Co-Constructing a Workable Reality:The Use of Clinical Neuropsychology

Victor Nell, Ph.D., and Carla Boer, M.A.

As in the medical model, a neuropsychological assessment tradi-tionally follows an individually focused diagnosis-treatment se-quence, leaving treatment to the referral source or other agencies.This case study demonstrates that neuropsychology can operatewithin a systems-oriented constructivist frame, even with an aban-doned husband whose family refused to present for family-therapysessions, and who, as a medical practitioner with many years ofexperience, had an especially strong bias in favor of the medicalmodel. In the process a new and more workable reality is co-constructed.

TRADITIONAL NEUROPSYCHOLOGYAND SYSTEM-ORIENTED THERAPY

Person and "family" are two aspects of a continuous process ofmutually determining change. . . . Clinicians working with this modelengage in a "tacking" amidst the biological, the psychological, and thesocial patient, looking for ports of entry that allow them to be helpful.The logic in this view provides a persuasive rationale for health careprofessionals to direct their focus toward patients and contexts to-gether. In this technical sense, it can be said that the "family" or the"context" itself becomes the patient (15, p. 233).

The implicit assumptions underlying the practice of modern clinical neu-ropsychology are that an accurate diagnosis, which usually includes a set ofcausal attributions by which one or more brain lesions is shown to explaina wide range of apparently unrelated behaviors, points the way to appro-priate treatment. Such treatment is characteristically multimodal, includingelements drawn from rehabilitation medicine, psychopharmacology, the tra-

Victor Nell, Ph.D., is a senior lecturer in the Department of Psychology, University of South Africa,Pretoria, South Africa. Carla Boer, M.A., is acting head of and senior counselor in the Centre forIndividual, Family, and Marriage Guidance, University of South Africa, Pretoria, South Africa.

40 Family Systems Medicine, Vol. 6, No. 1,1988 FSM, Inc.

Co-Constructing a Workable Reality 41

ditional acute-care therapies (physiotherapy, occupational therapy, andspeech therapy), and the acquisition of coping strategies drawn from cog-nitive-behavior therapy. In essence, this is the diagnosis-treatment model ofclinical medicine, which is focused on delivering an improvement to thephysical well-being of the affected individual. This model draws its powerfrom its effectiveness in the relief of suffering. A good part of the voguecurrently enjoyed by clinical neuropsychology, and the explosive growth ofthis area of behavioral medicine (3, 13), derives from the use of this model,and the promise it seems to hold out to "cure," or at least to ameliorate,some of the distressing psychosocial symptoms of brain damage.

This individually focused model is not congruent with current family-therapy approaches that derive from general systems theory (4, 11). Theseapproaches hold that change cannot be brought about in one element of thefamily system without affecting all the others, and that the identified patientcan only be released from his role by disruption of the surrounding systemand its reorganization into a new pattern.

Clinical neuropsychology stands at the confluence of numerous biomedicaland behavioral disciplines. The case of Dr. L is presented because its unusualfeatures show with great vividness that by drawing on medical diagnostictechniques on the one hand, and systems-oriented constructionism on theother (1, 5), a powerful rehabilitative momentum can be achieved. Essentialto this was the construction, with the patient, of a new reality that was bothacceptable to him and fit the "facts" of the case.

CASE PRESENTATION AND HISTORY

In June 1985, a 50-year-old medical practitioner arrived in the PsychologyDepartment at the University of South Africa. He carried with him a reg-istration form that had been mailed to him at his request by the NationalRegister of Brain Injury and Support Services, which is administered by thisdepartment. Because of his slow and aprosodic speech, rather shuffling gait,and air of intense single-mindedness, his arrival created something of a stir.

