Neuropsychological Interventions: Clinical Research and Practice. P. J. Eslinger, ed. New York: The Guilford Press, 2002. 360 pages.

I had the good fortune to learn about and practice brain injury rehabilitation during the early 1980s under the mentorship of Dr. George Prigatano. Based upon Ben-Yishay's pioneering work, Prigatano's intensive, milieu-based program in Oklahoma City addressed cognitive, physical, emotional, and social domains to ameliorate the consequences of severe acquired brain injury. In those days, there were no established clinical or critical pathways, so interventions were logically derived based on bodies of knowledge from other fields and a considerable amount of common sense. Some of these interventions were restorative in nature, whereas some emphasized the development of compensations. Both specific impairments and more functional disabilities were targeted; issues of patient awareness, premorbid personality functioning, current emotional functioning, and family dynamics were in the forefront of many clinical activities. We understood the developmental nature of these efforts and made attempts to assess success and failure.

Over the years my professional work has evolved into new areas and brain injury rehabilitation now composes a relatively small part of what I do. Thus it was a pleasure to review Neuropsychological Interventions and obtain a fresh update on the current state of the art. Of necessity, neuropsychological rehabilitation has remained substantially a scientifically and logically driven art. This edited volume includes chapters authored by a diverse group of clinicians and researchers, refreshingly not all from the United States. The general purpose of the text is to summarize contemporary concepts and methods to help guide the further development of effective rehabilitation practices for cognitive and social deficits following brain injury. In doing this, overriding central themes and issues related to specific types of impairment are discussed.

There are initial chapters that connect current thinking about brain plasticity to the rehabilitation enterprise; these sections review the unique nature of assessment for rehabilitation planning, briefly summarize issues related to pharmacological interventions, and detail research design methods for outcome assessment. Additional chapters outline theoretical issues, some current practices, and related outcomes for the rehabilitation of impairments of attention, learning and memory, visual-perceptual processes, language, praxis, executive skills, social impairments, and emotional functioning. Tying the text together are introductory and concluding chapters by the editor.

This text gratifyingly does not attempt to be a "how to" book of neuropsychological rehabilitation. Although some of the chapters describe in a summary fashion the nature of specific interventions, theoretical issues tend to be emphasized. As such, although a few of the chapters include reasonably comprehensive outcome literature reviews, this too is not a central purpose of the text. Neuropsychological Interventions very reasonably underlines the evolutionary nature of our attempts to override the major problems after severe brain injury. There is no apology for this, nor should there be. Although not knowing exactly what to do, by book's end the reader will appreciate the current state of the "art" and have a new foundation for the development of future brain injury rehabilitation strategies.

Throughout the text important concepts seem to repetitively emerge across the various chapters. Several chapters discuss the interplay between assessment and treatment and the related issue of measuring treatment effectiveness. Most of the authors stress the importance of intervening at levels of disability and handicap-as well as impairment. These ideas are connected directly to the now compelling evidence that impairment-related gains derived in the clinic generalize infrequently to functional behaviors in the patient's daily life. Rehabilitation must frequently be directed at the level of disability, even though this often complicates the nature of the intervention and related outcome measurement. The inclusion of strong chapters on the remediation of executive, social, and emotional function further reinforces this appreciation.

As with all texts the chapters vary in their scope, style, and emphases. In general they are all quite readable, though some seem to struggle in linking outcome reviews with proposed models of intervention. Although some of the discussions of theory become a bit arduous, the use of obscure terms or jargon seems to be nicely minimized. The editor's introductory and closing chapters are particularly helpful in highlighting and recapitulating important points. Individuals with relatively less of a foundation in neuropsychological rehabilitation will still manage this material without considerable burden.

The organization of the text into impairment chapters is consistent with the psychometric heritage of neuropsychological assessment and intervention. Although providing a useful organizational scheme, this time-honored tradition represents a clear abstraction of the nature of higher cortical processes. It also is somewhat at variance with the text's emphasis on issues of generalization, intervening at the level of disability, and remediating complex social behavior. Some of the more intriguing recent brain injury outcome data are derived from comprehensive day-treatment programs that formally interweave specific cognitive rehabilitation strategies into more complex social behavior in the clinic and natural world. Further discussion of the relationships between the impairment rehabilitation chapters and these integrated programs would have further broadened the readers understanding of current practices.

There is an accelerating tension between the supply of health care resources and the ever-expanding demand for medical and rehabilitative care. A growing population and the proliferation of more and more innovative, yet costly, interventions (primarily medical in nature) have generated significant funding and reimbursement pressures. Some brain injury rehabilitation programs have had to close their doors and those remaining face increasing pressures to be efficient and document outcomes. That the societal costs of severe brain injury are disconnected from cost-effectiveness analyses of clinical interventions and general insurance reimbursement further compromises a rational review of brain-injury rehabilitation work. How these economic realities will interact with the evolution of future brain injury rehabilitation practices remains to be seen. Noting that there will be increasing demands for the development of demonstrated cost effective interventions, I would have enjoyed a discussion of how some of the authors anticipate their suggestions for future rehabilitation development would fit into this very large practical issue-although this was clearly never a goal of the text.

I found Neuropsychological Interventions to be a sound, well-organized, up-to-date review of current rehabilitation strategies for a broad range of impairments common to severe brain injury. It is appropriately conservative in its analyses, and clearly outlines major issues important for anyone engaged in the brain injury rehabilitation enterprise. It is a desirable text for those relatively naive to the current state of these practices or those who wish to broaden their knowledge about a wide range of neuropsychological rehabilitation issues. Those already immersed in comprehensive brain injury rehabilitation will benefit from the discussions of outcome assessment methodologies and the specific impairment content areas that they are less familiar with.

Finally, this text emphasizes to me that although much has changed, much has not. Twelve years after moving away from daily involvement in comprehensive brain injury rehabilitation practice, it is clear that although efficacy demonstrations have begun to accumulate, their number remains relatively small, that controversies continue, and there still are few established critical pathways. Although the practice of brain injury rehabilitation is still characterized as a scientifically and logically driven art, the appearance of texts such as this one serves an important role in synthesizing accumulating knowledge for the applied practitioner.