Historical Perspectives in the Development of Neuropsychology As a Professional Psychological Specialty

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I I FROM: Harrdbook of Chi-Id Clinical PsYchologY Edited by CecJ.I R. Reynolds arrd Elairre nleLc he r- Janzert New York: Plerrum Press (1989)

Historical Perspectives in the Development of Neuropsychology as a Professional Psychological specialty

ANTONIO E. PUENTE

The growth of ncuropsychology, and clinicat neur> discussion of thc growth of publications, organiza- psychology in particular, has been rapid though tions, and conlinuing educadbn acriviries in ilinical poorly documented. Alrhough clinical neuropsychol- neuro,psychology. Recent trends in professional ogy tcxts provide overviews on theorics of brain practicc, certification, and credentialing arc also ad- onlya few review how !ry{o1, rhe field developed. etfl. The chapar concludes wirh suggcsrions for* This lack of informarion is nor typical of related disci- maximizing rhe growth and efficacy of rf,e fietd. plincs (e.g., neurology) or of orhcr specialries wirhin psycholog-y (e.g., clinical psychology). Clinical psychology, for example, has experienicd rapid growth Historical Perspectives ovcr the past 25-40 years and its in the dcvelopment is well Development documenrcd (Fox, 1982; Fox, Barclay, & Rogers, of Neuropsychology 1982). Documenration is helpful for a variery of rea_ Localization of brain function has becn the focus philosophers, sons. First, studens must be provided with a comprc_ of physiologisrs, and psychol- hensive analysis of rhe discipline's devcloprnent. ogists for many centuries. Around 4O0 BC, Hippoc- Historical perspectives should scrye as foundation rarcs anempted to corrclate his behavioral observa- for a more comprehensive appreciation of currcnt tions with what hc knew about anarcmical trends and limindons. Simitarly, hea.lrh profes_ localization; this was conjecture becausc he was le- gatly sionals not directly involved in rhe held should have a and socially prohibited from dissecring the clearer understanding ofour rcchniques and rrcnds, if human body, especially rhe cranium. later, Ariirode n9t rhe professional (not Plato) sumrised that the -for welfare of Cthicat neuopsy- heart was rhe seat of the chology, at leasl for the welfare of consumers ser- mind. Almo$ 600 years after Hippocrares, Galen viced. by rhe. discipline. shifted tbe sire of rhe Finally, and becoming in- mind o rhe brain. Clarificarion r crcasingly important, documcntation of overall mind function was larer offered murt be by De- , available to individuals ourside of health care who are scartcs who suggested thar the soul was tocalized in r in a posirion to affecr thc discipline rhrough funding thc pineal gland. In 1810, Call described corrical and lcgislarion. localization function of through the concepr of j This_chaprcr chronicles phrenology. and cririques rhe devel_ I opment of clinical neuropsychology asa professional Flourens and Broca introduced morc accurate pracririoner or specialry in psychology. A brief hisro_ observations of brain funcrion during rhe mid lgrh ry ot c€ntury, rcsearch and clinical developments precedes a forcing physiologists ro rescarch localization of function morc systematically and wid more precir measurement tools. This rescarch was in- AMONTO E. . PUENTE Dcprurrcru of hychology, Uoi- by carly recordings of brain funcrion or dys_ rcniry of Nonh Crrolina, Wilmingoo, function which .26403-329?. '1 No.rh Crroliru can be traced to at least the lTth cen- \ tury (Gibson, 1962) whcn scveral cascs describing ri C}IAPTER T

traurnatic brain injury werc documented. Prrecisc ex- normative approach." Such an approach builds on pcrimental, rather than observational, analysis began the uniqueness of the individual and on the complex- with the electrical stimulation work of Frirsch and iries of syndromes by tailoring the assessment. How- Hietzig in 1790. New scientific lechniques were in- ever, unlike the Russian methods, the British ap' troduced m the study of brain function by one of proach does rely on psychometric tests. An Catell's sntdenrs, Sheperd Franz, during the early evaluation may begin with the Wechsler Adult Intel- part of this cenory. While in Washingron, D.C., ligence Scale and proceed to the Wisconsin Card Franz taught Karl S. f ashley who, in turn, advanced Sorting Test, Halstead Category Test, or Trail Mak- the understanding of brain-behavior rclarionships as ing Test, depending on the functions that are to be yell as thc theory of equipotenrialiry. During the mid examined. Gaps in the asscssrnent are filled with 20th cenmry, Nobel laurcarc Roger Sperry and col- more cxperimental (i.e., poorly sundardized) and leagues extended rhis earlier work by developing pro- individual tasks. A hnal yet imponant aspcct of the cedurcs for experimentally examining disconnection British appmach is the shift from strict localization syndromes. (which is central to Luria's approach) to an under- As noncultural variables have traditionally been standing of behavioral and psychological deficits. anributed little value in neuropsychological informa- Canadian and American or North American ap tion, it is surprising ro noc rhar differcnt approaches proaches to clinical neuropsychology have historical to the applicarion of neuropsychological knowledge roots in the work of Franz and Lashlcy in Wash- have developcd across three major culturcs, i.e., ington, D.C. However, the clinical or applicd study North Amcrica, Russia, and Great Brirain. of brain dysfunction in the Unired Starcs could be The approach to clinical ncuropsychological un- traced back to Kurt Goldstein. Goldstcin's (1939) derstanding in Russia grcw from rhe classical psy- approach to the study of brain dysfunction was sim- chophysiological reflexive studics of pavlov and ilar to that of Luria's in the sensc thar he did not use other Russian physiologisa (Bechrercva, 1978). psychomeric tests and that an extcns-iie clinical case Clearly the best recognized individual to apply this study was favored over shon, stn.rcturcd contacts orientation to clinical assessment of neuropsychol- (Hanfmann, Ricken-Ovsiankina, & Goldstein, ogical dysfunction was A. R. Luria (1902-1977). r944r. According to Luria ( 1970), there are rwo basic princi- Early psychometric approaches to brain assess- ples that guidc assessment of brain dysfunction: lo- ment can be traccd to Babcock ( 1930). Howcver, ir calization ofbrain lesions and analysis ofpsychologi- was Ralph Reitan who launched clinical neuropsy- cal activities associared with brain funcrion. The chology in Nonh America toward the now-accepted Russian appmach to assessment is bascd on a psychometric tradition. ln his seminal paper in 1955, qualiutive, rather than quantitative or psychornetric he indicated that the purposc of a neuropsychological method. Specifically, this approach anemprs ro pr<> evaluation was lo ms$ure deficits accurately in a vide a "clinical description using flexible bur sys- standardized psychometdc fashion. An interesting tcmatic sets of tests" (Luria & Majovski, 1977,- p. comparison of Reitan's and Luria's approach to brain fti2). The foundation for this flexiblc appmach is assessmcnt is found in Diamant ( 198 I ). An extension based on the concept tlrat strong individual dif- of Luria's approach into the psychometric realm of fcrences preclude dcvclopment of accuratc nonns. brain assessment scrved as the foundation for the Empirically derived analyscs cannot rcplacc a com- work of Golden, Hammcke, and Purisch ( 1980) wirh prehcnsivc undentanding of brain or individual pa- thc Luria-Nebraska Neuropsychological Bartcry. tient functioning. Each client prcsens with an indi- Although numerous criticisms have becn leveled at vidual sct of sympoms; thus, individual hyporhescs this banery and approach (Adams, 1980), the batrery and expcrirncnts must bc performed. Obscrvation of continues to be uscd and with increasing regulanty form and contentr rcplication, and flexibiliry of (Serctny, Dean, Gray, & Hartlage, 1986; Lubin, thinking are ccntral to this approach. I-arsen, Matarazzo, & Seevcn, 1986). Although neu- Whcreas thc methods of Luria rcprescnt the his- ropsychology as a field of investigation has a long lorical foundations for rhe clinical application of past, formal efforts in clinical neuropsychology have ncuropsychological principles in Russia, Henry a more recent onsct and more of a divcrgent geo' Head and Hughlings Jackson rEpres€nr the founda- graphical origin. Nevertheless, the discipline has re- tion for British approaches to clinical neuropsychol- cenrly made significant strides toward the under- ogy. According to Beaumonr (1983), Brirish clinical standing of brain function from both rcsearch and ncuropsychologiss favor thc "individual-ccnrcrcd clinical perspectives. ;i HISTORICAL PERSPECTIVES

