluding case example will illustrate the neurofeedback process with brain injury (Hammond, in press). At the age of 38 the patient had suffered a brain aneurysm in her right carotid artery followed by a stroke during neurosurgery. She came seven years later for her first appointment. She was in a wheelchair and had almost no movement in her left leg, but a physical therapist had taught her to wear an ankle brace, use a cane with a large base, and to throw her hip. Her balance was very compromised and she relied heavily on the cane to move awkwardly on her feet. In this way she was able to move around minimally in her kitchen and she was able to leave her wheelchair outside my office door.

However, she spent an estimated 98% of her time in a wheelchair.

Her left arm was constricted tight against her chest, with her left hand clenched in a fist. She was unable to open her fingers or hand, and could not move her left arm. This was extremely uncomfortable for her, but she had resisted a physician's recommendation that they cut nerves leading to her hand and arm to allow them to relax. There had been a deterioration in general intellectual function following the stroke. She could no longer concentrate well enough to read very much, and she spent most of her days watching television in her wheelchair. She also had problems with urinary incontinence, having "accidents" 4-5 times a day, despite taking 30 mg of ditropan per day for bladder control.

Our initial sessions focused on her left hand and arm, with electrodes placed over the area of the homunculus associated with her hand and arm.

We inhibited 4-7 Hz and mildly reinforced 15-18 Hz. After 6-7 sessions, her arm had relaxed, fallen away from her chest, and her hand was now open. She said that it could do nothing else for her, she would still be profoundly grateful. We were unable to obtain further hand movement, presumably because the damage was too great. Next we began to work with electrodes over the area of the homunculus associated with her legs and in an area (Hammond, in press) low on the back of the head that promotes improved balance, incontinence and swallowing. Although she had commented on her problem with incontinence in the intake interview, I simply told her that this electrode placement was to improve her balance, along with the work we were doing to improve her ability to use her left leg, thus making this into a single blind case study.

At the conclusion of a total of 50 sessions, the patient was spending 95% of her time out of her wheelchair. She was taking one-half to full mile walks daily with her mother. When she was outdoors (for instance, going to get her mail from the mailbox at the edge of the road) she would use her cane because she was afraid she might fall. However, around the house and walking from the waiting area to my office, she was very obviously walking better without a cane than she had been with a cane previously. In our next to last session, the patient told me about some unantici22

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pated improvements with which she was delighted. She was now reading, and her mother confirmed that she had now resumed reading regularly.

She then said that there had been another unexpected improvement.

Instead of having 4-5 "accidents" a day, incontinence was now a rare occurrence and she had reduced her medication for bladder control from three pills daily to one pill a day.

Conclusion Frank H. Duffy (2000), a Professor and Pediatric Neurologist at Harvard Medical School, has said that scholarly literature now suggests that neurofeedback "should play a major therapeutic role in many difficult areas. In my opinion, if any medication had demonstrated such a wide spectrum of efficacy it would be universally accepted and widely used" (p. v). "It is a field to be taken seriously by all" (p. vii). Neurofeedback offers powerful cutting-edge technology that has been validated in being able to improve brain disorders. Better outcome research is still needed in its application with head injury and stroke, but it appears to be an encouraging treatment and it is being used clinically. Individuals who are interested in learning more about neurofeedback training and seeing a comprehensive bibliography of outcome literature may contact the International Society for Neuronal Regulation (www.isnr.org) or the Association for Applied Psychophysiology and Biofeedback (www.aapb.org), and those interested in QEEG may contact www.appliedneuroscience.com.

REFERENCES 1. Ayers, ME: Assessing and treating open head trauma, coma, and stroke using real-time digital EEG neurofeedback. In: Introduction to Quantitative EEG and Neurofeedback. J. R. Evans & A. Abarbanel (Eds.) Academic Press, New York, NY. Pages 203-222.

2. Baving L. Laucht M. & Schmidt MH, Atypical frontal brain activation in ADHD: Preschool and elementary school boys and girls. Journal of the American Academy of Child & Adolescent Psychiatry. 8(11): 1363-1371. 1999.

3. Bounias M. Laibow RE. Bonaly A. & Stubblebine AN., EEG-neurobiofeedback treatment of patients with brain injury: Part 1: Typological classification of clinical syndromes. Journal of Neurotherapy. 5(4): 23-44, 2001.

4. Bounias M. Laibow RE. Stubbelbine AN. Sandground H. & Bonaly A., EEG- neurobiofeedback treatment of patients with brain injury Part 4: Duration of treatments as a function of both the initial load of clinical symptoms and the rate of rehabilitation. Journal of Neurotherapy. 6(1): 23-38, 2002.

5. Bresnahan SM. Anderson, JW. & Barry RJ., Age-related changes in quantitative EEG in attention-deficit/hyperactivity disorder. Biological Psychiatry. 46: 1690-1697. 1999.

6. Chabot RA. & Serfontein G., Quantitative electroencephalographic profiles of children with attention deficit disorder. Biological Psychiatry. 40: 951-963, 1996.

7. Chabot RA. Merkin H. Wood LM. Davenport TL. & Serfontein G., Sensitivity and specificity of QEEG in children with attention deficit or specific developmental learning disorders. Clinical Electroencephalography. 27: 26-34, 1996.

8. Chabot RA. Orgill AA. Crawford G. Harris MJ. & Serfontein G., Behavioral and electrophysiologic predictors of treatment response to stimulants in children with attention disorders. Journal of Child Neurology. 14(6): 343-351, 1999.

9. Chambless DL. Baker MJ. Baucaom DH., et al., Update on empirically validated therapies II. The Clinical Psychologist. 51(1): 3-16, 1998a.

10. Chambless D. & Hollon SD, Defining empirically supported therapies. Journal of Consulting & Clinical Psychology. 66: 7-18, 1998b.

11. Clarke AR. Barry RJ. McCarthy R. & Selikowitz M., EEG analysis in attentiondeficit/hyperactivity disorder: A comparative study of two subtypes. Psychiatry Research. 81: 19-29, 1998.

12. Clarke AR. Barry RJ. McCarthy R. & Selikowitz M., Electroencephalogram differences in two subtypes of attention-deficit/hypoeractivity disorder. Psychophysiology. 38: 212-221, 2001a.

13. Clarke AR. Barry RJ. McCarthy R. & Selikowitz M., Excess beta activity in children with attention-deficit/hyperactivity disorder: An atypical electrophysiological group. Psychiatry Research. 103: 205-218, 2001b.

14. DeFrance JF. Smith S. Schweitzer FC. & Sands S., Topographical analyses of attention disorders of childhood. International Journal of Neuroscience. 87: 41-61, 1996.

15. Duffy FH., Editorial: The state of EEG biofeedback therapy (EEG operant conditioning) in 2000: An editorâ&#x20AC;&#x2122;s opinion. Clinical Electroencephalography. 31(1): v-viii, 2000.

16. Fernandez T. Herrera W. Harmony T. Diaz-Comas L. Santiago E. Sanchez L. Bosch J. Fernandez-Bouzas A. Otero G. Ricardo-Garcell J. Barraza C. Aubert, E. Galan, L. & Valdes P., EEG and behavioral changes following neurofeedback treatment in learning disabled children. Clinical Electroencephalography. 34(3): 145-150, 2003.

17. Fuchs, T. Birbaumer N. Lutzenberger W. Gruzelier JH. & Kaiser J, Neurofeedback treatment for attention-deficit/hyperactivity disorder in children: A comparison with methylphenidate. Applied Psychophysiology and Biofeedback. 28(1): 1-12, 2003.

18. Hammond, DC., Neurofeedback to improve physical balance, incontinence, and swallowing. Journal of Neurotherapy. In press.

19. Hoffman DA. Stockdale S. & Van Egren L., Symptom changes in the treatment of mild traumatic brain injury using EEG neurofeedback [Abstract]. Clinical Electroencephalography. 27(3): 164, 1996a.

35. Moore, N. C., A review of EEG biofeedback treatment of anxiety disorders. Clinical Electroencephalography. 31(1): 1-6, 2000.

36. Othmer S. Othmer SF. & Kaiser DA.: EEG biofeedback: Training for AD/HD and related disruptive behavior disorders. In Understanding, Diagnosing, land Treating AD/HD in Children and Adolescents. JA Incorvaia BS Mark-Goldstein & D Tessmer (Eds.) Jason Aronson, New York, NY. Pages 235-296, 1999.

37. Rossiter TR. & LaVaque TJ., A comparison of EEG biofeedback and psychostimulants in treating attention deficit/hyperactivity disorders. Journal of Neurotherapy. 1: 48-59, 1995.

38. Schoenberger NE. Shiflett SC. Esty ML. OchsL. & Matheis RJ, Flexyx neurotherapy system in the treatment of traumatic brain injury: An initial evaluation. Journal of Head Trauma Rehabilitation. 16(3): 260-274, 2001.

39. Sterman, MB., Basic concepts and clinical findings in the treatment of seizure disorders with EEG operant conditioning. Clinical Electroencephalography. 31(1): 45-55, 2000.

40. Sterman MB. & Lantz D., Changes in lateralized memory performance in subjects with epilepsy following neurofeedback training. Journal of Neurotherapy. 5, 63-72, 2001.

41. Suffin SC. & Emory W., Neurometric subgroups in attentional and affective disorders and their association with pharmacotherapeutic outcome. Clinical Electroencephalography.

26(2): 76-83, 1995.

42. Tansey, M. A., Righting the rhythms of reason: EEG biofeedback training as a therapeutic modality in a clinical office setting. Medical Psychotherapy. 3: 57-68, 1990.

43. Thornton K., Improvement/rehabilitation of memory functioning with neurotherapy/QEEG biofeedback. Journal of Head Trauma Rehabilitation. 15(6): 12851296, 2000.

44. Thornton, K., Electrophysiology of auditory memory of paragraphs towards a projection/activation theory of the mind. Journal of Neurotherapy. 4(3): 45-72, 2001.

45. Tinius TP. & Tinius KA., Changes after EEG biofeedback and cognitive retraining in adults with mild traumatic brain injury and attention deficit disorder. Journal of Neurotherapy.

