Neuropsychosocial Intervention: The Practical Treatment of Severe Behavioral Dyscontrol after Acquired Brain Injury. R. L. Karol, Boca Raton, FL: CRC Press, 2003. 199 pages.

Freud first put forth the theorem that all behavior is overdetermined. Behavioral manifestations following brain injury are often best understood as having a complex etiology involving pre-existing or premorbid variables as well as injury-related, neurologic variables. Additionally, the setting or environment in which the person with brain injury is attempting to meet social demands is also important in understanding the presence or absence of behavioral challenges.

In his book, Neuropsychosocial Intervention: The Practical Treatment of Severe Behavioral Dyscontrol after Acquired Brain Injury, Karol advocates for an eclectic and practical approach that takes into account multiple variables in arriving at an effective treatment plan. The goal is to create an accommodative therapeutic milieu for patients that will enable them to actualize their needs, thus resulting in decreased frustration and improved behavioral functioning. The author draws upon nearly 2 decades of clinical experience in describing common pitfalls in his work with patients with brain injuries and their families and provides instruction in practical strategies of intervention.

The book is organized with a theoretical introduction and discussion of the relative contributions of cognitive assessment, and psychological and phenomenological understanding of the patient as they are applied to behavioral management. There is also a chapter by Sevenich discussing the integration of medication management in the neuropsychosocial approach. Numerous clinical vignettes are provided that are used to guide the reader in clinical problem-solving approaches for various behavioral challenges. It should be noted that the approaches presented mainly focus on inpatient and community placement (ie, group home) settings.

In terms of direct clinical practice, perhaps the most immediately useful chapter is the contribution by Daniels that provides concrete core behavior plans for 18 commonly encountered problem behaviors. This chapter covers not only various forms of disinhibited behavior but also includes suggestions for management of suicidality, delusional syndromes, social withdrawal, and anosognosia.

Karol contrasts his multidimensional model to what he considers to be traditional treatment models for behavioral dyscontrol after brain injury. In discussing the shortcomings of common psychotherapeutic approaches, he identifies the limitations of insight-oriented, directive, and skill-building approaches, strictly defined. He correctly points out how cognitive deficits following brain injury limit the effectiveness of common psychotherapeutic approaches. For example, well-intentioned psychoanalytically oriented approaches may foster regression in an already fragmented personality. Similarly, cognitive deficits in memory and abstract reasoning limit the effectiveness of reinforcement feedback for patients undergoing a behavioral approach. While all interventions have their limitations, it is the art of the clinician that enables them to select interventions that are appropriate to the patient's needs and that combine an understanding of environmental contingencies in determining a strategy to effect the target behavior. Karol's work serves to call attention to and formalize this clinical process.

Karol's work focuses on patients in settings where environmental contingencies can be most easily manipulated. Unfortunately, in many clinical settings, this is not the case. In many postacute traumatic brain injury (TBI) rehabilitation settings, patients often find themselves discharged to real-world environments with changing contingencies. These settings include academic-, work-, and family-oriented placements. In such settings, an extension of the neuropsychosocial approach can be achieved by providing training for caregivers in the use of these procedures. 1

Karol's book is replete with clinical observations, truisms, and novel approaches to assist the clinician in understanding a variety of factors that may be contributing to a particular behavioral target. The tone of the book is upbeat and optimistic in discussing the potential to effect therapeutic change in patients with severe behavioral dyscontrol; even after previous program failures. The book was designed to appeal to a wide audience including neuropsychologists, rehabilitation professionals, family members, and persons with brain injury. As such, the book will likely disappoint those readers interested in a more data-driven or scientific approach to behavior management. To this reviewer, the book would appear to be most beneficial to beginning or intermediate career rehabilitation professionals, to assist them in organizing and categorizing important variables in the treatment of patients with TBI. Of course, all clinicians can benefit from gaining insight into how their own behavior may serve as as a stimulus cue that elicits their patients' behavior. If this book is of assistance in increasing that awareness and in making clinicians consider multiple variables in the etiology of their patients' behavioral response following TBI, then it is certainly serving a useful function.

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