fournal and Book Publications Georgemiller, and Hymen (1982) analyzed the affiliation, geographic region, and context of manu- The proliferarion of head-injured World War II scrips published berween 1979 and 1983 in these veterans into Veterans Administration domiciliary journals. Whereas the Univeniry of Nebraska repre- scnings occurred with the rapid growrtr of clinical scnted ll.3% of articles in CN, a wide variety of psychology. Such growrh was sready though nor nec- universities (e.g., City College of New york) were essarily rcmarkable rhrough the 1950s and ltX0s. representcd io JCN. Southern and nonh central snres This growth is well chronicled in research and were the geographic origin of articles in CN, whereas clinical srudies published in various journals. For nortbeastern states and Canadian locations 'n were bet- cxarnple, Reiran's (1955) classical psychometric ter representcd JCN. Furthermorc, institutional study of head-injured adults appeare d in the J ounwt contribution did not overlap from onejournal to the psyclwlogy of ,Comparailve and Physiological other. Cff was found to be morc assessment oriented (JCPP). However, by abour 1950 well over70% of (e. g., Luria-Nebraska Neuropsychological Banery) the studies inJCPP uscd thc Norway rat and closc ro whercas./CN focuscd more on methodological and E0% of the srudies dealt eirher wirh conditioning and theoretical articles, l7.l and 30.2% of articles, re- learning or with rcflexes and simple reaction panerns spectively. ln sumrnary, Ryan er a/. (1982) sug- (Beach, 1950). In many rcspecrs, Reitan'J articlc gesed lhat "one journal (CnD will become more was not mainstrcam physiological psychology. identified wirh pracrical issues while the orher (./CM) to socurncnt pubhcauon mnds, all clinical will deal morc with academic interest." neuropsychological citatio p rs'n syc lwlo g ical Ab_ Georgemiller, Ryan, and Settey (19g6) tater stracts. Biological Abstracts, and Indet Medicus as t surveyed I 15 sites offering neuropsychological train- well as in tluee s€parate compu@r ; scarches wcrc ing and asked the directors to rate the valui of neuro. chronicled. The rrcnd publishcd of articles approxi- psychology-rclarcd journals. In order of perceived*-- rnaes two articles per year until about 1960. - From imponance w ere J ountd of C linical and Etpe r ime n- 1960 until 1975, a sharp rise in publicarion ratc oc- i tal. Neuropsyclwlogy, Journal of Consuiting and currcd with an average of 28 articles per year. Be- , Clinical Neuropsychology, Clinical Neuropsychol- twecn 1974 and 1985 : the rate continued ro rise sha4> ogy, Cortex, Archives of Neurology, Brain, Brain ly to about 66 articles pcr year. Tbese , articles were and Langrcge, Journal of Clinical psychology, and found in a-wide variety of csoreric and interdisciplin- : Archives of Cercral Psyclwlogy. journals; ary to journals , ' dare, 16l differcnr have pub- If one examines book publishing, similar lished articles . on neuropsychology. The joumals q-*qt panerns emerge. prior ro the 1970s, publishing applica- rhc mosr aniclcs include (in alph;bedcal tion of neuropsychological principles *us .ur.iy .o"- order) Americsn Jourrwl of psychiatry', Clinical ered in - clinical psychology or relared texu. Howev_ uro p sy c ho lo gy I 1 I n t e r nat io no! J o urnal of C li nicat er, such books as l-ezak's ! journal Neuropsychological Cortex, . lyuropsychology, Intenuional of Assessment (1976) and Golden's Diagnosis and Re- Neuroscience, Journal of Clinical Neuropsychol- Iubilitation inClinical Neuropsychology ( l97g) dur- ogyl.Journal of Clinicol and Expcrimennl N-europry- ing the 1970s and more rccenrly Filskov and Boll's clo lo Sy, J o ur ru I of C I i nical p sy c ho I o gy, J o u r na I bf Handbook of Clinical NeuropsycholoSy (l9gl) and Cons ulting and C linical p syctwlogy, N europsycho-l Wcdding, Horton, and Webster' s The Neuropsychol- logia. and Percepual and Motor Siils. Tlne erihivesl ogy Handbook (1986) have inrroduccd thiJ .inew" of Clinical Neuropsychotogy, The Clinical Neuro-l field to clinical and nonclinical psychologisrs. Sever_ p_sychologist and Neuropsychotogy are new ro rhe,i al publishing companies have mounred intensive freld-, exclusivcty publishing cliniia.l neuropsycholo- . cfforts in the field and one, plenum, has develooed grcal studies, a and have not becn in existence long, book scries enrirled Critical Issues in Clinical Niuro- cnough to have bcen listed but psychology. should cenainlv-,1 This Harulboot is one of rhe firsr books achieue such smtus quickly. to bc published in rhe series. Until recenrly, . thc two major ncuropsychol-- Franzen, and Hartlage (19g7) re- ogical journals -Wedding, addressing clinical issues were cently reported the number of clinical neuropsychol- Clinical Ncuropsycholo7y (CN : ttow International ogy books published yearly from 196O ro tiS6. ge- Jgynwl of Clinical Neuropsychotogy) andJournal of tween 1960 and 1967 an average of lcss rhan one Clinical Neuropsychology (JCN: I now the Journal if book was published per year. Twenty years larer the Experimeual and C linical N europsychology). In m avefilge number published per ye ar was we ll over 10, inrcresting study d of publicarion rrenda: Ry-, with close ro 25 books published in 19g6. This pro- 6i CIIAPTER T