4(2): 27-44, 2001.

46. Whitsett SF. Lubar JF. Holder GS. et al., A double-blind investigation of the relationship between seizure activity and the sleep EEG following EEG biofeedback training. Biofeedback & Self-Regulation. 7: 183-209, 1982.

20. Hoffman DA. Stockdale S. & Van Egren L., EEG neurofeedback in the treatment of mild traumatic brain injury [Abstract]. Clinical Electroencephalography. 27(2): 6, 1996b.

21. Hughes JR. & John ER, Conventional and quantitative electroencephalography in psychiatry. Journal of Neuropsychiatry & Clinical Neuroscience, 11(2), 190-208, 1999.

22. Kaiser DA. & Othmer S., Effect of neurofeedback on variables of attention in a large multicenter trial. Journal of Neurotherapy. 4 (1): 5-28, 2000.

23. Keller I., Neurofeedback therapy of attention deficits in patients with traumatic brain injury.

Journal of Neurotherapy. 5: 19-32, 2001.

24. Kotchoubey B. Strehl U. Uhlmann C. Holzapfel S. Konig M. Froscher W. Blankenhorn V. Birbaumer N., Modification of slow cortical potentials in patients with refractory epilepsy: A controlled outcome study. Epilepsia. 42(3): 406-416, 2001.

25. Laibow RE. Stubblebine AN. Sandground H. & Bounias M., EEG neurobiofeedback treatment of patients with brain injury: Part 2: Changes in EEG parameters versus rehabilitation.

Journal of Neurotherapy. 5(4): 45-71, 2001.

26. Lazzaro, I., Gordon, E., Whitmont, S., Plahn, M., Li, W., Clarke, S., Dosen, A., & Meares, R., Quantified EEG activity in adolescent attention deficit hyperactivity disorder. Clinical Electroencephalography. 29(1): 37-42, 1998.

27. Linden M. Habib T. & Radojevic V., A controlled study of the effects of EEG biofeedback on cognition and behavior of children with attention deficit disorder and learning disabilities. Biofeedback and Self-Regulation. 21(1): 35-49, 1996.

28. Lohr J. M. Meunier SA. Parker LM. & Kline JR., Neurotherapy does not qualify as an empirically supported behavioral treatment for psychological disorders. The Behavior Therapist. 24(5): 97-104, 2001.

29. Lubar JF.: Neurofeedback for the management of attention-deficit/hyperactivity disorders.

In Biofeedback: A Practitioner’s Guide. M. S. Schwartz (Ed.) Guilford, New York, NY. Pages 493-522, 1995.

30. Mann CA. Lubar JF. Zimmerman AW. Miller CA. & Muenchen RA., Quantitative analysis of EEG in boys with attention-deficit-hyperactivity disorder: A controlled study with clinical implications. Pediatric Neurology. 8(1): 30-36, 1992.

31. Matsuura M. Okubo Y. Toru M. Kojima T. He, Y. Hou Y., A cross-national EEG study of children with emotional and behavioral problems: A WHO collaborative study in the western pacific region. Biological Psychiatry. 34: 59-65, 1993.

32. Monastra VJ. Lubar JF. & Linden M., The development of a quantitative electroencephalographic scanning process for attention deficit-hyperactivity disorder: Reliability and validity studies. Neuropsychology. 15: 136-144, 2001.

33. Monastra VJ. Lubar JF. Linden M. VanDeusen P. GreenG. Wing W. Phillips A. & Fenger TN, Assessing attention deficit hyperactivity disorder via quantitative electroencephalography: An initial validation study. Neuropsychology. 13(3): 424-433, 1999.

34. Monastra V.J. Monastra DM. & George S., The effects of stimulant therapy, EEG biofeedback, and parenting style on the primary symptoms of attention-deficit/hyperactivity disorder. Applied Psychophysiology and Biofeedback. 27(4): 231-249, 2002.

ABOUT THE AUTHOR D. Corydon Hammond, Ph.D. is a Professor of Physical Medicine & Rehabilitation at the University of Utah School of Medicine in Salt Lake City, Utah. He is a past President of the International Society for Neuronal Regulation. He is board certified in EEG and QEEG from the American Board of Electroencephalography & Neurophysiology and the EEG & Clinical Neuroscience Society, and is certified in neurofeedback. He has over 100 professional publications.

AGNEW&BRUSAVICH – LAWYERS Specialists In Representing Individuals With Acquired Brain And Spinal Cord Injuries Let Us Help Rebuild Your Life with Our Successful Team Approach • • • • • • • • • • •

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AGNEW & BRUSAVICH - LAWYERS 20355 Hawthorne Blvd. – Torrance, CA 90503 Tel: (310) 793-1400 – Fax (310) 793-1499 http://www.agnew-brusavich.com BRAIN INJURY PROFESSIONAL

23

Preliminary Consumer Guidelines

for Choosing a neuropsychologist for evaluation and Treatment after acquired Brain injury

by Michael F. Martelli, Ph.D., Nathan D. Zasler, M.D. and Patricia R. Babin, Ph.D. Selecting a rehabilitation neuropsychologist for evaluation and treatment after brain injury is too important a task to be conducted in a haphazard or uninformed manner. However, few guidelines are available to assist consumers in considering the utility of neuropsychological specialists for evaluation and treatment following brain injury.

Informational searches using the internet and a variety of search engines along with perusal of brain injury related websites, periodicals and newsletters is revealing. Guides for enhancing services to persons with brain injury for providers in most specialty areas including Neuropsychology are fairly easily found. Glossaries and descriptions of neuropsychological services are available from multiple sources and providers. Guides to assist patients in adapting and coping with brain injury sequelae, and seeking rehabilitation interventions and services are similarly available. These guides can be very helpful in identifying and coping with brain injury residua, seeking services, and picking a rehabilitation program and team, but not with selecting or evaluating an individual neuropsychologist.

A quick search conducted through Google (google.com) and the Brain Injury Association of America (biausa.org) using numerous keyword combinations (e.g., neuropsychologists, guides, provider selection, etc.) reveals only a few relevant links. One of the more relevant guides, “The Guide to Selecting and Monitoring Brain Injury Rehabilitation Services” (available at biausa.org) is located on the Brain Injury Association website. It provides a longer handout and a shorter summary brochure and is one of the initial “hits” provided through a Google search. However, this paper, while offering generally useful guidelines for evaluating brain injury rehabilitation programs, provides no specific guidelines for selecting neuropsychological providers.

Visiting the websites of the state chapters of the Brain Injury Association of America, other unaffiliated state brain injury associations, and some of the better brain injury related resource websites finds that specialty providers or even preferred Neuropsychology and other providers can be listed or even have their services advertised. Although this is generally helpful information, it is not specifically useful. Importantly, many of the better brain injury resource websites and available papers offer a wealth of information that spans the range of relevant issues in brain injury rehabilitation. However, these are not necessarily easy to find and when specialty provider guidelines are offered, it is usually incidental to recommendations regarding rehabilitation interventions and approaches and scattered across several sections and topics.

Professional neuropsychological organizations do offer some guidelines regarding professional standards. In the field of clinical Neuropsychology, board certification is recommended as the clearest evidence of professional competence. However, as Dr.’s Lees-Haley and Fox aptly point out in this issue, board certification is problematic on several grounds while available standards for Education and Training in Neuropsychology (i.e., The Houston Conference guidelines (1998)) are also highly controversial. Notably, these standards are not specific to brain injury and appear comparatively less 24

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relevant to rehabilitation than information available from other rehabilitation specific fields including the specialty field of Rehabilitation Psychology.

In other words, these standards are more germane to professional training, less relevant to brain injury or rehabilitation specialization, and not very practical for consumers.

As part of a previous effort to generate a list of competency guidelines two of the present authors (MM, NZ) offered competency guidelines related to practice of forensic neuropsychology in the area of brain injury services (Martelli, Zasler and Grayson, 1999; available at http://villamartelli.com).

However, these guidelines were limited to criteria primarily relevant to assessment in medicolegal evaluations and can be criticized on other grounds as well. Subsequently, Martelli, Zasler and LeFever (2000) offered a set of guidelines to consumers.

In the current paper, we intend to review and update clinically relevant and useful guidelines, intended to assist consumers in identifying, selecting and evaluating well suited rehabilitation neuropsychologists. They continue to be 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.

The following suggested guidelines are offered with the intention of helping consumers identify the most “useful” rehabilitation informed neuropsychologists. A summary of these guidelines are presented in Table 1. 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 not overly rely on 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 instruments used with psychiatric norms that are based on with primary psychiatric problems usually represent an improper comparison group. These instruments predispose psychologists to make psychiatric diagnoses and interpretations.

4. 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 the paper from Dr. Senior and Douglas in this issue for an excellent illustration).

5. Should adequately describe behavioral observations and test-taking behaviors, especially behaviors relevant to test performance (e.g., headache,

TABLE 1: Diagnostic Realities in Assessment of Acquired Brain Injury (ABI) Real Organic Disorder (i.e., ABI)

Residual Functional Impairments

Residual Testing Impairments

1. Yes

1. Yes & Exaggerated

1. Yes & Not Exaggerated

2. Mixed

2. Yes & Not Exaggerated

2. Yes & Exaggerated

3. Indeterminate

3. No & Exaggerated

3. No & Exaggerated

4. No 4

4. No & Not Exaggerated X

4

4. No & Not Exaggerated X

4

= 64

Summary of Proposed Guidelines for Selecting and Evaluating Rehabilitation Neuropsychologists 1.

2.

3.

4.

Reports and conclusions fit patients and are regarded as useful.

Recommendations are individualized, practical, helpful .

Not overly reliant on psychiatric assessment instruments and norms.

Employ the newest and most relevant and valid assessment measures for persons with brain injury.

5. Reports adequately describe observations and important factors relevant to test performance.

6. Reports and conclusions integrate personality data, observational data, collaborative data, test data and premorbid (pre injury) information holistically and sensibly.

7. Avoid reliance on test data alone.

8. Spending enough time with clients and significant others and reasonably understanding them and their situation (per reputation).