Dr. L's initial consultation with the Psychology I course leader was abouthis work as a student; he then asked to speak with the person who coor-dinated the National Register, the first author of this paper. Despite thecovering letter routinely sent with all registration forms, which explains thatthe National Register of Brain Injury is a data-gathering exercise and canoffer no services, Dr. L made it clear he would like to give a history. Hepresented the following facts about himself, more or less in the given order:He had been attacked by a patient during his psychiatric residency, and wasfound by colleagues some hours after the incident, unconscious on the floorwith a left frontal wound. There were no witnesses. He was unconsciousfor seven days. He had been married for over 20 years; his eldest child hadleft home, and the household was currently made up of his wife, "a work-aholic," a daughter in high school, an ineducable retarded son of 12, and

42 Family Systems Medicine, Vol. 6, No. 1, Spring 1988

Dr. L's mother-in-law. He went on to say that there was a great deal ofstress at home because his wife had cut off contact with him, although beforethe accident they "used to talk tremendously." He concluded by saying thathis goal at that moment, as a brain-injured person, was to be useful to otherbrain-injured people. If this happened, he would feel that his accident hadnot been in vain.

He explained that this alternative goal was necessary because he no longerfelt able to work as a medical practitioner, though he had done so quitesuccessfully for a 30-month period beginning six months after the injury.He had, however, felt that his memory was too unreliable and had beenworried that he would make a mistake. Accordingly, he had retired as dis-abled, though he remained on the medical register and was, therefore, li-censed to practice. Despite this explicit appeal for help, the first author didno more than place the material on file, though he felt guilty at not doingmore for this devastated individual who seemed to have stepped out of thepages of Luria's The Man with a Shattered World (10):

Because of that head wound I'd become an abnormal personexceptthat I wasn't insane. . . . My mind was a complete muddle and con-fusion all the time, my brain seemed so limited and feeble. Before, Iused to operate so differently (p. 24).

Two weeks later, the second author, a counseling psychologist trained insystems-oriented family therapy, who wanted to gain clinical experience inthe diagnosis and treatment of brain damage, needed a case to work up atthe Edenvale Hospital Head Injury Outpatient Clinic. Not surprisingly, theseeds sown by Dr. L's presentation now thrust forth, and the first author,a neuropsychologist, telephoned Dr. L to ask if a complete neuropsycho-diagnostic evaluation might not be useful to him, emphasizing that therapymight not be offered, and that the examination would take place with stu-dents present. He agreed with alacrity, saying that he wanted to understandhimself better.

The unique features of this history and presentation can be outlined asfollows:

1) The client (a term, which, in the present context, has special weightbecause of the client's determined efforts to identify himself as a patient)is a medical practitioner whose expectations of a health-care interventionderive from the medical model with which he is most familiar.

2) The client's self-identification lays the greatest possible emphasis on thephysical origin of the condition and, therefore, its hopelessness, since itis a neurological truism that central-nervous-system tissue does not re-generate. The nature of this self-identification as a brain-damaged personbecomes clear if an analysis of the presentation is made. Dr. L began byhaving an academic consultation about his difficulties as a brain-damaged

Co-Constructing a Workable Reality 43

student. He then presented himself, with a document formally acknowl-edging his brain injury, at an agency that had already informed him itwas unable to offer any services. The patient's selection of informationfrom his history and his dramatic behavior become a carefully histrionicplea for "treatment" in the context of incurable brain damage, the attackon his person, the destruction of his professional career, and the im-pending dissolution of his home life.

3) The patient's presentation has an excellent fit with the medical modeland a very poor fit with the family-therapy model: He arrived unaccom-panied and, as noted below, all members of his family explicitly or tacitlysupported the view that he should be treated for his "disease" in isolation,because his condition had nothing to do with them.

We will argue that these paradoxes produced a fertile therapeutic climatethat illustrates some of the ways in which the diagnostic and therapeuticcomponents of clinical neuropsychology can draw on two effective modelsthat usually operate in isolation from one another. Specifically, though thedifficulties standing in the way of a family-therapy approach appeared in-superable, this abandoned husband was in fact treated as a member of afamily; secondly, the diagnosis-treatment-discharge circle was broken at anumber of points by scheduling unexpected "family-therapy" sessions be-tween the diagnostic procedure and the communication of the results, andby insisting that the patient participate in the formulation of the diagnosisby co-creating it.

In order to sharpen these conceptual issues, diagnosis and remediation aredealt with in the following exposition as if separate, though in reality theseactivities were concurrent.