liferarion of books and journals shows no indicationi are practicing, rather than academic, professionals of and a large majority are involved in direct service, slowing. ll Upically in private practicc scnings. NAN mcm- I benhip requirements include specific training and Professional Organizations expcriential components rather than thc simple in- I rcrcst criteria of lNS. Along with the proliferation of published find- Division 4O of the APA (Division of Clinical ings has been the deve lopment of three major organi- Neuropsychology) was formed in 1980 to serve lhe zarions rcprcscnting clinical ncuropsychology. The growing intercst of APA membcrs in clinical neuro- Intcrnational Neuropsychological Society (lNS) was psychology. lnitially, APA memben from other di- established in 1970 by individuals of varying disci- visions (e.9., 6 and 12) joined to petition for this plines interestcd in neuropsychological issues. [n Division. As of January 1986, the Division had 49 l9?3 the first mecting of INS was convened in New fellows. 1829 mcmbcrs, and 153 associates with Orleans. Such well-known clinicians as Benton, But- rapid growth expected to continue. tcrs, Goldsteio, Hartlage, Kinsbourne, Minky, Pri- Ancillary divisions within APA as well as nu- bram, Rourke, and Satz dottcd thc srnall yet robust merous non-APA groups have also experienced prognun. Othcn, such as Frcd King, now dircctor for growth indirectly associated with clinical neuropsy- the Yerkes Primarc Rcscarch Center in Atlan(a, rcp chology. The Association for the Advancement of r€s€nt€d more academically oriented disciplines such Behavior Thempy has members interesled in clinical as physiological psychology and the neurosciences. neuropsychology as does Divisions 38 (Health Psy- Fmm thc 1970 membenhip of 175 (mosrly fmm chology) and 6 (Physiological and Compararive Psy- Nonh Amcrica), INS has grown to 2000 mcmbers chology). ln nonpsychologically orienred organiza- worldwidc rcprcs€nting a varicty of disciplines, in- tions, similar growth has been obse-rved in groups 'such cluding speech pathology, clinical neurology, and as the Society for Neuroscience-. Finally, it is neuropsychology. Of these, ovcr 600 residc outside wonh noting thatalhough not associated with specif- of the United States. To accomrnodatc the large ic national or international organizations, geograph- number of non-North American membcrs, INS now ically limited groups have surfaccd throughour the holds two mectings per year-one in Nonh America United Starcs and abroad. Croups in New York, phil- and the other in Europe. Ovcr 800 anended the 1987 adelphia, Califomia, and Pueno Rico (ro name a USA meeting (Washingon, D.C.) with a smaller few) have been formed lo serve more local needs. number attcnding the Europcan meeting (Barcetona, Onc particular group, the Philadelphia Neuropsy- Spain). chological Sociery, has recently launched irs own According to Hartlage (1987), the National journal. Thus, suong evidence exists ahat organiza- Academy of Neumpsychologists (NAN) evolved , tions in clinical neuropsychology are and, mosr like- from a group of INS and APA memben intercsted in Iy, will continue flourishing. developing a separate organization with nadonal rep rcsentation as well as focusing on the professional aspects of neuropsychology. The frst formal meet- Continuing Education ing was hcld in August 1976 the Washington School of Psychiatry. Roben Woody,^t the frrst presi- Though a rclative newcomer to the discipline, dent of NAN, was insrnrmental in initiating a news- another area of growth in clinical neuropsychology I letter, Gran-ma. W. Lynn Smith chaired the next has becn continuing education and the frecstanding i meedng held in coopcration with the annual APA workshop. These activities have served as a central meeting. ln 1981, NAN met independent of APA in focus in providing training for clinical neuropsychol- Orlando, Florida, wilh approximately 220 indi- ogists. Recent examples of these workshops include: viduals registered. Since Orlando, NAN has met in mild head injury in New York; Luria-Nebraska in

Atlanta, Houslon, San Diego, Philadclphia, Las Chicago; traumatic head injury in Brainrree, Mas- i' Vcgas, andChicago (19E7). Registration forthc Chi- sachusctts; head trauma in Kansas City; demcntia in \ cago meeting exceeded morc than 350 and mem- i Baltimore; behavioral neurology and neuropsychol- bcnhip in thc organization is cuncntly nearing 1000. ogy in l-ake Buena Vista, Florida; and head injury Although members rcsidc in many differcnt coun- rchabiliution in Williamsburg, Virginia. Many of tries, including Australia and scveral countries in Eu- thesc freestanding workshops now also havc free ropc, mcmbenhip is largely composcd of individuals communications or poster sessions as part of the from the United States and Canada. Most members o':o* HISTORICAL PERSPECTIVES

Akhough - rhesc freestanding workshops ofren !9!$eJing eenrers. Intercsringly, approximarely sharpen rhe skills of pmfessionals, rhey poienrially 50% of the rcspondents havc secondary employment, pose. -rctraioing significant complicarions (e.g., engaging rlindependent group or individual privare involves more than workshops). To avoid thesc pitl practice. Of those providing health scrvicej, over falls, (1987) ..lrarn- Meicr ourlined rhe concepr of half werc involved in clinical acrivities in indepen- ing and Assessment Cenrer" for cliniial neuropsy- dent practices, clinics, hospitals, or counseling/other chology pracrice ro define personal insufficieniiis scrvicc senings (in order of prominence). and to provide the necessary knowledge, scienrific or Although not as currenr as thc Stapp er a/. professional, to respecialize in clinical neuropsy- (1985) data, Dorken and Webb (1981) reporred large chology. Educational materials would be based dn incrcascs in the number of clinical psychologisa dur- identified knowledgc, skills, and attention needed o ing the mid to lare 1970s, supponing the trend rhar practice and provide an advanced levcl of profi- more and more individuals are providing health care , crency. rcgardless of their primary employment. ln a rccent The informarion ro bc disseminard could rake analysis of docroratc productions by subfield, rhe onc of several forms including workshops, convcn- APA Comminoe on Employment and Human Re- tiors, and publishcd materials. However, of the spc- sourccs (Howard et ol., 1986) indicared that whercas cific modaliries of professional informarion, somc 50 years ago 70% of all new PhD recipients were in forms of dissemination appear to be morc efficient experimental psychology, in 1984 53.2% were in than othen. For cxample, Allen, Nelson, and health services specialties. Furthermorc, "the trend Sheckley (1987) reported on conrinuing educarion was for new doctorarc rccipients in clinical, counsel- activities of Connecricut psychologists. Books and ing, and school psychology ro increasingly assume contacts with othcr professional psychologiss werc positions in organized human scrvice settings" lhc most favored continuing educarion activities, (Howard et al.. 1986, p. 1322). with books rued as rhe mosr valuable. Surprisingly, ln a review of the 1982 APA's Human Re-- the average respondent read 9.9 books, 3.8 joumals, sourcres Survey, VandenBos and Stapp (1983) pro. and attcndcd 2.5 workshops and 2.2 conventions pcr vided a detailed analysis of rhc characreristics of ycar. Continuing education acriviries appear ro bc practicc senings of service providers, proliles of pro- critical in the devclopment of professional practice fessional practice, and other aspects of independent and to date, numerous opponunities have been avail- practice. Whereas the hrst two issues were addressed ablc for rhose inrere stcd in funhering their raining in in the Stapp et al. (1985) report, issues of profes- clinical neuropsychology. sional practioe were more comprehensively dc- scribed by VandenBos and Srapp (1983). Healrh problems, substancc abuse, menhl retardation. and Psychological Health personnel schizophrenia combined rcprcsenred close to 50% of Care thc rypcs of clienr problems and Practice secn by health providers. ln an earlier study by VandenBos and colleagues (VandenBos, Stapp, & Kilbcrg, l98l), about4O% of During the 1970s there occurred an influx of the respondcnts reported performing complete as- psychology personnel into rhe workplace. This influx scssmcnts regularly or often. has continucd unabated and has affectcd clinical neu- Tbese rcsults str,ongly suggest that the number ropsychology. According ro Stapp, Tucker, and of hcalth providers is rapidly increasing and they are VandenBos (1985), rhe esdmared number of psy- quickly bccoming the majoriry of psychology per- chology penonnel in rhe Unired Stares was 102;tm sonnel in the Unitcd States. Although independenr in mid 1983. Of rhese, 61.6% werc primarily pmvid- practice groups or individuals appear to be enjoying ing health scrvices, 49.Z% wcrc invblved in risearch the most significant growth, similar trends are seen in and67.7% in educarion. Approximarcly rwo rhirds of all health service senings (e.g., hospitals). Assuming thcsc werc doctoral levcl psychologiits, and most that a significant percentage ofall health service cli- (both masar's and docroraie lcvcl) idcntified rhem- cnts have organic disorders and rhar few health pro- sclvcs wirh clinical psychology (followed by coun- vidcn limit their practice to one type of service or scling and educarional psychology). Univcrsity sct- client (VandcnBos and Srapp, 1983), one may con- trngs werc the largest single catcgory of cmployment clude that a large perccnrage of psychologists are lor doctorates; approximately 44% of the rc- involved either in therapy or in assessmenr of indi- sPondenr wcrc cmploycd primarily in dirccr scrvice viduals with neuropsychologicalty based problems. tlrough ..it indcpendenr practice, hospirals, clinics, or According to VandenBos and Srapp (1983), is I