9. Diagnostic formulations are not generally black / white or either / or, and are consistent with: a) the complexity of the individual client’s situation, b) how common the symptoms are, and c) prevailing biopsychosocial models – recognition that emotional symptoms can be both a reaction to, as well as a cause, of post brain injury symptoms, that psychological factors and biological factors can each affect the other and that both are usually intertwined.

10. Avoids bias or preferential tendencies with regard to inferences about psychological or organic contributions to client conditions (e.g., tendencies to see most things and most clients as psychologically determined; or conversely, tendency to doubt psychological influences and assume everything and everyone’s behavior is organically determined).

11. Does not specialize in or primarily do medicolegal work.

12. Is on guard against, and makes efforts to protect against biases in opinions and findings.

13. Reports are clear, logical and “sensible” to most readers.

14. Reports are appropriately tentative and recognize the inherent limitations of testing.

15. Avoids over-reliance on non-doctoral technicians and students.

16. Collects data regarding validity and predictive accuracy of diagnostic inferences, predictions and recommendations.

17. Provides a balanced amount of treatment services (not all or mostly assessment services).

18. Treats many persons with brain injury (and with other problems that may accompany a client’s brain injury – e.g., pain, sleep disturbance).

19. Demonstrates openness to new ideas and new learning along with genuine interest in improving services and the lives of the clients.

20. Employed in a specialty brain injury and rehabilitation center.

21. Identified as a specialist in the assessment and treatment of brain injury.

22. Conducts training, talks and/or writings in areas relevant to brain injury and neurorehabilitation.

23. Is listed on one or more national or state Brain Injury Association websites or reputable Brain Injury Resource websites (excluding paid advertisements).

sleep, fear of losing disability, anxiety).

6. 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 holistic picture of the client in their particular circumstance. Tentativeness regarding diagnosis and clinical formulations should be afforded as indicated.

7. Should avoid reliance on test data alone, making sure to spend enough time with the client and perform a thorough interview while obtaining collaborative data and other information from family members and other relevant persons.

8. Should receive consistent feedback from clients that 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 paper by Dr. Cripe in this issue).

9. Should generally employ a biopsychosocial assessment and treatment model that recognizes how biological, psychological and social variables interact to affect a client’s behavior. All relevant factors should be looked at in a reasonable fashion while simplistic or black / white, either / or unidirectional models should be avoided. Diagnostic formulations should be consistent with: a) the complexity of the individual situation (i.e., things are not typically black and white or either / or), b) known base rates (i.e., how common the symptoms are in the non-affected population), and c) prevailing biopsychosocial models (i.e., multifactorial models that consider vulnerability variables and interaction of multiple factors versus black or white formulations). Dichotomous diagnoses and conclusions as “it’s all psychological/psychiatric” or “it’s all organic/biological” should be infrequently found versus a recognition that emotional symptoms can be both a reaction to, as well as a cause, of post brain injury symptoms, that psychological factors and biological factors can each affect the other and that both are usually intertwined.

10. Should be free of bias or preferential tendencies with regard to inferences about psychological or organic contributions to client conditions (e.g., tendencies to see most things and most clients as psychologically determined; or conversely, tendency to doubt psychological influences and assume everything and everyone’s behavior is organically determined). 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 likely demonstrating a predisposition to bias.

11. Should not do an unusually large amount of medicolegal work, or specialize primarily in such work. Such professionals should be critically evaluated for several reasons. One of the salient reasons is that courts and attorneys usually prefer black/white opinions and eschew practitioners with more complex diagnostic and conceptual viewpoints. Practitioners can be subtly to overtly reinforced by much higher reimbursement from forensic sources (vs. much lower reimbursement from clinical fees and dwindling managed care resources) and may therefore be more tolerant of dichotomous and more simplistic (and easier) adversarial “ethic/ or” opinions.

This is not to say that these practitioners are intentionally or even consciously biased. However, economic reinforcement is universally powerful and operates below the level of consciousness.

12. Should be sensitive to, and make efforts to avoid, bias. Psychologists are human and possess human frailties, including reinforcement from money and motivation to confirm our beliefs. Recognition of bias in professional psychologists has led to an emphasis on blind clinical trials in research, for example. Clinicians sensitized to the signs and symptoms of their particular specialty may misdiagnose or over-diagnose problems, with inadequate attention to competing explanations. Numerous papers have been written arguing that symptoms of chronic pain can present similarly to those of brain injury. Failure to adequately diagnose and treat these symptoms can limit rehabilitation outcome and produce unnecessarily protracted disability (e.g., Martelli, Zasler, Bender and Nicholson, 2004; Nicholson and Martelli, 2004; Martelli, 2004; Nicholson, 2004). Chapman and Einstein (2000) have discussed how biases can occur in the face of uncertainty in medical decision-making. Examiners may also display response bias by tendencies to either blindly accept (Lees-Haley, Williams, Zasler, et. al, 1997) or doubt the sincerity of complaints and disregard their veracity (McBeath, 2000). Finally, there is increasing realization of bias in arbitrators’ case perceptions and award recommendations (Eylon, Giacalone & Pollard, 2000).

BRAIN INJURY PROFESSIONAL

25

Preliminary data regarding the common suspicion that examiner bias is influenced by compensation issues has been provided by Martelli, Zasler and LeFever (2000). Compelling evidence of perceived expert witness bias comes from a recent report from a Federal Judiciary Committee sanctioned study (Johnson, Krafka & Cecil, 2000) involving a large sample of active Federal judges and the lead plaintiff and defense attorneys who presented the docket cases before them. Findings, based on compliance enhanced return rates of 51% for judges and 66% for attorneys, were consistent from 1991 to 1998 in revealing that the primary problem with expert testimony was experts who “abandon objectivity and become advocates for the side that hired them (p5).” On a 1 (very infrequent) to 5 (very frequent) Likert Scale of this problem, the mean response was 3.69 for judges and 3.72 for attorneys.

Better rehabilitation neuropsychologists also: 13. 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.

14. 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 test performance and results, and; d) recognize that, in science and medicine, things are rarely either-or, clear cut or unidimensional. This should include understanding the limitations and cautiously interpreting results from any single test or single testing occasion, or results of tests of purported effort or malingering, and so on. A host of factors, including pain, fatigue, medications, perceptions of or expectations of mistreatment, etc., can interact to affect test performance.

15. Avoid over-reliance on non-doctoral technicians and students to spend most of the time and perform most of the billed assessment with the client. In general, the more time a neuropsychologist spends with the patient, the better the rehabilitation assessment and recommendations will be. Technicians and students do not have the necessary training, experience, knowledge and skills to do interviewing. Although they may be trained in administration of tests, they are not adequately trained to assess, interpret or integrate test observations and behavior with interview, test results, personality and collaborative data, or directly observe and analyze and integrate ongoing test behavior to generate hypotheses, modify tests or procedures, make deductive inquiries or add interview questions, etc. In fact, they should not be doing the interview, are not informed by it in general practice, and couldn’t fully benefit from even if they were).

Unfortunately, many standard practices are established on, and financially dependent upon, the primary utilization of non-doctoral testing technicians who are usually paid a small percentage of the billed service fee.

16. 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 its 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 overconfidence and assumed accuracy of diagnoses and predictions. When those most able to evaluate the utility of their work do not try to, consumers should ask questions. When these practitioners are not collecting validation data (i.e., being true scientistpractitioners) needed to refine their ability in order to help patients (i.e., becoming more useful clinicians) one might ask why they do not accept the same accountability of plumbers and mechanics for the results of their work and justification of their fees.

Because this is rarely practiced, we offer a model and suggestions derived from a hospital Rehabilitation Neuropsychology Service’s Continuous Quality Improvement program which has been formerly attempted by the first author. It is intended as a guide to self-evaluation for Neuropsychology practitioners in the field.

Formal data collection is ideal and might include a structured Continuous Quality Improvement (CQI) program with continued extended followup efforts to assess validity and predictive accuracy longitudinally. It should include a mechanism for modifying practice based on findings. For example, are other potential sources of lower test scores (e.g., chronic pain, sleep distur26

BRAIN INJURY PROFESSIONAL

bance, psychological disturbance) being adequately considered in the differential diagnosis of brain injuries? Are provisions for appropriate treatment being made or recommended? Are predictions of ability or inability to benefit from treatment supported? Do predictions about work capacity and ability in other areas of functioning hold true? Are recommendations useful or helpful to patients? 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 – and not just comparing diagnostic and prognostic statements with those available in cookbooks) 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.).

For example, follow up phone calls to patient or significant other at one to several years following evaluation are one of many tools for examining the validity of report findings and predictions.

At a minimum, informal data collection is essential, and would be reflected in efforts to solicit, from patients and others, follow up information regarding treatment outcome, etc. Data regarding findings (i.e., track record) should be maintained and 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 verifiably diagnosed and repaired. Should anyone settle for a neuropsychologist who makes predictions when he/she may never be held responsible for the accuracy of their diagnoses, ability to fix problems, or even efforts to make credible estimations? 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?

17. Provide 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 patient 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).

Have conducted training, talks and/or writings in areas relevant to brain injury and neurorehabilitation, and/or Be listed on a national or state Brain Injury Association website or one of the many reputable and Brain Injury Resource websites (excluding paid advertisements).

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

●

●

●

●

●

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.)

Part-time consultants to rehabilitation or Neuropsychology programs who are employed and primarily associated with traditional psychological assessment and treatment services Psychologists who perform primarily assessment versus treatment, including psychologists associated with agencies or departments labeled as assessment specialty services (e.g., Psychological Assessment Service) 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.

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.

world abilities as well as exam scores that may or may not have immediate utility outside the clinic.

The tracking results should be open to anyone’s inspection, allowing the neuropsychologist and others to examine accuracy and utility of diagnoses and prediction and affording suggestions for refinement. The person looking for a rehabilitation neuropsychologist should avoid people without a background in brain injury rehabilitation or who are associated with firms or agencies that do not concentrate on neurorehabilitation.