DIAGNOSIS

Intake Interview

Those present at the intake interview were Dr. L, the authors of this paper,two first-year clinical psychologists doing their two-month rotation at thishead-injury clinic, and a visiting observer. During this interview, in con-formity with the diagnostic aspect of the medical model, the counselingpsychologist remained passive, taking notes, while the neuropsychologistconducted the interview. As in the first interview, Dr. L's responses to ques-tions were made at an extraordinarily slow pace and in a dull monotonethat had a soporific effect on all those present.

A question that produces a rich information yield during the intake in-terview of a brain-damaged person is the following: "In what ways do youthink you have changed as a result of your brain damage?" In reply, Dr. Lsaid: "I have had a complete personality change. Before the accident I wasa heavy drinker, and for many years I was a member of Alcoholics Anon-

44 Family Systems Medicine, Vol. 6, No. 1, Spring 1988

ymous. I was a very depressed person with frequent thoughts of suicide. Idid try to kill myself a number of times. Alcohol was my tranquilizer. NowI have no need to drink. I am not anxious, and I have no suicidal thoughts.I did a leucotomy on myself."*

During his years as an alcoholic, Dr. L continued, his wife had been anactive member of AA and an office-holder in Alanon. Now that he hadstopped drinking and was no longer suicidal, she had cut off contact fromhim. They no longer have intimate contact, she is continually depressed,suffers particularly from lower-back pain, and is readily upset by manythings that he says or does. He describes his living situation by saying, "I'vegot to be so careful."

Dr. L's main complaints centered on his dissatisfaction with his familysituation. He said that when things got too stressful at home, he would moveout and live with his mother, now in her 70s. He does not enjoy stayingthere and gets irritated, but says that "at this stage" he has no option. Hedescribed everybody in his own home except his teenage daughter as "nuts."He believes he is nuts because of his brain injury,** his wife because of herdepression and being a "workaholic," his son because of his retardation,and his mother-in-law because of her inconsistency. A second set of com-plaints focused on the absence of life goals. He did not feel competent topractice as a medical practitioner, and said that his life had no purpose.

Testing Sessions

Immediately after the completion of the intake interview, the counselingpsychologist took over the case and commenced testing, which, includingthe discursive interpolations described below, occupied a total of four anda half hours spread over the remainder of the intake session and one ad-ditional testing session.

Behavior during testing. Effort and concentration during testing wereexcellent. Dr. L enjoyed the interaction during testing, thrived on praise, andgave the examiner plentiful feedback about what he was doing and expe-riencing during the testing. He enjoyed "being understood," and often saidhe was looking forward to getting the results so he could understand hisbrain injury better.

Test performance. Dr. L brought with him a report from a clinical psy-*Claims of an improvement in personality as a result of brain injury are not uncommon. Sometimes

these arise because of a lowered arousal level with a consequent diminution of dyscontrol and aggression;sometimes because inhibitions are lifted and a shy introvert finds it easier to approach people and initiateconversations; sometimes, as in the present case, because depression is relieved, and the patient enters(as with Dr. L) an anxiety-free ego-syntonic state. An elevation of mood is often associated with injuriesto the retrolandic nondominant hemisphere, which, given the left frontal impact Dr. L sustained, is aplausible location for a contracoup injury.

**An item of evidence Dr. L drew on to confirm his "craziness" was a vivid recollection of talkingsensibly to people at his bedside when he was emerging from coma, only to be told later that he hadbeen speaking "rubbish," i.e., jargon. This rare insight into the subjective experience of jargon aphasiais in itself of interest.

Co-Constructing a Workable Reality 45

TABLE 1Results of 1984 and 1985 Assessments of Dr. L

Subtest

InformationComprehensionArithmeticDigits combinedSimilaritiesPicture completionObject assemblyBlock designDigit symbolPicture arrangement

Verbal IQ:Performance IQ:Full Scale IQ:

13389

112

Standard scores

1984 1985

13189 11

1017 16'/2

7Vi89 9Vi7Vz 7

12

chologist who had assessed him nine months earlier. His standard scores onthe SA Wechsler Adult Intelligence Scale at this 1984 assessment, togetherwith the scores on the four subtests repeated during the current assessment,are reported in Table 1.