IlcrrAPrEnr

intcrcsting to note thar psychologiss rend rtor to spe- clinical psychology was the bcst prcparation for de- cialize with specific problems or widr specific age livery of clinical neuropsychology services. Finally, populations" (p. 1346). Thus, more psycbologiss Benton and Golden werc cited for their unique contri- will either cvenrually be involved in or specialize in butions to the development of clinical neuropsychol- clinical neuropsychological scrvices. ogy as a professional specialry. Using Social Securiry Administration data as a ln a morc recent study, Serctny et al. (1986) specific cxample, organic clients do comprise a sig- suweyed members from APA's Division 40 (l/ = nilicant segmcnt ofgeneral clinical practicc. In fiscal 314) and the National Academy of Neuropsychol- years 1984 and 1985, 22.5% (or approximarelyr ogists (N = 300). The purpose of the survcy was 250,000 pcople) ofall thosc applying for Social Se-l esscntially to follow-up earlier surveys and to expand curiry disability were mental impairment cases (Dap i the information available for specific aspects of pro-

per, 1987). Of these, 67o werc classified as organic r fessional pnctice settings. Private practice was rc- mental disorder and 35% as mentally retarded. Retar- | ported as the primary work sening of the re-

dationcould be "caused" by head trauma, forexam- r spondens, followed by (in decreasing order of

ple, as IQs and not etiologies of behavioral disruprion , occurence) hospitals, medical schools, and academ- are important in a disability evaluarion. This ac-; ic senings. According to the authors, there has been a counts for between 200,000 and 300,000 potenrial I shift to privatc practice senings over rhe last 5 yean. neuropsychological per year. clients ln summary, it I Whether this is due to academicians going into prac- appears that noa only arc more psychologisS dealing; tice or new doctorate recipients choosing profes- with neuropsychologically impaired clienrs, but rhat; sional rather than academic s€ttings, or both, is un- a large number of mental bealth consumers have I certain. Little has changed in terms of the average organic disorders. number of evaluations per month ( I l. l3) or the aver- agc arnount of time required to complere a full evaluation (7.30 hours). About half of rhe respondents I cmployed tcchnicians. The Wechsler Intelligence Professional Practice I Scales rcmaincd thc most frequenrly used instru- I ments followed by the Halstead-Reiran and rhe The practice of clinical neuropsychology hasl Luria-Nebraska Neuropsychological barreries. bccome incrcasingly popular in the last few years. Other single tests frequently used included the Several survcys ovcr the last 5 ycars haye outlined the WRAT, Bender, and Benton. as wcll as the MMPI curent practice of clinical neuropsychology in the and the Wechsler Mcmory Scale . A wide variery of United States. ln 1982, Hartlage and Telzrow com- referral sources was cited. Referrals were primarily pleted a mail survey of all members of the National from neurologiss, although neurosurgeons, psychol- Acadcmy of Neuropsychologisa. Four majorcontent ogists, general physicians, physical rehabilitarion areas wcrc covered: professional practicc, lests, specialiss, and attomeys also referred regularly. The practicc prcparation, and most important figurc in the mean dollar ulrnounr for a complete neuropsychol- history of clinical neuropsychology in the United, ogical cvaluation was $479.30 or abour $65.65 per Statcs. From thesc data, onc can develop a basic i hour. Most rcspondcns indicated that they wcre in- sense of a "typical" clinical neuropsychological I volved in some nonncuropsychological activities as practice. The mean ncuropsychological cvaluation I well as cognitivc rchabilitarion and forensic evalua- timc was 8 houn. Approximately 59% of the rc- | tions. Thesc results support the fact that specific spondents used technicians. Only three tests werc r trends are surfacing in terms of tests used, time used used by at least 50% of the respondents and these i for an evaluation, and the use of technicians. Addi- Wechsler (89%), included the Intelligence Scales I tional longitudinal information would bc useful wirh ponions of thc Halstead-Reitan Neuropsychological i rcgard to such issues as cosa of service, place of Banery (56%), and thc Widc Range Achicvcmcnt i employment, and referral sources. Tcst (52%). Thc remaining tcsts used wcre (in order; Ryan, Farage, and Lips (1983) idenrified psy- of descending popularity): Bender Gestalt Test, chological hcalth providers in rhc 198 I ve nion of the Halstead-Reiun Ncuropsychological Batrcry, Ben- National Register of Health Semice Providers in Psy- ton Visual Rctention Test, Luria Tests (Christcnscn chology and the winter l98l-1982 supplemenr, who or Golden vcnions), Wcchsler Mcmory Scale, Mem- offered neuropsychological services in an effort to ory for Designs, and the Minnesota Multiphasic Per- undentand the geographical disrribution of penons sonality lnventory (MMPI). With rcgard to pracrice providing such service. The rangc noted was rela- prcparation, 7E% of the rcspondenrs indicared that tively large with the District of Columbia having one HISTORICAL PERSPECIIVES