REFERENCES

1. Author: A Guide to Selecting and Monitoring Brain Injury Rehabilitation Services. Washington, DC: Brain Injury Association of America. Downloaded from the internet, July 15, 2004.

2. http://www.biausa.org/word.files.to.pdf/good.pdfs/ Guide.to.Selecting.Monitoring.Brain.Injury.Rehabilit.pdf 3. Chapman GB & Elstein AS. Cognitive processes and biases in medical decision making, In Chapman, Gretchen B. (Ed); Sonnenberg, Frank A. (Ed); et al. Decision making in health care: Theory, psychology, and applications. Cambridge series on judgment and decision making 183-210. New York, NY, US: Cambridge University Press, 2000.

4. Eylon D. Giacalone RA. & Pollard HG., Beyond contractual interpretation: Bias in arbitrators’ case perceptions and award recommendations. Journal of Organizational Behavior 21: 513-524, 2000.

5. Hannay HJ Bieliauskas LA. Crosson BA. Hammeke TA. Hamsher K. & Koffler SP., Proceedings: The Houston Conference on Specialty Education and Training in Clinical Neuropsychology. Archives of Clinical Neuropsychology.

13(2), 1998.

6. Johnson MT Krafka C & Cecil JS: Expert testimony in federal civil trials: a preliminary analysis. Washington, DC: Federal Judicial Center, 2000. Available at http://villamartelli.com.

7. Lees-Haley PR. Williams CW. Zasler ND. Margulies S. English LT. & Steven KB., Response bias in plaintiff’s histories.

Brain Injury. 11(11): 791-799, 1997.

8. McBeath JG., Labelling of postconcussion patients as malingering and litigious: a common practice in need of criticism.

Headache. 40: 609-10, 2000.

9. Martelli MF. Zasler ND. & Grayson R., Ethical considerations in medicolegal evaluation of neurologic injury and impairment. NeuroRehabilitation: An interdisciplinary journal. 13(1): 45-66, 1999. Note: Competency Checklist available at http://villamartelli.com.

10. Martelli MF. Zasler ND. & LeFever F., Preliminary consumer guidelines to choosing a well suited neuropsychologist for assessment and rehabilitation of acquired brain injury. Brain Injury Source. 4(4): 36-39, 2000.

11. Martelli, MF: Ethical Challenges in the Neuropsychology of Pain: Part 1. In A Casebook of Ethical Challenges in Neuropsychology. SS Bush (Ed.) Swets & Zeitlinger, New York, NY. In press.

12. Martelli MF. Zasler ND. Bender MC. & Nicholson K., Psychological, neuropsychological and medical considerations in the assessment and management of pain. Journal of Head Trauma Rehabilitation. 19(1): 10-28, 2004.

13. Nicholson K. Martelli MF., The Problem of Pain. Journal of Head Trauma Rehabilitation. 19(1): 2-9.

14. Nicholson K: Ethical Challenges in the Neuropsychology of Pain: Part 2. In A Casebook of Ethical Challenges in Neuropsychology. SS Bush (Ed.) Swets & Zeitlinger, New York, NY. In Press.

ABOUT THE AUTHORS Michael F. Martelli, PhD directs Rehabilitation Neuropsychology at Concussion Care Centre of Virginia and Tree of Life. He has 17 years of experience in rehabilitation psychology and neuropsychology with specialization in practical, holistic assessment and outpatient and residential treatment services in rehabilitation of neurologic and chronic pain disorders. He has several academic appointments at Virginia Commonwealth University and the University of Virginia, serves on several journal editorial review boards and brain injury related boards, is the current President of the Brain Injury Association of Virginia and High Hopes, Inc. (non-profit providing affordable housing opportunities for persons with traumatic CNS injuries), and serves as the commissioner of psychology for the Commission on Disability Examiner Certification.

He frequently lectures and publishes, with over 300 papers, abstracts, articles, chapters and talks in numerous areas relating to disability, rehabilitation, Neuropsychology and chronic pain. (http://villamartelli.com)

continued on page 36

Finally, the other papers in this issue offer illustrative examples of the utility of the recommendations offered herein. One can only wonder if Scott Hall’s poignant review of his post TBI experiences might have benefited had guidelines for both rehabilitation programs and Neuropsychology providers been available.

CONCLUSION In this paper, an attempt is made to offer a set of preliminary consumer guidelines for evaluating and choosing a well suited rehabilitation neuropsychologist following brain injury. We attempt 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 describe what a person should look for in a rehabilitation neuropsychologist but emphasize assessment services. We specifically address things to look for in his/her reports and in his/her rehabilitation program. The “ideal” rehabilitation neuropsychologist ought to be openminded, accessible, willing to design a program to the needs of his/her client and interested in a holistic picture of the past, present and future of the client. He/she should have a background in the rehabilitation of people with brain injury and enjoy working with them. His/her reports should reflect less of the courtroom’s “black-and-white” appearance and more of the scientist’s awareness of the many “gray” areas in brain injury. They also should be understandable to non-specialists and offer data to back up the assertions made. The neuropsychological services should track realBRAIN INJURY PROFESSIONAL

27

CONFLICTS AND CONTROVERSIES AFTER BRAIN INJURY:

Struggling to be me

by Scott Howard, MS Introduction Intact cognitive states are, for the most part, taken for granted even by healthcare professionals working with individuals with compromised brain function. As psychologists / healthcare professionals, we can know of the devastation caused by brain injury, and the impact such injury commonly has on many lives. We can devise clever ways of determining disability.

But do we really appreciate the magnitude of suffering one goes through on a daily basis, trying to resume one’s life after such an injury? How does one address the sense of loss an individual may feel while trying to cope with these unexpected changes, in many domains of one’s life?

I am in the unusual position of having been a bright, 20-year-old, third-year honors chemistry student and athlete when a pick-up truck swerved to avoid hitting a kangaroo, crashing into me instead. The driver of the pick-up truck was carrying sand bags on a two-lane highway in Australia when he crashed head-on into my jeep. His blood-alcohol level was .21. I sustained a severe traumatic brain injury (TBI) with a GCS of 4-5, fifteen days of coma, eight weeks of post traumatic amnesia, four months of inpatient rehabilitation and an additional year of intentsive multidisciplinary outpatient rehabilitation, and more. He fractured an ankle. That was 10 years ago. Today I am a psychology intern in a clinical psychology program. Before my crash, I planned to study medicine and was funding my education through a soccer scholarship. My life was turned upside down by this crash, but now I am accomplishing much more than anyone could have predicted.

Dr. Martelli asked me to contribute my unique experiences as an “insider” of both brain injury and clinical psychology. Health care professionals need to hear this feedback – some positive, some negative – so they 28

BRAIN INJURY PROFESSIONAL

may learn from another perspective what it is like to experience everything from emergency care, to rehabilitation, employment, and finally the educational system. Throughout this paper, I will attempt to convey some of the struggles I face daily, as a highly motivated individual living with the aftereffects of severe brain injury, as well as controversies I have encountered in my years of informal rehabilitation.

Following the identified theme of controversial issues in neuropsychology, I intend to shed some light on the rehabilitation “derailment” resulting from the interaction with the legal system, and conflicts among professionals / families / self. Controversy arises sooner than this, however; few individuals have full neuropsychological assessments conducted before their injuries. Hence, estimating pre-injury cognitive functioning is a controversial issue upon which the legal profession partially relies to prove loss of earning potential. And it’s a guess, really. We have a limited ability to predict capability before neural injury, and we are not that good at predicting post-injury potential.

I have been encouraged to be brutally honest in this article. I am going out on a limb to give professionals a glimpse into the very issues with which the individuals at various stages of life post-brain injury undeniably struggle. Individuals living with brain injury should not continue to struggle in silence while creating the false impression that everything eventually returns to normal.

In this paper, I will address four important areas in which controversy is certain to arise after an injury. I will supplement these points with personal experiences to illustrate the impact of our behavior as healthcare professionals on individuals with brain injury, as well as family members and friends. These four areas are as follows: i) global communication breakdown; ii) controversial use of assessment materials; iii) cognitive fatigue fol-

lowing brain injury; and iv) role of the legal system versus rehabilitation system.

Global Communication Breakdown A primary issue needing adjustment is communication; without clear communication, the anxiety-filled, turbulent waters of life post-trauma are increasingly treacherous. Communication difficulties begin within moments after the injury occurs, before the individual with brain injury is even conscious. Messages are often mishandled or misinterpreted, and families may receive inaccurate information. Some messages may be distorted by individuals in crisis. Regardless, at this time it is critical that this vital information be relayed appropriately and in a timely manner. Individuals typically function better when they are informed of events as they occur, in a straightforward manner.

To illustrate this confusion, I refer to my initial involvement with emergency services. While family and friends struggled to obtain information regarding whether there had indeed been a crash at some point that evening, they were jostled from department to station to territory offices.

Finally they did find out that I had been involved in a crash, and that I was at the local hospital; one of the difficulties was figuring out who I was, since my identification had been left on the seat of my jeep while I was rushed to the hospital. Upon phoning the local hospital, they were told my condition was “not too serious”, then they were passed over to another hospital staff member, who asked my family to describe me. At this point, my family was told, “it does not look good. You should come immediately. We’re transferring him as soon as possible to the Trauma Center 3 hours away.” Confusion. Lapses in communication.

Medically, everything was handled appropriately. My family arrived just as I was being loaded into the land ambulance, as it was too stormy to fly to the trauma center. Meanwhile, back at the local hospital, an on-call physician who was presumably unfamiliar with the frequent experience of serious trauma dictated a report regarding my emergency head CT scan. In this report, she gave the potentially damaging “guess” about a stroke as the etiology of my deep brain hemorrhage – without first gathering the facts that would have indicated that the force of the collision caused the bleeding and shearing of the axons in my brain – something referred to as diffuse axonal injury, accompanied by focal contusions.

When I arrived at the trauma center, unconscious, intubated, chest tube inserted, on a spinal board with restraints, limb fractures splinted, I was taken to the Emergency Department. Because I was combative in the community hospital, I had to be pharmacologically paralyzed before transport. The physician greeting my parents only relayed part of this message before he rushed off – the part that told my parents they could not see me yet, I was paralyzed. He neglected to explain that I had been paralyzed by a drug because I was combative. Think of the impact of hearing your 20year-old son is not only severely brain damaged, but also paralyzed. Taking those few extra seconds to accurately relay medical information may have averted unnecessary emotional trauma.