The test instrument used in the current assessment, the Nell Neuropsy-chological Screening Procedure (12), which incorporates four Wechsler sub-tests, is a 22-item battery that assesses 12 discrete functional domains suchas arousal and orientation, motor and sensory function, visuomotor per-formance, cognitive flexibility, language production and comprehension, andcomplex processes such as humor and metaphorical language. Significantfindings were as follows:

Cognitive flexibility was notably impaired. On the Goldstein-Weigl-Scheerer Color-Form Sorting Test (6), Dr. L took 190 seconds to sort thecounters in a different way after his initial sort by shape. Although heverbalized "color" to himself, he was repeatedly drawn back to the shapesof his previous sorting principle. This difficulty in breaking away from anexisting cognitive set was confirmed by the strong echopraxis.

The most significant language deficit was impoverished controlled asso-ciate generation, with only three, five, and four words to the letters c, /, and/. This is a performance preeminently associated with left-sided prefrontallesions.

Verbal memory and learning: Immediate recall on two 22-item paragraphswas 13 and 12, about two standard deviations above the population mean(8), but seven for each of the two paragraphs after a 30-minute delay oc-cupied by other testing. Since delayed-recall scores in control subjects havebeen shown to run only one or two points below immediate recall scores(8), this loss of five to six items is diagnostic of poor encoding and retrieval.

46 Family Systems Medicine, Vol. 6, No. 1, Spring 1988

This finding was confirmed by the "frontal plateau" phenomenon (16) onthe verbal learning task, in which 10 words are to be acquired under con-ditions of homogenous interference and selective reminding. On this pro-cedure Dr. L scored five, six, three, and five on each of four trials, and threeafter a 30-minute delay.

Visual memory was markedly better. On the 7/24 pattern memory test(8), all seven counters were placed correctly on the second trial, with perfectrecall at 30 minutes. Similarly, four of the five geometric designs were spon-taneously recalled.

Formulation

The picture that emerges is one of a somewhat ponderous individual withexcellently preserved intellectual abilities that are compromised by two def-icits that are consistent with a left frontotemporal injury: reduced cognitiveflexibility, which gives rise to a somewhat viscous cognitive style; and re-duced verbal fluency and verbal memory, with impaired learning of newmaterial. These changes are sufficient to justify a diagnosis of traumaticbrain injury with marked sequelae in thinking and behavior. Within neu-ropsychology's traditional frame, if remediation were offered, it would verylikely be within the cognitive-behavior therapy modality that is the theo-retical base for many current cognitive rehabilitation programs. Our ap-proach, described below, focused on a personal redefinition rather thancognitive retraining.

REMEDIATION

The Informing InterviewThe catastrophic erosion of self-esteem that accompanies intellectual and

adaptive changes after a brain injury seems to derive less from the deficitsthemselves than from the perplexity (9) that surrounds these changes. Likethe owner of a clock that has suddenly struck 13, the perplexed survivormistrusts even correct responses and decisions (8). In this context, sharinginformation has the unique power to at least partly resolve the perplexityby drawing a map of the affected individual's strengths and weaknesses inways that augment the victim's resources and self-esteem on the one hand,and his or her grasp of reality on the other (12).

A session dedicated to a review of the client's test performance, and theappraisal of these performances for the light they throw on future planning,is not a standard part of neuropsychodiagnostic procedure. In many settings,client contact ceases at the termination of testing, and the findings are com-municated to the referral source in written form. Once incorporated in theclient's file, these findings may either be used by a variety of disciplines orlie dormant. In either case, failure to communicate the findings directly to

Co-Constructing a Workable Reality 47

the client means that the potential benefits of several hours of intensiveskilled observation are lost, or, at best, dissipated in their passage througha variety of filters before they reach the patient. Moreover, a unique aspectof the neuropsychologist's professional skill is the grasp he or she has ofcognitive psychology in relation to its neuroanatomical substrates, so thatboth the origins and the implications of performance deficits for thinkingand adaptive problem-solving can be vividly and clearly conveyed.

Structured information-giving was singularly successful in resolving someof Dr. L's difficulties.