geurop;lchology. providcr pcr 42,510 persons, and Unril the 1980s, clinical neuropsychology wirh onc provider per 690, wils ::-r:_:gl_". I Zt. The rop p1a fgrryllV rccognized subspecialiy yf1rr^s of per capia providen in hedff care. :i,_r?Tr were (in q:h3v1oral neurologists, speech ranx ordcr): california, pcnnsyl- parhologisrs, and f:*_ygrk, Texas, cuntc:lJ psychologrsts (among vania, llinois, Ohio, Florida, othen) with an interesr Michigan, N"* i"r""y, tn Dfln dyslutrcrlon and Nonh Carolina. worked using informal titles, Alaska and scieral ,ia*""". and in manycases, construcs. Realizing the need starcs had rhe fewcst numberof practicing neuropsy- for pe9ifrc professional idenrity in rtre apiliea chologists. Ir is intercsting ro aoG field of that in lidiana onty brain dysfuncrion, scveral piychologiii 2l individuals offered neuropsychological *lrt in ,""- scrviccs eral Divisions of ApA,. espctiatty urd only one did so in South 6 lfhysiotogical Outotu.-tt"." .or., and Comparadve) and 12 (Clinicat psychology), the geographical origins the as fp.resen_t of Ha.lstcad_ well as within INS and NAN, initiared Kcllar (Indiana) and Luria_Nebraska iiscussiln for Neuropsychol-r-r - thc developmenr of guidelines ogical batreries (Sourh thar would defrni trow Dakora). a.psychologisr (and not an individual of a related Sladen, MozAzien, and Grccnblan (t9g6) also discipline) would be identified as a ctinicJ niuropsy- geographical disrriburions oi lIT1ed,O" n"u-pry- chologist. Prior to the developmenr of Division-4b, service providens using rhe :Tllgl."t sarne suU;.h informat discussions were centered within s€tcctfon cnreria as Ryan et al. (19g3). INS cir- Sladen ei a/. cles. By rhe early l98Os, qO rcryncd "marked disparities" ApA Division had been in dre distriburion of tormcd, and rhe prclcsslonal psychologists original group of individuals devel- providing clinical ncuro. oping thesc gu.idelines psycnotogtcal serviccs. sptir inro t*o maioria"t,onr. Thcsc disparitics exisrcd une group, who both arnong remained entrenched within lNS, statcs:rs wcll as between rura.t and mecro_ politol devcloped rhe American Board of Clinicuf N"uiopry_ arcas. Generally, rhese services *.rc ofierca chology,.Inc. morc (ABCN),. by larc l9g2 for Oe trcqucnrly in densely populated snGs and in furp"re mcropolitan centers. rpfif y diptomas in ctinical n.irropry._- ln a relared survcy of 316 ran- :l::dlg The domly 9h9logy. initial eligibiliry crireria rcquired rhe chosen comrnunity hospirals, Anchor tiS8fl following: rcported on the availability and awareness of ncuropsychological services. The average hospital in the A. degrec in psychology s-urvey had 143 bcds ry*rgg from a re_ and all had emerg.n.y roorns. gionally accredired univenirv-- Only 8.5% of rhe hospitats offered iyp" 6i*uro_ B. Licensed or certified psyclotogrcal, neuropsychiaric,-y at rhe level of indepe n- or neurological dent practice in some starc tcsttng services. or province C. Areas of training and experienl. in.iuO.a, recent anicle by .A Molloy (t9S7) indicared thar I. Basic neurosciences facing. !9|ott1o1s neuropsychologisrs appear more 2. Neuroanatomy orntcult rn countries outside of Nonh Amlrica. Rc_ 3. Neuroparhology M" I loy, in s u g f trc i en r undcn ran a i n!, u - 1 4. Clinical olctal:g:,1,;.9 lrq neurology dlstrust, and limited rcimbursement trave tram- 5. psychologicd pcred the developmcnt asllssment of neuropsychology as a 6. clinical.specialry Clinical neuropsychological assess_ in nusralia. Howl"'ei, l""i'.* ment ial i sa. appear ro "na .rp... consrirure rhe irimary 7. Psychoparhology sourccll:1 of referrals there. Such patterns appear orcva- 8. Psychological lent in intervenrion orher counrries as well. for.*u*pi!, in Lr. tstve years Sprn, of postdoctoral professional ex_ qTryF. of practirioners exisr onty in'targer iiries perience in psychology which could in_ (Uaari! and Barcelona). tn orher i,oun,r,rilu.r, clude: Argenllna, * clinical neuropsychological services arc Clinicat css€ntially nonexistent. Research Tcaching Certification and Credentialing Adminisradon E. Threc or more years of clinical neuroDsv_ chological Although a expcrience defined as foltowsi fparac chaprcr on certificarion, l. Equivalcnr ofat Idling,-s.uu6,, dtuand credenrialingsrE(rcnualtng is'founJ;ffi;;#$ least I ycar of full book, tirne supervised clinical neuropsy_ the currcnt models of trtraining and credendal- chology expcrience at the postdoc- ing-have rhcir roots in and havc -bc - i'.p""i"" iffi- i toral lcvel (6 months ical rends and, rhus, waranr tristoriciianaiiil" may cred- I itcd for docurnenrcd predoctoral I I CHATTERI

specialry internship in 2. Licensure by a state board of psychology neuropsychology) 3. At least 5 years' postdoctoral experience in 2. Equivalenr of at leasr I yearof addi- professional neuropsychology rional experience as a clinical 4. Combination of courscwork; additional neuropsychologist raining such as continuing education work- 3. In thc abscnce of any supervised shops, supervised pre- orpostdoctoral train- clinical experience, rhe equivalent ing; and rcle vant work experience to provide of 3 years of unsupcrviscd postdoc- evidence of high degrce of competence in tord experiencc as a clinical professional ne uropsychology ncumpsychologist 5. Recommendation by at least two supervisors or professional colleagues attesting to high The applicarion form also rcquired rhc submission of: degrec of competencies in professional I A copy of currcnt state licensc or cenificate, neuropsychology 7 2. Names of two professionals who could attest i To date, ABCN and ABPN havc not made to the extent, nature and quality of your , 1 stridcs to mcrge and appear to be taking independent cxpericnce and compctcnce l in clinical courses. However, rcgardless of the apparent split, ncuroPsychology. I agreement has bcen reached on spccilic guidelincs In April 1985, Manfrcd Meier, rhe prcsidcnr of i for idcntifying requiremenrs for clinical neuropsychology education. ABCN, announced affiliation of this group wirh rhe , Arnerican Board of Professional Psychology To alleviate porenrial complications for indi- (ABPP). According to Meicr, ABPP voted on March viduals wishing ro be trained in the field of clinical 4-5, 1985, to add clinical neuropsychology ro rhe neuropsychology, recent guidelines have been pub- cxisting fields of applied compecncy of ctinical, lished by INS and Division 40 (Augost 1986). The counseling, school, and indusuial/organizational guidclines, in their enrirety, are as follows: psychology. As a function of irs ABPP affiliarion, Doctor.l tnining in Clinical Ncurcpsychology should ABCN adoptcd ABPP's dcfinition of a psychology ordinarily rcsult in thc a*ardingofa Ph.D. degrcc from graduate program as well as adding scveral related e rcgionally accrcditcd univcnity. tt may bc accom- p4uircments (e.g., APA mcmbenhip). At rhe cur- plishcd tlrough a Ph.D. prograrn in Clinical Ncuropsy- chology offcrcd by psychology rent !ime, the ABPP/ABCN examination includes a r dcpanrncnr or mcdi- cel frculty or rhrough rlrc complcrron of a ph.D. "work sarnple" (e.g., neuropsychological evalua- Fograrn io e rclarcd spccialty arca (c.9.. Clinical psy- tion or treatmcnt summary) as wcll as an oral e&un- cboloty) which offcrs sufficicnr spccietizarion ination. in The oral examination involves analyscs of Cli:nical Ncuropsychology. the work samplc, elhics, and a sample casc. The Trainrng prograrns in Clinical Ncuropsychology wrinen multiplc-choice examination is being stan- prcparc stu&ns for hcalth scrvicc dclivcry, basic dardizcd as of this writing. The new ABCN-ABPP clinical rcscarch, tcaching end consularion. As such, cxamination has bccomc more rcfincd and extensive thcy mus cotuin (a) a gcncric psychology corc, (b) r rclative to the original crireria publishcd in 1982. gcncnc cliaical corc, (c) spccializcd training in thc ncu- Thc American Board of Professional Neuropsy- roccicnccs ard basic human and animal ncuropsychol- (d) chology (ABPN) was developed in 1982 under rhe ogy, spccific training in clinical ncuropsychology. Tbis should includc e 1800 hour inrcmship whrch direction of l,awrcnce Hanlagc and scvcral other sbould bc proccdcd by an appropriatc pncricum ABPP membcrs, most of whom werc associated with crpcricrrcc. NAN. The guidelines for rhe original diplomare sra- tus, which are shown tlelow, esseotially focuscd on A. Gcncric Psychology Colc relevant training and education, work with rclevant l. Statistics ard Mcrhodology 2. kanring. Cognition and Pcrccprion populations, and supcrvision wirh a qualified practi- r 3. Said Psychology and Pcrrcnaliry tioner. At prcsenl, thc ABPN is being rcstructured 4. Physiology Psychology and will probabty include actual a.tong rcsring wirh an, 5. Lifc Spaa Dcvclopnrnr cxtcnsivc application form. The basic rcquiremenr I 6. Hi*ory havc becn as follows: B. Crrcric Cliaical Corc I l. Psychoparhology l. Minimum educational rcquircmenr is the 2. hychonrmc Theory Ph.D. (or similar docroral degrce, q.g., 3. Intcrvicw and Asscssnrcnt Tcchniqucs Psy.D., Ed.D.) e. Intcrvicwing HISTORTCAL PERSPECTIVES 11

