Challenging dogma in neuropsychology and related disciplines

Archives of Clinical Neuropsychology 18 (2003) 811–825 Challenging dogma in neuropsychology and related disciplines夽 George P. Prigatano∗ Division of Neurology, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 West Thomas Rd., Phoenix, AZ 85013, USA Accepted 19 July 2002 Abstract Challenging “dogmas” in neuropsychology and related fields is important for the advancement of our professional development. Five dogmas that I have found worth challenging are reviewed in this article. © 2002 National Academy of Neuropsychology. Published by Elsevier Ltd. All rights reserved. Keywords: Neuropsychology; Psychotherapy; Self-awareness; Rehabilitation; Dogma 1. Introduction In the course of our clinical work, we frequently encounter phenomena that have not been adequately addressed by our teachers or by professional journals. Sometimes these phenomena are considered unimportant to science and to the practice of neuropsychology. In my experience, however, it is sometimes worthwhile to challenge dogmas in neuropsychology and related disciplines. Doing so produces predictable conflict and mental tension but often improves our understanding of a given phenomenon and is associated with the pleasure of reducing tension over a misunderstanding. This article focuses on five dogmas or beliefs commonly held in neuropsychology that I believe are worth challenging. 夽 The initial portion of this paper was presented at the National Academy of Neuropsychology Convention meeting on November 2, 2001, in San Francisco on the occasion of receiving the Distinguished Neuropsychologist Award. Due to fire alarm interruptions, the entire paper was not presented. ∗ Tel.: +1-602-406-3671; fax: +1-602-406-6115. E-mail address: (G.P. Prigatano). 0887-6177/$ – see front matter © 2002 National Academy of Neuropsychology. PII: S 0 8 8 7 - 6 1 7 7 ( 0 2 ) 0 0 2 0 5 - 6 812 G.P. Prigatano / Archives of Clinical Neuropsychology 18 (2003) 811–825 2. Dogma Dogma can be defined as a belief that is proposed by authority figures to be “true” even though no or marginal data support the belief. The term dogma has often been applied to religious beliefs, but dogmas also exist in science. In fact, the history of science reveals the necessity of questioning the unquestionable beliefs of the time if substantial advances are to be made. In his well-known book, The Structure of Scientific Revolutions, Kuhn (1970) named this process “paradigm shifts.” Paradigm shifts allow new and more useful ways of conceptualizing a problem after cherished beliefs in science are challenged. Challenging dogma or cherished beliefs often comes with a price for the individual who does the challenging. Historically, for example, challenging the religious dogmas of the Catholic Church could result in anything from excommunication to being burned at the stake. From a psychological perspective, excommunication is an interesting phenomenon. It means that one is no longer welcomed as a member of a group and that is the price typically paid for disobedience. The disobedience is not following the cherished beliefs of the group. Such disobedience is a part of the process of individualization, and everyone must experience it if they are to grow psychologically. The critical question becomes what beliefs are worth challenging and which are not? The answer is an individual matter. From my perspective, beliefs that appear to impede our clinical work with patients and that restrict our thinking about the nature of the phenomena that we encounter in neuropsychology are the ones most worth challenging. I find five dogmas worth challenging: 1. Randomized controlled studies provide the most convincing evidence of the effectiveness of an intervention (e.g., neuropsychological rehabilitation). 2. The material that emerges during the psychotherapy of brain dysfunctional patients is of no interest to the field of neuropsychology (i.e., the scientific study of brain-behavior relationships). 3. Because of their subjective nature, disorders of self-awareness cannot be studied scientifically. 4. The study of lateralization of higher cerebral functions is most important for advancing the science of neuropsychology. 5. Psychotherapy is often ineffective with persons who have brain damage because their behavioral sequelae are caused by underlying disturbances in neuronal circuits. 2.1. Dogma 1 In 1998, the National Institutes of Health sponsored a conference on the rehabilitation of traumatic brain injury (TBI). During that conference, a neurosurgeon presented a paper on the efficacy of cognitive rehabilitation using an evidence-based practice model to select papers for review. It was a classic example of how research design and statistical methodology guide which articles are chosen for review and what conclusions can be drawn. The review told us little about the efficacy of cognitive rehabilitation because it focused on methodology rather G.P. Prigatano / Archives of Clinical Neuropsychology 18 (2003) 811–825 813 than on the phenomena under investigation. This type of reporting is common in professional journals and does not aid clinical practice. This point is highlighted further by considering a recent example of the dogma that randomized controlled studies provide the most convincing evidence regarding the efficacy of an intervention. In the Journal of the American Medical Association, Salazar et al. (2000) reported that a cognitive rehabilitation program modeled after a neuropsychological rehabilitation program described by Prigatano et al. (1986) did not notably improve outcomes compared to a limited home-base rehabilitation program. They used a prospective, randomized control design. Based on the so-called evidence-based practice model, this type of design produces “Class 1” data. The findings are misleading. Why? First, the program of neuropsychological rehabilitation that they referred to was designed for postacute brain dysfunctional patients, not for acute patients (Prigatano, 1999a). However, Salazar et al. (2000) applied the program to patients within the first 30 days of their brain injury, ignoring recommendations to the contrary. Second, Prigatano et al. (1986) repeatedly emphasized that the working alliance between the patient and treatment team has predictive value for who will benefit from such neuropsychological rehabilitation (Prigatano et al., 1994). This finding has been cross-validated and expanded (Klonoff, Lamb, & Henderson, 2000). Salazar et al. (2000) neither mentioned nor studied this important variable. Third, Salazar et al. (2000) reported that the rates of patients returning to work after participating in the hospital and home programs were 90 and 94%, respectively. Yet they state that their patients had moderate-to-severe TBIs. World statistics indicate that only about a third of patients with severe TBIs are able to return to work 2–3 years after brain injury. Given these established statistics, (...truncated)