Cocreating the Informing InterviewTraditionally, the work load at the informing interview is skewed, with

the neuropsychologist much more active than the client and family. WithDr. L, who certainly expected this traditional "treatment" model to befollowed, a format based on the principle of system-oriented family therapywas followed. This required that the selection of content areas for discussion,and the sequence in which these were to be dealt with, were determined notby the diagnostician alone, but by the client and the therapist jointly. Thisprocedure may be termed the cocreation of the informing interview. It is nomore time-consuming than the standard informing interview, yet creates thecontext in which the ecological force of the findings, which are linked atevery point to the client's inner world, is greatly increased. This is becausethe client's perception of his or her own performance can more easily belinked backward to interview data and aspects of the history, and forwardto vocational and family-life goals.

A conceptual framework for this process is provided by constructionism,which explains: "the processes by which people come to describe, explain,or otherwise account for the world (including themselves) in which theylive. . . . Descriptions and explanations of the world themselves constituteforms of social action" (5, pp. 266268).

Emotions are thus also construed as socially determined "patterns of ritualaction" rather than natural passive states (1). These formulations accordwith Keeney's (7) suggestion that living process and mental process areidentical.

The informing interview began with the following question to Dr. L: "Ifyou cast your mind back to the test sessions, what do you think you didwell on?" Later in the interview, the question was turned around and theclient was asked to specify the procedures on which he thought he had donebadly. By way of illustration, one aspect of this information-giving is de-scribed: In a session soon after the completion of testing, Dr. L shared withthe counselor his feelings of loneliness, inadequacy, being misunderstood,and being called names that drew attention to his brain injury. Thoughresenting these barbs, he had studied his own brain scan, and was himselfconvinced that he was little more than a "vegetable" because of what he

48 Family Systems Medicine, Vol. 6, No. 1, Spring 1988

described as gross prefrontal damage and severe contracoup injuries in theright parietal lobe.

The neuropsychologist took this cue to say: "Your scan shows that thefrontal damage is confined to the left hemisphere. The gross personality andbehavior changes you attribute to yourself require extensive bilateral dam-age." The neuropsychologist then described the case of a young medicalpractitioner whom the neuropsychologist had seen some years previously,emphasizing this unfortunate person's fatuous jokiness and gross social dis-inhibition.

"It is very striking that you display none of these gross disorders. In fact,both of us have been impressed by your social skill and your considerationto others. Your motivation is excellent, and you have shown that you canstay with a task over long periods. These achievements are not consistentwith the kind of injury you attribute to yourself." Dr. L was extraordinarilyattentive during this part of the session.

By the end of the informing interview, Dr. L was able to construct ametaphor of his inner ecology. He said he had built a wooden fortress aroundhimself for defense, and within this stockade he had behaved in ways ap-propriate for a brain-damaged person, because all those outside the stockadeexpected this of him. The thought that this fortress might be breached if heno longer had to think about himself as "brain-damaged" was frightening,because he saw he now had a choice about whether to see himself as brain-damaged or not. He was also afraid that his wife would not share theexcitement of his new perception, and that she might find it unacceptable.Accordingly, the counselor accepted Dr. L's suggestion that until such timethat Mrs. L presented for a family-therapy session, Dr. L would keep onbehaving as if he was brain-injured, so he could continue to wear the "brain-injured" label he and the family had hung around his neck. In response toqueries about what had taken place at the interview, it was agreed that hewould say, "Things don't look as bad as I thought."

A striking aspect of the informing interview was the change that had takenplace in Dr. L in the weeks since the intake interview. His speech rate hadincreased, his inflection was more vivid, his facial expression was more lively,his walking brisker, and his spontaneous movement when sitting was freer.

Failed Family Therapies

In the weeks before and after the informing interview, 11 failed family-therapy sessions were conducted. They were failed in the sense that despiteelaborate arrangements, Mrs. L failed to show up. By using the Milan group'scircular questioning technique (14), it was possible to "include" the wholefamily in the interviews, thereby creating new complexities and realities forDr. L.

Co-Constructing a Workable Reality 49

Outcome

Reports from the three women in Dr. L's lifehis mother, his wife, andhis mother-in-lawindicated a good deal of movement away from previous"illness behaviors."

Though no further attempts were made to involve Mrs. L after the fourthsession, she later initiated contact with the counselor because she was dis-turbed by the changes in her husband. She said he had become more ag-gressive, did not accept everything as he had before, and "was a differentperson." She agreed to phone after the summer recess for an appointment,but never did so.