b. Ilalligcrc Asscsscnt tniairy prcgrun in c of rhc hcalrh scrvicc dclivcry c. Pcr$oality Asscssarnt uc.s of pcychologpr or e Ph.D. in psychology wirh 4. lotcrvcntioo Tcchnhucs rddidooal complcrioo of a "rcspccializarioo" program e. Couascliag rnd Bychorbcrapy dGigncd lo @t cquivalcot critcria as a hcalth scrviccs b. Bctuvior Tbcrapy/Modificarioo &livcry pmgram in psychology. ln all cascs, can- c. Consulr-doo didecy for post{ocrord uaining in ctinical ncuropsy- 5. Profcssionel Erhics cbolo$f mlrlt bc basod on dcmonstnrion of trrinhg Ncr.umcicncc C. .od Ba$c Hunen ud Anioel rad rcscach Gtbodology dcsigncd ro nrccl cquivalcnr Ncuropsychology criarir rs I hcelth scrviccs dclivcry prcfcssional in rtr Besic l. Ncurucicm ricntis-pncudors rnodcl. Ordinarily, e clinicel in. psycholoXpr 2. Advuccd Phyriologicet rnd lctuhip. list xl by thc Assaiadoo of hyctrology In. Phannecologr tcmship C.carcrs. must dso havc bccn complcrcd. pcrccpoal, 3. Ncruopsychology of Cog- A pctdtrtord rraining program in clinicat rcu- proccsscs nitivc end Erccutivc ropsychology shotild bc dirEctcd by I board ccrtificd 4. Rcssrh Dcsign rod Rcscarch hrcricum clinical rcuropaychologist. ln nrosr escs. thc prognm in Ncuropcychology should crtcnd ovcr rt l€ast . two-ycar pcriod. Thc only D. Spocific Clidcd Ncuropsychotogical crccpdoo would bc for irdividuals who havc com- Tnioing plctcd e spccifrc clinical rcuropaychology spocializa- Clinical Ncurologr l. erd Ncuroparbology tioa ia tbcir grduarc prognrns and/or e clinical rtcuro 2. Spccializrd Ncuropsychologicd Arscss- poychology iarcmship providcd rhc cria crir.ria arE nEr rrEtrt Tcchriqucs (rcc bclow). As e gerrcral gui&linc. thc posr{ocaorat 3. Spocialir.cd Ncuropsyctological larcr- rrining pmgrdtr should providc at lc.sr 5096 of rLnc in vcnrion Tcchniqucs cliaical scrvicc urd at lcasr 25% of tistc in clioical 4. Ass€ssrrEot Prcdcum Cbildrcn rnd/c rcscercb. V.dancc within rhcsc gui&lincs should bc Aduls in Uaivcniry Supcrviscd Asscss- t ilorcd !o thc occds of rhc individual. Spocific ncuro. Frcility mil psycbology raiaiag mus bc providcd. irrctuding any 5. Clinical Ncuropcychologi:el Intcroship ercas whcrc thc irdividual is dccrDcd to bc dcficicnt 1800 of houn prcfcnbly in e univcrsiry (tcsting, coosultatioo, intcrvcnrion, muroscicrrces, friliry. (As pcr INS-Div. 40 rEsk forcc Eurology, crc.). gui&lirs). Ordinarily rhis inrcmship Such a postdcroral training program rhould bc will bc complcrcd io r singlc ycar, bur il rssoci.rtcd wirb trospitd saings which havc rru- crccpriooal ciJcurnstanccs rray bc com- rological an&or ncurosurgical rrviccs o offcr and dr plcrcd ia a two,ycar pcriod. trainiog sbould bc providcd in borh e didactic and crpc- Docroral E. Disscrtadoo rrcntial formar and sboold itrlude rhc following: It is rccognizcd ph.D. lha rhc complcuoo of r ia A. Training ia ncurological and psychiaric Clinicd Ncuropoychology prcparcs rhc pcnot ro bcgin diagncs. work as e clinicd neuropsychologist, la nros jurisdic- B. Training ia comularion to ncurologicat and Iroos, u rdditiord ycar of supcrviscd clinical prrticc rurosurgial rrviccs. will bc rcquired in ordcr o qudify for liccosurc. Fur- C. Tnioiag il dircct consularion ro Fychiarric, thcrmorc, tnining a thc poctiocbral lcvcl to irrrcss. pcdrauic, or gcneral medical rrviccs. both gcncral ard subspcciality compccacics, is D. Exposurc o rrrhods erd pracdccs of ncu- vicwcd es &sinblc. rological end ruru;urgical consuttarion Po.t{ocbrd rreining. &scribcd trcrch, s is &- (Grard Routrds, Bcd Rourds, Scmhars, signcd to provi& clinicEl rraioing. in ordcr o producc ctc.). eo rdvrnccd lcvcl of compctcncc in thc spialiry of E. Obscrvrrioo of rrurosurgical proccdurcs and cliaicel rrurogcychology. lr is rccognizcd lhar clinicat bionrdical lcsts (rcvascularization pro- ruopaychology is a ricnritically-bascd cvolving dii- ccdurcs. ccrebrat blod flow, WADA rcsdng. ciplir erd rhar srrh training slould rho providc e ca.). si8nifrc.d rcrarch comporrat. Thus. this rcpolr is F. hniciparioo in scminars offcrcd to ncurology conccrncd with posr-doctord rrioing in clinical ruro, rrld rEurosurgcry rcsidcnc (ncurophar- which is spccifrcally gcarcd oward pro, Fychology mrology, EEC, brain cuning, crc.). &ring in&pcn&nt pr:rdriorcr bvcl compctcllcc. G. Training in rcuropsychological rcchniqucs. which includcs borh ncccssery clinicel alrd rcscarch crarninatioos, inrcrprcradon of tesr rcsults. rc- skillr. Thb rcporr dcs rq rd&ess rriaing in rcuro. porr writing. psycbology wilch is focuscd solcly on rcscrrch. H. Tniaing ia consuJarion to paticots ard rrfcr- Enry iao e clinicel rcuropsychology posr.dc- rd rcurccs. tord feining prog;rem ordinarily should bc bascd oo l. Training in mrhods of intcrvcntioa spccilic to conrplctioa of ph.D. r rcgiorully rcrcditcd gr.du& clidcd ncuropsyctrology. I 12 I CTIAPTER T I

