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| Robert Bilder, Ph.D., ABPP/CN |
The discipline of clinical neuropsychology is at a
cross-roads, confronting an array of options to redefine its parameters, and without
any option to turn back. The forces
propelling this shift have been brewing for decades. First, assessment of brain structure and
function for both clinical and research purposes continues to migrate to novel
technologies. Neuroimaging already has
displaced neuropsychology’s role in structural lesion localization, and now is
providing the lion’s share of new information about functional localization and
network mapping. Computerized
neuropsychological assessment continues to make steady inroads as evidenced by
the introduction of iPad systems for conventional testing, and the
proliferation of other products including computerized and Internet-based
assessment systems. Second, health care
reform is changing every facet of clinical service delivery in the United
States, and neuropsychology is among the services that may be most affected. Our professional societies, including notably
the Society for Clinical Neuropsychology (SCN; APA Division 40), have
inaugurated efforts to keep us up to date and help us navigate the shifting
sands of new systems that aim to manage health care costs, including accountable
care organizations. The Affordable Care
Act further mandated electronic medical records that are increasingly
facilitating the aggregation of medical test results and the evaluation of
health care expenses and allocation of services following evidence-based
models. Third, treatments are
increasingly being delivered by the lowest-cost providers, which are in some
cases electronic. It is hard to compete
with a computer if it can execute an assessment or administer a therapy, and
while currently available systems have their limitations, the day is coming
when humans will be more important in designing but probably not in
administering assessments and treatments.
What path should clinical neuropsychology follow to forge its own
future? Some answers include efforts,
already underway, to increase our shared evidence-bases and collaborate on a
grand scale (see Bilder, 2011). For other
answers we need to look further into the future.
I faced this challenge a few years ago when asked to speak
about the “Next Wave” in brain research, to a smart lay audience (see TEDx San
Diego talk here). I first thought the talk might cover
advances in genetics, genomics, and brain-related phenotyping, before realizing
that the allotted 12 minutes would be gone before I could finish defining the
word “phenotype.” I had just read Ray
Kurzweil’s book – “The Singularity is Near” – foretelling the implications of a
future in which nonbiological intelligence will supersede all biological
intelligence (if you are curious, Ray predicts this will happen in 2029, so
stay healthy to live forever in the post-singularity era). But what intrigued me the most was our
inevitable progress towards a point when we will know enough about how the
brain works to use it differently, and by design, enabling Personal Brain Management and entering the next stage of human
evolution (for more, see this). I started teaching courses in PBM at UCLA,
and then was lucky to be involved in our new Healthy Campus Initiative,
specifically to focus on how to enhance mind, brain, and spirit and promote
creative achievement among our students, staff, and faculty (see http://healthy.ucla.edu). As we have developed this initiative, I
increasingly have come to believe that there is enormous opportunity for our discipline
to pursue Positive Applied
Neuropsychology, and that this will be an important path for clinical
neuropsychology as we travel further into the 21st century. A recent volume defines positive
neuropsychology as a field that “… incorporates positive psychology principles
and aims to promote cognitive health through various means…” (Randolph, 2013). I believe an even broader definition may be
warranted, extending beyond cognitive health, to consider any method to
promote well-being that leverages knowledge about the brain.
How does Positive Applied Neuropsychology (PAN) differ from
the rest of positive psychology? A
strength and a weakness of positive psychology is that it does not
necessarily consider the brain mechanisms underlying beneficial effects of its
practices. The strength is that it is
not limited by current knowledge about the brain. It is absolutely reasonable to select
positive psychology treatments without knowing anything about the brain systems
that are involved. In contrast, a PAN intervention should be
informed by our understanding of the brain systems that mediate its effects, so
in theory PAN will lead to the design of treatments that would never have been
developed if we did not know about the relevant brain systems, and that may be
more specific and effective because we do know the relevant brain
mechanisms.