The time I spent in the Intensive Care Unit on a respirator was stressful for my family. They dreaded seeing my neurosurgeon, for he was the bearer of bad news on a daily basis. He was very brief, to the point, painting a grim picture of my recovery. My Mom pleaded for more detailed information when I had been in a coma for 8 days, and he responded with, “Your son has the severest of head injuries, and could be in the hospital for many, many months”. My Mom felt sick for hours after hearing this.

Physicians were careful not to offer any false hope, nor give my family anything to grasp.

I question the premise that strong efforts should be made to avoid creating false hope. Sometimes hope is all these people have to hang onto. I do not think we have the right to rip this lifeline from families struggling to accept the gravity of the situation in which they find themselves. What is the harm in not injecting worst-case scenarios at every opportunity?

Health professionals are well aware of studies demonstrating better outcomes with an increasing number of positive prognostic indicators; this should be a reason for hope, if nothing else. Perhaps this is just another form of communication breakdown between some healthcare providers and family members.

In addition to communication difficulties among health care professionals, and family members / friends, the individual with brain injury often has receptive and / or expressive deficits to complicate the picture. In addition to these communication difficulties, deficits in self-awareness confound rehabilitation outcomes. To illustrate a miscommunication resulting

in agitation, imagine the frustration of being handed a brand new red toothbrush, but being cognitively at the point in time when a red toothbrush belonged to your Dad – and you do not have the language skills or the functional vocal cords, to verbalize this dilemma. How would you react? When someone is trying to push this ‘brand new’ toothbrush on you, would you not lash out in frustration when no one is able to figure out why you are protesting? You may be labeled as an individual with significant behavioral problems and emotional lability.

There is usually more underlying agitation than simply an urge to be difficult on the part of the individual with brain injury. It is the job of the team to work together in determining why, exactly, a person might be agitated. At the very least, it is important to speak in a calm, soothing voice using small words, delivered in a non-condescending manner. Individuals with brain injury may be wearing diapers and struggling to remember two words in a row, but underneath the injury exists a person. As rehabilitation progresses, posttraumatic amnesia resolves, and the assessment phase begins.

Controversial Use of Assessment Materials Assessment of neuropsychological abilities seems to test one all-encompassing domain: the ability of an individual to complete, under strict time constraints, ecologically invalid or at least questionable tasks which do little more than frustrate the bejeepers out of neurologically impaired folks, eliciting behaviors which end up in reports supporting an examinee’s anger dyscontrol / emotional lability. Or better yet, sometimes neuropsychological assessments are conducted in an inpatient setting, and the pre-injury history is given only by the individual being tested – freshly out of posttraumatic amnesia. No corroborating sources, other than a brief review of medical records, which may or may not actually have been done, due to time constraints.

Of course, neuropsychological testing is not quite that primitive, but nebulous concepts critical to rehabilitation – such as CNS fatigue – are, in many cases, not even addressed, and certainly not given as much importance as should be the case. Some psychologists do not seemed bothered by the overwhelming evidence that after a serious injury, many individuals struggle with sleep – wake cycles, morning routines, transportation issues, following directions, remembering the location of the directions to the testing center – shall I go on? Despite these very real obstacles, and the effect of neurogenic fatigue on altering cognitive performance after brain injury, in private practices these exams are frequently scheduled to start at 8:30am or 9:00am, and may last for 6 or 8 consecutive hours. Incidentally, 5-minute breaks were not long enough to re-energize my brain cells - 20 minutes and a pillow, maybe, but not a little “stretch break” of 5 minutes.

With an already compromised speed of processing, the deterioration in performance is rapid.

Overall performance on these assessments is contingent on one’s ability to stay awake long enough to complete the testing. Even though I was wheeled to the testing room in the hospital, by the neuropsychologist, I was fatigued and ready to go back to bed within minutes of engaging in any task – particularly one in which my cognitive resources would be required.

As I emerged from PTA (as documented by my serial performance on the G.O.A.T. – Galveston Orientation & Amnesia Test), I began brief neuropsychological testing. I remember being irritated that my therapist always seemed to be late (I had no concept of time, and he was not actually late), asked me difficult questions that seemed intentionally designed to trick me, and would never show me or remind me of things that I had forgotten, even when I pleaded. After a short period, I would invariably be fatigued, and would be returned to my room, only to wonder why this ridiculous testing had to continue the next day. Imagine my surprise when the neuropsychologist showed up “unannounced” the next morning to take me to the testing room.

Progressing through rehabilitation, I grew to dislike Occupational Therapy with a passion. Everything my therapists wanted me to do, I could not. I could not circle the numbers on the page. I could not fit the proper shapes into a ball. I could not list the ingredients of a tuna sandwich. And I certainly could not explain why a little boy on a sled would start at the bottom of the hill and end up on top – but, dammit – those cards were in the right order. My frustrations would increase, until I either cried or pushed my wheelchair away from the table in agitated dismay.

This sequencing “game” – better known as Picture Arrangement - was taken right out of a standardized psychological test. While I realize this BRAIN INJURY PROFESSIONAL

29

may have been helpful for the OT’s to use, perhaps different cards could be made up for use in therapy, instead of employing the actual testing material. Trying to explain logic to an individual still in PTA after a severe brain injury is futile; it is an entirely different world. This is to say nothing of diluting the validity of the test.

Later, at the rehabilitation hospital, I was administered the HalsteadReitan Battery, among other tests. I was given many photocopies of the Digit Symbol subtest of the WAIS-R so I could practice my speed and dexterity. Not sure which discipline gave me these, but nonetheless… Even if therapists need to design their own real-world activities or therapy games, photocopying segments of standardized protocols to hand out to patients, “just for practice”, should never happen. It will artificially inflate subsequent scores in the particular domain, which would distort estimations of ability and disability.

Neither should the MMPI-2 be handed to a patient to take home on a weekend visit, to complete and return on Monday, as it was in my case. I realize therapists’ time is precious, and having to be in the room while an individual is completing this - - well, it is just easier to give it to me to take home on the weekend while my girlfriend reads the MMPI-2 questions out loud to me, and I fill in the little answer sheet. It happened, and I guarantee it happens a lot more than anyone wants to admit. I suspect this practice occurs all over the world, even if we like to believe it does not. Incidentally, I was unable to complete more than ten questions at a time due to the next topic…fatigue.

Cognitive Fatigue following Brain Injury Supporting the previous section on assessment practices, there are no standardized psychological tests to measure fatigue. How does one quantify fatigue? It manifests differently in everyone, but several individuals with brain injury have described the similar feeling of “hitting a wall” followed by the “need to crash”. After brain injury, the experience of fatigue is very real, and persistent. In ten years I have seen limited improvement in my own level of fatigue; essentially I have become more focused in the activities in which I choose to invest my precious energy. Through experience, I have learned that it is neither wise nor productive to work when I have reached the point of exhaustion. The kicker is that the bar for pushing myself has increased dramatically since my injury occurred, simply because I know what I have to do in order to “keep up” with individuals without brain injury.

The more distractions there are, the more cognitive energy that must be expended to filter out background – or foreground – noise, increasing the attentional demands on my brain to complete each task. Everything takes more cognitive energy after serious brain injury. Sometimes it is very difficult to access information; information which I know is stored in my brain somewhere. To not be able to access well-learned facts is exceedingly frustrating. Overlearned information is easier to recall, so I methodically learn new material to improve my access. The only problem with this is that it requires me to be awake, and the fatigue factor interferes with learning. Too many times I have fallen asleep at my desk, only to awaken wearing my wristwatch imprint on my forehead.

Because of the damage to my reticular activating system, sustained alertness has been a significant barrier in my return to pre-injury life. With the help of my Physician, I have tried various medications, and found an effective combination which allows me to stay alert for longer periods. It is as if a very good, functional brain is wrapped in thick cloth coverings – a sort of barrier between me and the outside world – and is fighting to get out and experience life. With this medication, these coverings are peeled away, revealing me.

Professionals I have worked with in the field of brain injury will often look forward to the end of the day / week after many grueling hours spent with individuals with brain injury. I go home to my disorganized apartment and pass out on my bed for the weekend, because I rarely have the energy to do anything, including eat. When it comes down to the decision to eat or sleep, usually sleep wins out. I would look forward to a holiday so I could sleep, peacefully, or work on organizing my apartment, trying to remember where I had placed the keys to my filing cabinet. I have locked myself out of my apartment countless times, more than I choose to admit, because I was distracted, on the phone, or simply taking the garbage out.

Please do not think encouraging an individual with brain injury to slow down, take it easy is necessarily a positive thing. In my case, I know I’ll have to struggle to accomplish what I want, but I am okay with that; I have structured my life accordingly. To illustrate that taking things easy is not always the best solution, I refer to my encounter with the chemistry 30

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department head upon my return to university seven months after my injury. I enrolled in three classes, one of which was a third year physical chemistry course. After seeing my 33% failing mark on his midterm, the professor reacted by telling me to ‘just go home – you’ve had a serious head injury. You don’t need to do this’. This was a highly intelligent professor, and he dismissed me because of my injury. Devastated, I simply dropped his course, but passed the other two.

Navigating to the university was an exhausting adventure in itself. I would take two city buses to get to school. Invariably, I would forget to ask for a transfer, since I was preoccupied with keeping track of the location of my bus fare. I refused to sit in the seats reserved for the “disabled” folks, since I did not see myself as disabled. Sitting at the front increased the probability of someone speaking to me, and I knew I could not always find the words nor the voice to answer. Then there was the challenge of walking to the back of the bus without falling, while frantically grabbing for the metal rails – or whatever passenger happened to be within staggering distance. My balance was poor; I just had the last cast removed from my leg, and the driver would always take off fast, sending me flying. I fell asleep on the bus too many times to count, and ended up somewhere unfamiliar when I awoke.