Scnio.rs, rcadi[gs, ,. ctc.. il ruropsychology Scheer and Lubin ( 1980) also published an inde- (escs coofcreoces. .toursd discussioos. op. pendent survey of "training" programs in clinical ic-spccific scminars). neuropsychology. In this survey, the aurhors K. Didrctic training ia Eufilaoarorny, Gurr> sampled the 627 ricnccs. memben of INS in 1977. The resulrs indicated thar, at mosr, training "minimal Addirioul crpcrLnrial rniaing should bc offcrcd included rs follows: neuropsychological training acriviries associared A. Ncuropsychologicd cxerninarioo and cvalue- with primary service function and allied disciplines" tioo of paricots wirh acod aod suspccrcd ncu- (e.g., ncurology). Several internship programs exist- mlogical discascs ad disordcrs. ed at both the prc- and the postdocroral level. Scheer B. Ncuropcychologicd crarninarioo ard cvelua- and Lubin nored rhat a rypical parrern of training tioo of paricnrs wirh psychiatric disorde.rs involved obtaining a standard Ph. D. with l - or 2-year rnd/c pcdiatric or gcrrd mcdicd p.rrcnrs postdoctoral specializarion in clinical neuropsychol- with rcurobcbaviord dbordcrs. ogy. Another patrern of rraining was to specialize in a C. Panicipation ia cliaical activitics with ru- specific Ph.D. program (e.g., rologisrs and rcurmurgcoos (Bcd clinical or neuro- Rouods. science) with neuropsychological Grand Rorrads, ca.). concenuation. The authors reported that "notable pioneers" D. Expcricncc ar a spccialty cliaic, strh as I &- such as trEnaia clinic or cpilcpoy clidc, which cmpba- Benton, Sarz, Milner, and Reiran followed this mode sizcs mulridiriplinary ryprochcs ro diag- of training. One panicularly interesring observation mis and trcat.gEot. by Scheer and Lubin was rha! "notable pioncers" E. Dircct coosulbdon to paricnrs involving mu- acnrally "individually designed" rheir curricutum. ropsycbological arscsssEot. With the recent guidelines or recommcndations, it F. DLcct inrcrvcntion wilh paricars, spccifrc o would appear that such an approach would be in- muropsychological issr.rcs, end to includc creasingly difficulr, if not impossible , r-o accomplish. Fycborhcripy ed/or family drrapy whcrc Although Meier ( 1982) cogcnrly argue d iodicarcd. for differe nt models of education in clinical G. Rcscarch in rruropsychology, c.g., collab neuropsychology, it appears thar such a variety ordion on a rcs.arch prolcct or othcr scholarly of models might acrually rca&mic activiry, iaidarion of al in&pcn- be replaced with one or two specific oncs as pressurc &nt rcscarch projcct or othcr scholarly ace- from licensing orcredendaling groups becomes morc &mic activiry, atrd prcscntariotr or publica- dcfined and intensified. tioa of rcrarch .latr whcrc appropriarc. The major re:rson for certilication and credentialing the practice of clinical neuropsychology At thc corrlusioo of thc post{ocoral traiaing is ro ensure p.ograrn. drc irdividud sbould bc ablc ro un&nal,c that our clients/patiens in particular, and so- coosultation lo padcnrs ud profcssiooals on ao indc- ciety in general, are not harmed by incompetent or pcndcnt basis. Accomplishnrnt in rescarch should also unethical practitioners (Hogan, 1983a). However, bc &moosratcd. Thc program is &signcd o producc e unexpected, even undesired by-products of this cur- compctcna preridorEr in drc rrcrs dcsignatcd ia Scc- rent trend are gcncrally not being considered. tioo I of thc Tark Forcc Rcpon rad opmvi& cligibili- The first step in rcgulating a particular discipline ty for ccnifrcatioo in Clinicd Ncuropcychotogy by ttr is not to regulaE the practitioners, but to regulare Amricatr Board Professiooel (1986, of kychology. educational institurions or formal intcrnships PP.+-5) (Hogan, 1983b). This approach was first used in As strict as thesc guidelines may bc, they pre- 1803 in the state of Massachusetts to regulate the sumably ar€ more prcscriprive of how programs mayl medical profession (Shryock, 1967). However, devclop neuropsychology rracks than descriptive ofi Hogan (1983b) argued rhat despire rhe fact rhar so- cxisting neuropsychology programs. phistication in the licensing and cerrificarion proccss For example, I Golden and Kupcrman (1980) surveycd alt APA-apl grows, "little evidence suggesrs rhat the quality of pruvqrproved clinicalslr[rciu psysnotogypsychology glzlquategraduate programs professional s€rvices has improved" (p. l2l) (see inm I North America in 1977. Approximarcly 6O% of thesei also Kesscl, 1970, and Gross, 1978). Specifically, he prognuns offered clinical neuropsychology courses j contcnded that such an approach is aimed to "elimi- including h€turcs, praclicums, and work placc-l nalc compedtion, rather than incompetence." Sec- ments. lntcrcstingly, howcvcr, fcwer schools wercl ond, such restrictions tend to increasc the cost of involved in neuropsychological rcs€arch. Further-i services and limit the services to disadvantaged morc, most schools offered rraining by one or two j groups. According to Doney (1983), resrrictions suff mcmbers and rclarively few had specific neuro- i tend to decreasc the "lowcr-quality and price" ser- psychology vice that low-income individuals would tracks. I be able to