So what do we have today? Not much yet, reflecting the current relative
lack of detailed knowledge about the specific mechanisms of action in the brain
for any treatment of any disorder. Consider
for example, how little we know about the ultimate mechanisms of action of
antidepressant or antipsychotic drugs. But
this knowledge is burgeoning. Its rate
of growth is so fast, and interest is so strong, that there may well be many novel
practices available within the next decade.
Consider the growth of mindfulness meditation practices, a now classic
positive psychology intervention that has yielded substantial benefits to its
practitioners despite our ignorance of the brain systems that are involved in
its effects. But now we are learning how
mindfulness impacts both brain structure and function, and it is conceivable
that future tools will promote specific prescriptions for practices that either
more narrowly focus or diffusely broaden attention to achieve desired outcomes.
Perhaps such practices will be augmented by EEG neurofeedback using inexpensive
consumer-grade headsets, or transcranial direct current stimulators. It is now difficult to go on line (or even
turn on the TV) without seeing advertising for diverse “brain training”
systems. Cognitive exercise regimens that
focus on promoting neuroplastic changes within key brain systems may become as
routine as is training dedicated to muscle groups (and to this end, we have
opened at UCLA a new “brain gym” to help familiarize our university community
with the relevant tools). For us
“boomers” it appears this brain fitness market may have a long way to go before
it is saturated.
What is our role as members of the SCN in the next wave of positive
applied neuropsychology? First, our
unique training and expertise is required to determine what paths will be the
most fruitful for development. What
cognitive training procedures (if any) are truly effective? Do any of these procedures lead to
generalization? What evidence would be
necessary to support more widespread application of neurofeedback? Can we augment meditation practices to
enhance capacity for focused attention or anxiety-reducing broadening of
attention? Second, we must provide a
counterweight to the commercial forces that already are attempting to
capitalize on these ideas before they are proven. SCN
members need to provide well-informed opinions about the merits – and lack
thereof – of applications already in widespread use. Finally, we must champion consideration of
the ethical considerations that attend to this brave new world that involves
brain-altering practices. What do you
recommend to your baby-boomer patients who wonder if they should have personal
genetic testing to learn their APO-E genotype, get a positron emission
tomograph, or get neuropsychological testing to learn if they are “at increased
risk” for Alzheimer’s disease? How do we
help parents navigate the increasingly dizzying maze of choices being offered
for attentional problems (medication, neurofeedback, working memory exercises),
particularly for kids who do not
satisfy criteria for a syndrome like attention-deficit/hyperactivity
disorder? What are the components of a
regimen that supports long-term cognitive and emotional health? We all know this must go beyond “cognitive
exercise,” but exactly what components of physical, psychological, social,
emotional, and spiritual practices should we be recommending as practitioners
of the healthy brain sciences? These
questions already are prominent in many of our clinical practices and in the
coming years we can expect this emphasis to increase. The time is at hand for us to establish best
practices and to anticipate a future that will further blur the lines between
health optimization and clinical care. We
are in a unique position to advise the public and other stakeholders how to
harness new knowledge about the brain to help us advance the values we possess
as individuals and share as a society.
References
Bilder, R. M. (2011). Neuropsychology 3.0: Evidence-based science and
practice. Journal of the International Neuropsychology Society, 17(1), 7-13.
Bilder, R. M. (2010, Nov). Personal Brain Management, from TEDx
San Diego "The Next Wave." http://youtu.be/rG494qden64.
Bilder, R. M. (2012, July). Huffington Post Blog on Personal Brain
Management. http://www.huffingtonpost.com/robert-m-bilder-phd/personal-brain-management_b_1651308.html.
Randolph, J. J. (Ed.).
Positive neuropsychology: Evidence-based perspectives on promoting
cognitive health. 10.1007/978-1-4614-6605-5_2.
Springer Science+Business Media, New York, 2013. [quote from
location 146; Kindle edition].