Dr. L's mother reported that he had lived in his own home for fourmonths, the longest continuous period since his accident. She said he hadbecome more assertive and confident, his memory seemed to have improved,his speech was livelier, and there was less tension in his home because heseemed to be relating to his wife in a more relaxed way. Even the behaviorof the retarded son was seen as improved.

Dr. L's mother-in-law, a vigorous lady who was the family's housekeeper,complained that he had become more aggressive and did not do things theway she wanted them done. She made it clear that she would continue totreat him as brain-damaged. The counselor reframed this opposition bysuggesting that he and his mother-in-law were good for one another becauseboth were strong people, and by opposing one another, each made the otherstronger.

Dr. L adopted the view that he had sustained brain damage but could stillfunction adequately in many areas. Accordingly, he enrolled in a universitycorrespondence course in psychology, and decided to return to medical prac-tice, though he refused to prescribe medication. His aim as a practitionerwas "to help other people with brain injury." He also said he was determinedto get divorced unless relations with his wife improved by the end of thecurrent year, at that time nine months off.

SUMMARY

This single case study indicates that an isolated individual can be treatedwithin a family context, and that significant behavioral change can beachieved by following a family-therapy model under circumstances that ap-pear to be inauspicious. It also demonstrates that the informing interviewcan be recast within a systems framework to create an ecologically morerelevant context. There are also indications that a settled pattern of illnessbehavior, with gross maladaptive histrionic overlays, can be substantiallymodified by a combination of neuropsychological diagnosis and systems-orientated remediation. These gains are the more striking in the present case,in which the expectations for a traditional diagnosis-treatment approachwere particularly strong.

50 Family Systems Medicine, Vol. 6, No. 1, Spring 1988

In August 1987, in the time between first submission of this paper andits revision, Dr. L died a few days after he had been burned in a fire at hishome. Until the end of 1986, he had attended monthly therapy sessions;between December and May 1987, he and his wife attended four jointsessions, saying at the last session that there had "never before been suchlove and understanding between them." Then they drifted apart again, sheplanning a holiday on her own and he going back onto tranquilizers.

In 1972, Bateson wrote: "Let me then conclude with a warning that wesocial scientists would do well to hold back our eagerness to control thatworld which we so imperfectly understand. The fact of our imperfect un-derstanding should not be allowed to feed our anxiety and so increase ourneed to control. Rather, our studies could be inspired by a more ancient,but today less honoured motive: a curiosity about the world of which weare part. The rewards of such work are not power but beauty" (2, pp.239-240).

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1. Armon-Jones, C. Prescription, explication, and the social construction of emotion. Jour-nal for the Theory of Social Behaviour, 1985, 15, 122.

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Journal of Clinical and Experimental Neuropsychology, 1985, 7.4. Dell, P. F. Understanding Bateson and Maturana: Toward a biological foundation for

the social sciences. Journal of Marital and Family Therapy, 1985, 11, 1-20.5. Gergen, K. J. The social constructionist movement in modern psychology. American

Psychologist, 1985, 40, 266-275.6. Goldstein, K. H., & Scheerer, M. Abstract and concrete behavior: An experimental study

with special tests. Psychological Monographs, 1941, 53, (2), Whole No. 239.7. Keeney, B. P. Aesthetics of change. New York: Guilford, 1983.8. Lezak, M. D. Neuropsychological assessment, 2d ed. New York: Oxford, 1983.9. Lezak, M. D. Subtle sequelae of brain damage: Perplexity, distractibility, and fatigue.

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partment, Whole No. 12. Pretoria: University of South Africa 1985.13. Nell, V. Proposals for the training and credentialing of clinical neuropsychologists in

South Africa. In K. W. Grieve & R. D. Griesel (Eds.), Neuropsychology II: Proceedingsof the second South African Neuropsychology Conference. Pretoria: University of SouthAfrica, 1985.

14. Penn, P. Circular questioning. Family Process, 1982, 21, 267-280.15. Ransom, D. C. Random notes: The patient is not a dirty window. Family Systems

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Edinburgh: Churchill Livingstone, 1985.

Requests for reprints should be sent to Victor Nell, Ph.D., Department of Psychology, University ofSouth Africa, Box 392, 0001 Pretoria, South Africa.