! " HISTORICAL PERSPECTIVES

use. The possibiliry exisrs, furrhermore, rhat indi- | may be applied to ensue continued and appropriate viduals unable to bc credenrialcd by formal pro- l growth of our discipline (based on Hogan, l9-S3b). would bc relegard rc less prtsdgious yd*jr ioUs. I Fint, clinical neuropsychology pracrice should be Another issue is thar having ro be iccepted at I narrowly defined. For example, how is clinical the highest level, -tailed an individual, due to interest ori ncuropsychology differcnt from clinical psychology, would srill pracdce yility: out of rhe mainsneaml behavioral neurology, or spcech rherapyi Second, of clinical neuropsychology wirhour adequare dLec- i standards used in defining qualified ctinical neu(> lion, informarion, or technique (which wbuld be es- | paychologist must be based on empirical assessmenr, pecially critical in clinical neuropsychology duc ro is I comp€tence, and related to acrual (versus hypo.. inherent complexity and novelry). Furtherrnore, this i thetical) performance. Shimberg (l9gl) provided tnend ryould probably occur more frequently j wirh specific suggestions as to how these conccrns may popularions. lndeed, recenr sadstici puUi 3rlo1y apply to psychology, in general, with regard to con- lished by APA (Howard et al.. t986) indicate'tharl tcnt, criterion, and construct validity of tests for psy- although women arc bccoming increasingly reprc- chological certification. Third, altemative pathl scnted, other minorities, including io Utaifs anA ccrtificarion should bc kepr open (see also Meier, Hispanics, arle nor. Analysis of narnJlists available I 987, for. spccifrc suggestions bn from both ABPP/ABCN conrinuing educa- and ABpN appears ro con- ntir mighr includc firm this. |on). inrcmships, posfuoctoral fcllowships, supervision, pccr and cltnt rcview, An altcrnative to such efforts is the more rwcnr workshops, and at horne/office study. Founh, reg- pecr review system, fint enactcd by Congress in ulatory policies should be based on thi rcprcsentadon 1972 to moniror federally aidcd healrhiarc pfogras,, of appropriaE constituencies. This would involve y9h as Medicare (Young, l9E2). Such anipp-roach clinical neuropsychologisrs wirh different ap, is bascd on the assumprion ttrat if professional work is proaches (even geographical locarions) as well as-= not acceptable, professionals would learn fmm their government and possibly health carc/insurance agcn- pccrs through defined interactivc mcthods. Never- cy officials. Most of all, our clients or their rcorescn- theless, if testing is to be continued as a me:ns ro tatives should also be incl uded. Ncxt, our go jshould dcfine clinical neuropsychology or neuropaychol- not be !o resrict the righr of a competeni person to ogrsts, a more accurate analysis of an individual's pracdce clinical neuropsychology, but to rcstrict the capabilities would be to have a ccnificarion Droccss utle clinical neuropsychologisr. Finally, the con- which is based on empirically validared siruations. sunrers of our product should be educated. psychol- As Milon Fricdman so aptly indicarcd in 1962, ogists, ncurologists, anorneys, allied disciplines, "conforming to 'prcvailing orrhodoxy,' is cenain ro agencies (to name but a few) who amount refer ro itinica Tdr::.rtq of expcrirnenradon rhar gocs in [a ncuropsychologiss disciplineJ should be educatcd. and hcnce ro reducc rhe rares of irowrh of ; !o Olson (1983), the unempirical ex- knowledgc" (p. 157). The currenr renA cfinicJ . .According ii i cfryign of the compercnr as a legal prorccrion of spe- neuro.psychology appears o be toward grearer so- i cral ultimarcly has negative phisrication, efficacy, .rnterEst effects on the rccognition, and ceirilicarion. i osclplrne and sophistication, on sociery. Mahoney (1995) argued efficacy, and recognition are necded i for the importance of '.open and ongoing e*in-g"' ' Ior thc devetopmcnr of a healrtry subspecialiry_in psy- i as part of rhe epistemological proceiscs chology. Howcver, more ..precir"" anA rhar it is i gTcssary for scientific progress may be, as Fricdman (1962)-argued, "enifi"arron in psychology. As incomparible i (1970) with experimcnhdon. f-akatol suggesred, iupened:ing rtre iiesenr Such exfrimcntation, after i Dy exptorauon and novelty (rather than assuring ad- ** rhe catalysr for our prescnr growth and *, sr"t*. i herence to curent orthodoxy) is critical to r.rnc way to assurc such continued rhe devel- growth and shrus , opm:nl of is to facilitate any sciendfic discipline. Clinicat ncuro- a system, in whatcier way possiblc, , psychology has too much to offer; tnal meels the needs the need for our of rhe public insrcad of prorect- scrvices, expcrtise, ing thep.ublic (Hogan, and knowledge is too critica.l to l9g3a). This is espcci,iffy,rul focus on limitations. tn a field such as clinical neuropsychology where rhe If such theoretical arguments field ofpracrice do not provide and appropriari siunaarjs i ofpracrice cnough support for the continued development of arc. bcing devcloped. Divenity l and expcrirnenarion clinical. ncuropsychology, rhe work of McCaffrey wtu approp_riarc cmpirical analysis and validation of I and collcagucs (McCaffrey, 1985; McCaffrcv & Is_ whu is profcssional or acc€praLlc io clinical . ncu(> aac, 1984) provides additional rcasons ro beiareful psychology must be encouragcd. I about our recent trend for exclusiviry. In a survey of lf ccnification is m be uscd, scvcral merhods I intcmship insrrucrors of clinical neuropsycholbgy ,i CHAPTER T

(with low rcsponse rate), instructors fared surprising-l must become more reliable and less biased. Crcative ly well on how they compared to lNS/Division 4Ol imagination must have ia place next to meth- guidelines. Howevcr, in a scparate survey (with bet-1 odological rigor. tcr respons€ rate ), McCaffrey and lsaac ( 1984) found 3. Meier (1987) recognizcd the importance of that few instructors at the pre- or postdoctoral levels education in the general mission of our discipline. met the educational rcquirements of the INS/Divi- Great care must be taken to rccruit and train new sion 40 guidelines. Possibly many of thosc curcntlyi ncuropsychologists. Of spccial significance herc is providing training would themselves be excluded. the alarmingly low number of minorities (including women, blacks, and Hispanics) entering the discipline. Additionally, Meier (1987) also aptly consid' I cred continuing education as critical to the continued practicing the This Future of Clinical Neuropsychology I development of thosc in field. as larger segments I becomes especially imporrant of As Fishman and Neigher ( 1982) aptly noted, the i individuals in clinical, counseling, school, and phys- 1980s (and presumably thc 1990s) have bccn and will i iological psychology become interestcd in clinical bc an age of incrcasing accountabiliry. We havcl reuropsychology. taken psychology to the public, to the referrali 4. With rcgard to social policy consultation, sources, to thc governrncnt with an overwhplmingl clinical neuropsychologists must leave their clinics, degree of success. Indecd by the carly 1980s, we1 hospitals, and laboratories to go to their capitols, werc spending over 52 billion pcr year in the support j both in the Unitcd States and abroad. One critical test of psychological endeavon (Fishman & Ncigher, j of clinical ncuropsychology will undoubtedly be 1982). The public now wants to account for the 52i federal legislation recognizing our discipline (see billion. One way clinical ncuropsychology has pro-l Dekon, VandenBos, & Kraut, t984). The public, vidcd accounhbility has bcen to provide the hcalth whether it bc lay and uninformed or professional and 1 marketplace with a plethora of asscssment and re- i in health care sctlings, must bc educated to the unique habiliradon tcchniques. The assumption has bccn contribution of clinical neuropsychology. Clinical

that nonrcsearch or service activities have been built I neuropsychologists have typica.lly becn sheltercd on a solid foundation of "scientifically derived l fmm outsidc-institution political issues. Although knowledge. " As dtnristic and as intercsting as thcse r establishing political ties within institutional settings techniques rnay bc, they must t-lrst be subject to the is clearly an important lirst step, national (and possi- same rigorous scientific tests that otherpsychological bly international) political advocacy is needed. An

and hcalth practices (e.g., psychotherapy) have r excellent example of this was the Horne vcrsus Goodson case in North Carolina.,In this workmen's ln a rcvicw of Fishman and Neighcr's (1982) compcnsation case, the testimony of a clinical neuro- acdviry by mission Ealrix of psychology's goals, it ' psychologist (the author) was considercd by the ini- appears that clinical neuropsycbology has focused tial Industrial Commission judge and later by the full over thc necent years mostly on service delivery. Industrial Commission Board of the state as being However, much effort needs to bc placed on other incompetcnt and not credible because the injury in- aspects of thc activiry by mission malrix of these "volvcd physical "brain darnage." Despite rcpeatcd authors. These would include, in no specific order, testimony and repons describing the role of clinical basic and applied rcsearch, social policy consulta- neuropsychology as defining behavioral (and not an- tion, cducation of the gencral (and hcalth carc) pub-' atomical) dysfunction, the pleas went unneeded. lic, training ofnew clinical neuropsychologists, con- With the assistance of both the Nonh Carolina Psy- tinuing education of both general clinical and clinical chological Association and the American Psycholog- 'ncuropsychologists, and political advocacy for thc ical Association, a comprehensive amicus brief was discipline. submined on behalf of the claimant when the case To illustratc cach of lhesc areas, examples arc was appealed to the North Carolina Courtof Appeals. prcscnted. While ttre decision (North Carolina Court of Ap l. ln tcrms of research, spccifrc efforts must be peals, 1986) and amicus (American Psychological placed on replicating existing studics (including Association, 1986) are available elscwhere, the deci- thosc historically cited). Furthermore, studies that sion was ovemrled. ln the dissenting opinion, Judge yicld negative rcsults must be considercd, especially Pbillips stated that it was erroneous to:lssume "that thosc focusing on rehabilitation. only docton of medicine can make more reliable 2. ln publishing, rcvicw and editorial pr$ess deductions as to conditions in the bnin." According HISTORICAL PERSPECTIVES

to Judge Phillips' "psychology is the srudy oj Doacv. s. human mind and 4" I 09E3). oscup,ariorur liccnsing ao

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