I was unaware of any special accommodations at the university for students with disabilities, and it was not until three years after I resumed parttime studies that I was granted formal accommodations as a student with a disability. Unfortunately, the letters written by the Coordinator of the office for students with disabilities indicated that my reasons for requesting additional time were to “accommodate a motor function impairment”.

True, in addition to my hemiparesis, I had extensive nerve damage, but that was healing well, right on schedule. There was no mention of my brain injury, which was the most relevant reason for needing accommodations. I needed peace and quiet, earplugs, no distractions, and a new writing arm, to be even in the ball park with other students. Then there was the arduous retrieval process, which followed the acquisition / retention exercise. I could not bring myself to admit to others that I needed help, for fear they would think I was whining, or making a big deal out of nothing.

Yes, nothing.

There is a certain amount of personal dignity on the line every day when one is living with any sort of disability. Apart from being hosed down like a horse in a stall by a nurse in G.I. Joe garb while on the rehabilitation unit, there has been an increase in the number of situations in which my dignity as a high-functioning human being is compromised.

While their knowledge base of brain injury is strong, many physicians / psychologists / therapists have failed to apply what they know about functioning post-severe brain injury. One example of this occurred when my professor who published in the area of brain injury politely denied my request to take an incomplete and finish the course over semester break, despite my protests. His insistence that I was handling everything fine ignored my difficulty managing multiple new tasks. He prescribed increasing my social activities and proscribed taking work home or staying late.

With a smile I left his office and went home to cry (yes, something I had never done preinjury) over my new dilemma. I felt as if the walls were closing in on me. Theoretical and practical knowledge seem to mean little at times. It took this supervisor three additional months to realize I was struggling. In my practicum, this same supervisor also tried to convince me to tell the entire staff of his agency about my brain injury; I cautiously refused, since I did not feel this was necessary. After a few weeks of trying to convince me to tell everyone, he admitted that he had already told the staff before I started at the agency – without my permission, of course.

Ouch!

At a part time clinical job, a supervising neuropsychologist took advantage of my vulnerability as an employee and individual with a brain injury.

He elicited details of my crash in conversation, and then used this information as the basis of an article he was writing. Fortunately, I explicitly told him I wanted to read the article before it went to press. This article inaccurately portrayed me as an individual with an overwhelming number of residual effects of brain injury. Many of his statements seemed to have originated in an acute rehabilitation text. He had already emailed this article to the editor of the periodical pending my final permission for publication. I had to involve the ethics committee of a governing body, and was praised by the committee for handling this professionally. The ethical dilemmas I faced cause me to wonder how often this happens to other individuals, even without brain injury, and without being reported.

Another controversy exists here: if an individual develops very effective coping strategies, such that it appears there is no underlying deficit, the

individual may be assumed to have had a much less significant injury with no residual deficits. This is often a false assumption, as there are changes that occur, which do not necessarily present unless the individual is in a particular situation. Sometimes the disorganization will not be evident depending on the level of independence of the individual, and the particular challenges faced by this individual. Typically, individuals with disabilities have learned to cope extraordinarily well with everyday challenges, and will know what they need to succeed – but will others listen to their needs?

How is one to deal with the demands of ongoing rehabilitation and the legal system?

Conflicting Roles of the Legal System versus Rehabilitation The role of the legal system seems to be diametrically opposed to that of the rehabilitation system. Legal professionals are compelled to identify worst-case outcome scenarios to ensure clients, some of whom lack or even deny deficits, are duly compensated for their injuries. Worst case scenarios, however, conflict with the optimism and drive necessary to persist in efforts to achieve formidable goals. Superimpose these two systems on an already cognitively impaired, fatigued brain struggling to return to preinjury life and the result can be a meltdown.

I had two lawyers working for / with me. Everything I did required significantly more cognitive fuel. This legal pursuit was relentless. I spent much of my time gathering documentation and traveling to my lawyer’s office. That I should have to spend so much of my tiny post-injury reservoir of energy to substantiate my own pre-morbid capabilities seemed ludicrous. I just wanted to get on with my life where I left off – except I could not remember where I had left off. Everyone around me seemed to be getting on with life – but mine had come to a screeching halt. Everything changed. Now I had to prove I was ME, to obtain some kind of financial settlement, in lieu of my life. And this was supposed to placate me, to make everything right? I wanted my uninjured brain back, my life as it existed before the injury, my athleticism, my academic facility. Nothing – and I mean nothing – could ever compensate for the potential I had at 20 years of age.

Not only was I severely brain damaged through no fault of my own, but now I had to defend the person that was me, before my injury. And if the defense succeeded, through some kind of maniacal backhanded manipulation, I would have walked away with nothing but a handshake. How, as personal injury attorneys, does one defend a client who almost killed another human being? How can attorneys sleep at night knowing an innocent 20 year-old man with a very, very bright future has just had everything taken away from him - all because of something their client did. And this client did not even get a parking ticket for his driving error.

The tangible proof of my injury, in the form of radiological films and broken bones, did not even approach the magnitude of emotional suffering I have endured, due primarily to generalized unawareness of brain injury outcomes. Real live, in-the-flesh outcomes. Not neuropsych testing datadriven outcomes, but actual life experience, phenomenological, live-in-myhead outcomes. I would like to see how many neuro / rehab psychologists could actually stick to their own well-organized recommendations given in rehabilitation. It is just not that easy, for a multitude of reasons; this, coming from a highly motivated, driven individual.

In preparation for the Discovery Deposition, I pleaded with my lawyers to allow me to take notes into the Hearing, simply because I was afraid I would forget things. My lawyers denied my request, which left me upset, and feeling vulnerable. Everything I had done since my injury required some sort of written reminder, note, or picture, and I was to have none of the above. In addition, under time pressure or stress due to situational factors I would experience blocking, and had significant retrieval difficulties. Often times the information would be lost forever, or trickle back hours too late.

The Discovery was proceeding well, until I was asked if I remembered wearing my seatbelt. Every time I tried to answer, although I admittedly had trouble retrieving the evidence of having received welts from the seatbelt, I was forcefully cut-off by the defense lawyer telling me, “but you don’t remember…” . I had had enough; I jumped up, exasperated, and shouted the remainder of my answer at the defense team. I was fighting back tears at the thought of being blamed for something I had no control over. I was an emotional mess since my injury, and this was not helping me to control my frustrations. I was completely innocent, now forever damaged, and there was actually a question as to fault?

Looming over me was the dreaded defense neuropsychological exam, which was to be conducted by a psychologist noted for his rather “slippery” practices. I was cautioned about his ability to somehow turn a serious, welldocumented injury, into a much less life-altering event. I had no reason to be concerned, yet I was. Again the thought of not only being stripped of my identity, everything that was me, but of facing another examiner – this time, one with the expected intention of minimizing my injuries to the status of a skinned knee. Since I already minimized things nicely myself, I certainly did not need assistance in this department. I didn’t need someone interested in minimizing my injury taking advantage of my wanting to believe I would have the best possible outcome.

My appointment with Dr. Lubeit had been scheduled, and as it approached, the pressure to settle my case increased. Fortunately, I was able to settle the case without having to withstand this exam. My injuries were well documented. During settlement negotiations, however, I felt unfairly treated as if I had no ability to decide matters independent of an assigned financial representative. I was told by my lawyer that clients have, in the past, squandered settlements, and he implied I may do the same this is for ‘my protection’. Although his line of reasoning was sound, I question his delivery. Since I have always been thorough and independent, I spoke with a competitor in the financial industry to obtain another opinion. I wanted to be sure I was treated fairly, in case there was any sort of reciprocal relationship between the insurer and the financial representative.

I was the one with the brain injury, and it was I who made the decision to involve a third party. Judgment anyone?

The legal system has a strong influence on one’s outcome after serious injury. In cases consisting of few visible injuries it is understandable that individuals want to be heard. Exaggerating symptoms in order to convey the seriousness and long-term impact an injury is likely to have on future functioning is one aspect. After all, it is virtually impossible to quantify future neuropsychological functioning - but oh, how we like to try. Are we, as legal and psychological professionals, not responsible for creating adversarial and hostile environments – hence more emotional suffering – while individuals are just trying to survive? Do we consider genetics in terms of resilience and optimism, and take this into account while figuring out a reasonable financial settlement? Certainly, my injuries were well documented, and even I was very uneasy with respect to how my projected examination with Dr. Lubeit would proceed. How would someone without focal brain damage, fractures, or other notable injuries feel? Would such an individual not want to scream until someone understood his / her struggles in life? How would each of you react to the antagonism, rigorous examinations, legal advice to do one thing – and rehabilitation assistance to get on with your life in the best possible way? Any volunteers to live the life of an individual with brain injury for, say, six months? I did not think so.

Next time you consider an individual’s motivation regarding performance on a neuropsychological or medicolegal exam, consider the forces which may have led to this behavior in the first place.

Conclusions Throughout this article, I have addressed issues pertaining to controversies in neuropsychology occurring after brain injury. Specifically, I addressed controversies arising as a result of: global communication breakdown, focusing on the manner in which information is relayed between health care workers and families / friends, and considering communication deficits commonly experienced by individuals after brain injury; questionable use of assessment materials, in terms of timing with respect to stages of recovery, use of standardized protocols in rehabilitation exercises, access to testing materials out of the office; implications of cognitive fatigue following brain injury; and the adversarial role of the legal system with respect to the rehabilitation system. Tip-of-the-iceberg, really. My perspective will hopefully help strengthen the coalition between individuals providing and receiving treatment as we navigate these challenging waters after brain injury. Most importantly, I hope this article stirs up these waters and challenges us to reconsider our roles.

ABOUT THE AUTHOR Born in New South Wales, Australia, Scott Howard resumed his studies in chemistry on a part-time basis, completing his undergraduate degree in chemistry in his country of birth before beginning clinical psychology graduate training in the U.S.A., where he is currently a predoctoral intern. Scott’s parents and younger sister currently live in Australia; his older brother is a physician in the U.S.A. and lives an hour away from Scott. Email the author: scott_howard4407@yahoo.com.

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Forensic Neuropsychology: Things are Getting Better all the Time A Reply to Drs. Less-Haley and Fox I would commend Drs. Less-Haley and Fox for their critical thinking and pithy editorial on the state of forensic neuropsychology. However, as they suggest about attorneys who shake their heads and comment that neuropsychology is all “smoke and mirrors”, I think their complaint is overstated. Whereas I would agree with most all of what they have commented upon, I think that their focus is too narrow, possibly cynical, and that they are at risk of Keith Nicholson, Ph.D. throwing the baby out with the bath water. Although there are certainly problems with neuropsychological expert opinion, this is not unique to our profession and many of the concerns or criticisms they raise may be applied equally as well to other professions that may be called upon to offer expert opinion. In contrast, I believe that properly trained (which should include being made aware of the issues raised by Drs. Lees-Haley and Fox as well as numerous other issues) clinical neuropsychologists are in the best position to provide relevant and appropriate expert opinion concerning neuropsychological (e.g., cognitive and behavioral) sequelae of numerous conditions affecting the integrity or functioning of the nervous system. It should not be so surprising that there may be controversy or difficulty understanding our views given the complexity of brain-behavior relationships and related issues at hand. Again, the same can be said of many scientific endeavors, especially when attempting to understand phenomena that are not well understood.

In this context it may be noted that there are many “medically unexplained” and poorly understood problems afflicting people and impacting on behavior or performance (Brown, 2004).

Most of the contentious issues or complaints raised by Drs. Less-Haley and Fox are concerned with cases of mild head trauma, mild traumatic brain injury (TBI), concussion or the persistent post-concussive syndrome (PPCS). I do not think that these terms are so loosely defined as to be meaningless or that they may be warped and turned to justify any view. Although these entities have long been controversial, in my opinion and I am sure many others, there is increasing clarity and recognition about what the relevant issues of concern may be, some of which are raised by Drs. Less Haley and Fox. I would agree that there is some variability in the meaning or use of these terms, some of which reflects important distinctions. For example, a recent systematic review of mild TBI studies found an estimated prevalence of intracranial CT scan abnormalities of 5% in those with a Glasgow Coma Scale (GCS) rating of 15, 20% with a GCS rating of 14, and up to 30% in those with a GCS rating of 13 (Borg et al, 2004). Of course, these would generally be considered complicated mild traumatic brain injuries and there was likely some selection bias of patients included in the studies accepted for review (i.e., hospital treated). Whereas it is quite well established that most cases of mild TBI have good recovery (Binder, Rohling & Larrabee, 1997; Carroll et al, 2004; Schretlen & Shapiro, 2003), many reports indicate that a significant minority (with estimates of the actual number varying widely) 32

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go on to present with what has become known as the PPCS. Although Carroll et al (2004) suggest that compensation/litigation is the only clear identifiable variable associated with the PPCS, numerous studies have suggested that the primary problem in this syndrome is post-traumatic headache (Nicholson, 2000). Post-traumatic headache is very common following head trauma and is more frequent in cases of known or suspected mild TBI in comparison with more severe TBI (Evans, 2004), possibly because of sensitization effects (Nicholson, 1998; Miller, 2000). Several reviews of both acute pain challenge studies with healthy normal controls as well as numerous chronic pain conditions indicates that pain may be associated with marked performance deficits on neuropsychological tests (Nicholson, 2000; Hart, Martelli & Zasler, 2000; Nicholson, Martelli & Zasler, 2001). In addition, problems that are often associated with chronic pain such as psychoemotional distress, sleep disturbance or medication side effects may interfere with aspects of cognitive function. Such problems are most clearly associated with deficits in aspects of attention, concentration, memory and processing speed, functions that have been considered to be most vulnerable to the effects of TBI. Notably, not all chronic pain patients complain of or show evidence of cognitive deficits. Hart, Wade and Martelli (2003) reviewed the literature concluding that pain-related negative emotions and stress potentially impact cognitive functioning independent from the effects of pain intensity. In any case, there is increasing understanding of what some of the confounding factors in neuropsychological assessment may be (Nicholson & Martelli, accepted for publication). Whereas neuropsychological tests may be very sensitive, they are often not specific and, as Drs Lees-Haley and Fox advocate, there needs to be better differential diagnosis.

Space constraints do not allow me to address all the issues raised

by Drs. Lees-Haley and Fox but I would like to briefly make some further comments. Drs. Lees-Haley and Fox raise concern about patients’ or others’ (e.g., relatives) self-report regarding symptoms or other issues. Whereas one would hopefully not naively and uncritically accept the self-report of any person, within the context of a neuropsychological assessment or otherwise, self-report data is obviously very often extremely important and there is clearly a science of self-report (Stone et al, 2000).

It appears that Drs. Less-Haley and Fox may have some ambivalence about lawyers, on the one hand suggesting that involvement with lawyers has compromised the intellectual integrity of the field but also that attorneys offer us an important opportunity for intellectual growth. It is still later suggested that lawyers are advocates and not seekers of truth. In this regard, following the Daubert v.

Merrell Dow Pharmaceuticals (1993) ruling, it is noted that the judiciary has been set up to be the gatekeepers of what is good scientific evidence. It is suspected that this may, at least in part, be secondary to the nature of the adversarial medico-legal system which polarizes opinion and may often be more concerned with impression management, i.e., to convince a judge or jury, than presentation of the truth. I would certainly agree with Drs. Lees-Haley and Fox that financial interests have the potential to perversely affect all parties involved in the medico-legal process, including the Continued from page 34

Controversy Does Not Equal Failure: Baby and Bath Successfully Separated Reply to Keith Nicholson

David D. Fox, Ph.D.

Paul Lees-Haley, Ph.D.

Dr. Nicholson has kindly replied to our article on controversies in forensic neuropsychology (Still Controversial After All These Years, Lees-Haley and Fox, this issue). We are pleased to see that he fundamentally agrees with most of our comments and we generally concur with his response as well. We do not disagree that there has been improvement in forensic neuropsychology but we think it is important to focus attention on festering controversies when so many basic concepts and diagnoses go unresolved. Many of these concepts, such as postconcussion syndrome and the role of self-report, are so fundamental to typical forensic neuropsychological practice that we are concerned that it undermines the credibility of the field to fail to clarify such basic issues. In addition, if we do not understand what we are diagnosing or fully appreciate the nuances of our diagnostic techniques, it bodes ill for the field of neuropsychology to ever address more profound ideas such as, "how do brain mechanisms and personal psychology interact?" and, "is there a viable distinction between psychological processes and brain processes?"

In response to some of our citations, Dr. Nicholson describes some research regarding persistent postconcussive syndrome. His writing exemplifies why this controversy continues in forensic neuropsychology. He quite correctly cites data indicating there is no agreement as to the cause of these symptoms. What we wished to point out was that in forensic practice oftentimes individual practitioners/experts cite only some of the research literature and confuse various mechanisms with actual brain damage in order to "sell" their case. He quite correctly notes that neuropsychological procedures often lack specificity. Yet, in practice the neuropsychological tests are often used as though they were pure, objective "xrays" of the mind that are superior to neurologic techniques. Our concern is that these issues have gone on for decades and seem no closer to solution.

Although we agree that there is a great deal of scientific research on self report data, we respectfully disagree with the view that there is a science of self report in the sense of having established self report as a reliable and valid data set in general.

Dr. Nicholson cautions that our cynicism might result in excessive baby loss when disposing of bath water. We prefer a dif-

ferent metaphor; that the emperor's sartorial choices often go unexamined and that it is in the forensic arena in which are deficiencies are laid bare. Ironically, it is through the legal system that our field may eventually confront these unresolved controversies.

We pointed out that the interface with attorneys and the legal system is complex and often unsatisfactory. Our purpose was, in part, to point out that sometimes it takes non-healthcare professionals to force us to examine our assumptions, reasoning and data analysis. Controversy is not necessarily a negative indicator. Nor does this mean that there has not been progress in illuminating what we know about neuropsychology. The purpose of our article was to call attention to the field's very natural tendency to overlook thorny but crucial issues. We hope that our article and Dr. Nicholson's thoughtful reply contribute to neuropsychology's awareness of its limitations so that determined scientists can finally address some of these issues.

In closing, it may interest the reader to know that, ironically, when we sought someone to write a rebuttal or critical reply to our article, we had difficulty finding someone who disagreed with the views we expressed in this paper. When Dr. Nicholson agreed to provide a commentary, as noted above he generally agreed with us, and we generally agreed with him. So much for the hypothesis that the controversial nature of neuropsychology is controversial!

publisherâ&#x20AC;&#x2122;s comment Certainly neuropsychologists, like professionals in other fields, would agree with their colleagues on most professional matters. Yet where there is professional disagreement between neuropsychologists, it seems opposing viewpoints are particularly acute and the debate especially heated. To make matters worse, the issues they disagree upon are often central to the outcome of personal injury cases. Practically everyone reading this special issue of Brain Injury Professional understands that due to the adversarial nature of our legal system, plaintiff attorneys support certain positions in neuropsychology, while defense attorneys advocate others.

An important part of the mission of the North American Brain Injury Society â&#x20AC;&#x201C; and this publication â&#x20AC;&#x201C; is to present all viewpoints in the hope that providing this platform for debate and exchange will contribute to professional advancement overall. We therefore encourage you to send us your thoughts by emailing: contact@nabis.org, or visit our forum at www.forum.nabis.org.

J. Charles Haynes, J.D. BRAIN INJURY PROFESSIONAL

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Forensic Neuropsychology..., continued from page 32 Injury. Journal of Rehabilitation Medicine, 43S, 61-75.

behavior of individual psychologists or neuropsychologists as well as the institutions representing them.

Finally, Drs. Lees-Haley and Fox provide a number of suggestions to promote solutions to controversies in neuropsychology although such an endeavor is likened to providing solutions for modern society.

It is suggested that the most profound scientific need is more fundamental descriptive research. Although citing Darwin, there is no mention of the need for rational understanding of empirical data. I think that neuropsychology has progressively been addressing controversies in the field and is successively approximating the truth or reality as occurs in other fields of scientific endeavor. In conclusion, things are getting better all the time.

Nicholson, K. & Martelli, M. (Accepted for publication).

The confounding effects of pain, psychiatric disorder, sleep disturbance and motivational factors on neuropsychological test performance. In Young, G., Kane, A., Nicholson, K. (Eds). Causality: Psychological Knowledge and Evidence in Court. Kluwer Academic/Plenum Publications.

REFERENCES

Nicholson, K., Martelli, M.F. & Zasler, N.D. (2001). Does pain confound interpretation of neuropsychological test results. NeuroRehabilitation, 16, 225-230.

Binder, L. M., Rohling, M. L. & Larrabee, J. (1997). A review of mild head trauma. Part I: Meta-analytic review of neuropsychological studies. Journal of Clinical & Experimental Neuropsychology, 19, 421-431.

Borg, J., Holm, L., Cassidy, J. D., Peloso, P. M., Carroll, L. J., von Holst, H. & Ericson, K. (2004). Diagnostic procedures in mild traumatic brain injury: results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain

Brown, R.J. (2004). Psychological mechanisms of medically unexplained symptoms: An integrative conceptual model.

Psychological Bulletin, 130, 793-812.

Daubert v. Merrell Dow Pharmaceuticals, Inc., 509 U.S. 579 (1993).

Hart R.P, Wade, J.B. & Martelli, M.F. (2003). Cognitive impairment in patients with chronic pain: The significance of stress. Current Pain and Headache Reports, 7, 1-12.

Miller L: Neurosensitization: A model for persistent disability in chronic pain, depression, and posttraumatic stress disorder following injury. Neurorehabilitation, 14, 1, 25-32, 2000.

Nicholson, K. The Neuropsychology of Pain. Special Presentation. 1998 National Academy of Neuropsychology annual meeting. Washington, D.C..

Nicholson, K. (2000). Pain, Cognition and Traumatic Brain Injury. NeuroRehabilitation, 14: 95-103.

Schretlen, D. J. & Shapiro, A. M. (2003). A quantitative review of the effects of traumatic brain injury on cognitive functioning. International Review of Psychiatry, 15, 341-349 Stone, A.A., Turkkan, J.S., Bachrach, C.A., Jobe, J.B., Kurtzman, H.S. & Cain, V.S. (eds) (2000). The science of self-report: Implications for research and practice. Lawrence Erlbaum Associates, Mahway, New Jersey.

north american brain injury society supporters (through 3rd quarter, 2004) CHAIRMAN'S COUNCIL Julian and Kim MacQueen, Robert and Karen Voogt, Anthony Gamboa

SUSTAINING MEMBER Michael Bee, Carlton Bennett, Joel D. Bieber, Gordon Johnson, Thomas Keefe, Dale K. Perdue, Randall Scarlett, Bruce Stern, Mariusz Ziejewski

CONFERENCE, CORPORATE AND GENERAL SUPPORTERS Timothy Titolo, Brain Injury Law Center, Harrell & Johnson, P.A., Creative Capital, Vocational Economics, Charles Haynes, Michael Pietrzak, Margaret Roberts

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professional appointments

Multiple Openings - Lakeview Specialty Hospital & Rehabilitation, has the following available opportunities open: Resident Assistant, Director of Therapy Services, Certified Nursing Assistant; Registered Nurse, Licensed Practical Nurse, Driver, Receptionist; Respiratory Therapist, Housekeeping, Charge Nurse. Qualified candidates will have the ability to work with all ages and be skilled in the treatment of TBI and a wide range of neurological disorders. We provide a competitive compensation and benefits package in a team-oriented work environment. Lakeview Specialty Hospital & Rehabilitation, 1701 Sharp Road, Waterford, WI 53185, (262) 534-7297, fax (262) 534-8579, TTY (262) 534-8596. For more information visit: www.lakeviewsystem.com EOE-JCAHO Accredited.

Behavior Specialist - ResCare Premier, a recognized leader in brain injury rehabilitation, is looking for a full-time Behavior Specialist at the Texas Hill Country School in San Marcos, Texas. Master’s degree with specialization in Behavior Analysis required and Behavior Analyst Certification preferred. 1-2 years experience in field of acquired brain injury or working with children with neurological behavior disorders preferred.

Please email resume to: Patrice_adoue@rescarepremier.com or fax to 512.396.2024 EOE, M/F/D/V Physical Therapist - Tree of Life Services, a nationally known transitional/residential rehabilitation program directed by Nathan Zasler, MD, is seeking a full-time physical therapist due to program expansion. Experience in neurorehabilitation highly preferred. Must exhibit good interpersonal skills, great initiative and flexibility. Excellent opportunity to shine and grow as an active part of a comprehensive rehabilitation team. Highly competitive salary. Please e-mail resume to: abrown@cccv-ltd.com or fax to (804)346-1803 to the attention of Andrea Brown.

To list your professional appointments on this page, please contact Joyce Parker, (713) 526-6900, or by e-mail: jparker@hdipub.com.

Preliminary Consumer Guidelines..., continued from page 29 Nathan D. Zasler, MD, FAAPM&R, FAADEP, CIME, DAAPM is an internationally respected specialist in acquired brain injury (ABI) care and rehabilitation. He is CEO and Medical Director of the Concussion Care Centre of Virginia and Tree of Life living assistance and transitional rehabilitation program in Glen Allen, Virginia. He is board certified in Physical Medicine and Rehabilitation and fellowship trained in brain injury, a clinical associate professor of PM&R at the University of Virginia, Charlottesville, 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. He has lectured and written extensively on neurorehabilitation issues and is very active in relevant national and international organizations. He has co-edited three textbooks (“Rehabilitation of Post-Concussive Disorders”, “Medical Rehabilitation of Traumatic Brain Injury” and “Rehabilitation of Functional Disorders”) and is currently working on several others including a TBI core textbook “Brain Injury Medicine: Principles and Practice”. He is on several journal editorial boards and is an editor of the international scientific publications “NeuroRehabilitation: An Interdisciplinary Journal”, “The International Neurotrauma Letter”, “Brain Injury” and “Brain Injury Professional”.

Patricia Rogers Babin, PhD, ABPN, ABPP earned her doctorate at the University of North Carolina at Chapel Hill.

She completed her clinical internship, fellowship, and post-doctoral experience in Houston, Texas before taking a neuropsychology position at Charlotte Institute of Rehabilitation where she was active in research, consultation, evaluation, and teaching. After 9 years in Charlotte NC, she took a position as Clinical Director of Virginia NeuroCare in Charlottesville VA, a community reintegration program for persons with acquired brain injury. Dr. Babin’s interests include mild TBI, awareness, competency and capacity, ethics, and psychopharmacology.

36

BRAIN INJURY PROFESSIONAL

conferences

2004 DECEMBER 9-11 – Brain Injury Association of America Conference, Rehabilitation for Persons with Brain Injury, the State of the Art, Washington, DC. Contact: (703) 761-0750, web: www.biausa.org.

14-17 – Ontario Brain Injury Association Certificate Training Program: Level 1 - Home and Community Based Rehabilitation of Persons with Acquired Brain Injury, Brock University, St. Catharines, Ontario.

Contact: Ontario Brain Injury Association (800) 263-5404, e-mail: obia@obia.on.ca, web: www.obia.on.ca.

2005 MARCH 31- April 3rd – Fourth Annual Galveston Brain Injury Conference, Opening the Black Box: Characterizing Brain Injury Treatment for Research & Practice, Galveston, Texas. Contact: geastmond@tlc-galveston.org, web: www2.utmb.edu/TLC/MoodyPrize/conference.htm.

APRIL 2nd – Neuroimaging: Current Developments; Implications for Assessment and Treatment; Neurobehavioral Correlates presented by the New York Academy of Traumatic Brain Injury, New York, NY. Contact: (212) 947-7111 ext. 328, e-mail: rolland.parker@med.nyu.edu, web: www.nyacadtbi.org.

14-16 – First International Conference on Vocational Outcomes in Traumatic Brain Injury, Vancouver, BC. Contact: (604) 875-1775email: sljproductions@telus.net, web: www.tbicvancouver2005.com.

11-13 – Ontario Brain Injury Association Certificate Training Program: Neuropsychological Assessments: Beyond Testing, St. Catharines, Ontario. Contact: Ontario Brain Injury Association (800) 263-5404, email: obia@obia.on.ca, web: www.obia.on.ca.

12-13 – Brain Injury Conference presented by Contemporary Forums.

Seattle, Washington. Contact: (925) 828-7100, ext. 102, e-mail: info@cforums.com, web: www.contemporaryforums.com.

12-15 – American Occupational Therapy Association's 85th Annual Conference & Expo, Long Beach, California. Contact (301) 652-2682, web: www.aota.org.

JUNE 8-11 – Annual Conference & Exposition of the American Physical Therapy Association, Boston, Massachusetts. Contact: (800) 999-2782, web: www.apta.org.

14-17 – Canadian Association of Rehabiliation Professionals National Conference, Charlottetown, Prince Edward. Contact: (902) 3686123, e-mail: kdmullins@gov.pe.ca, web: carpnational.com.

21-25 – Case Management Society of America's 15th Annual Conference & Expo, Orlando, Florida. Contact: (501) 225-2229, e-mail: cmsa@cmsa.org, web: www.cmsa.org SEPTEMBER 29-October 2 – American Congress of Rehabiliation Medicine, Achieving, Evidence-Based Rehabilitation, Chicago, Illinois. Contact: (317) 915-2250, e-mail: acrm@acrm.org, web: www.acrm.org.

22-24 – 18th Annual Brain Injury Medical-Legal Conference presented by the North American Brain Injury Society, Amelia Island, Florida.

Contact: (800) 321-7037, e-mail: contact@nabis.org, web: www.nabis.org.

MAY 5-8 – International Brain Injury Association's 6th World Congress on Brain Injury, Melbourne, Australia. Contact: +61 3 9682 0244, email: braininjury@icms.com.au, web: www.icms.com.au/braininjury.

To list your professional event on this page, e-mail: conference@nabis.org

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