Monday, July 15, 2013

Positive Applied Neuropsychology

Robert Bilder, Ph.D., ABPP/CN
Robert Bilder, Ph.D., ABPP/CN, is speaking about Positive Applied Neuropsychology as part of the SCN program at the upcoming meeting of the American Psychological Association, on Wednesday 7/31/2013 from 1000am to 1050am in Convention Center Room 304B. 

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].

7 comments:

  1. "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."

    I will grant you the above but I have to wonder how the Ethics Code may be interpreted when we get to that day. 9.02(c) requires us to use assessment methods that are appropriate to an individual's language preference. If we remove the human interface altogether, and the assessment or therapy is administered entirely via electronic interaction, does this adhere to the spirit of the code?

    What about 9.07 disallowing assessments by unqualified "persons". How does that apply to a computer? If it does, how do we qualify a computer? I assume that 9.06 still requires a live psychologist to interpret the results?

    I recognize it may be somewhat different in the more technical specialities but we must not lose sight of our Principle B "to establish relationships of trust". No machine will ever be able to do that.

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    1. Just as with the rest of the field, so too will the APA Ethics code require revision to ensure that it addresses current and relevant clinical practices. The language issue (9.02c) is essentially irrelevant as digital assessments and interventions can be developed readily in any language.

      In regard to "qualifying a computer," I'm not sure if you're serious or not, but certainly trained and qualified professionals will be integrally involved in the assessment process, however, not in the same capacity as we are currently (i.e., clipboard in hand with pencil and paper at the ready for 4+ hours). Similarly, conducting an interview, interpreting results and providing feedback will all require carefully trained and well-qualified psychologists at the helm, and in many ways may require advanced training to be able to do so effectively. This also speaks directly to Principle B. The main premise is that technology needs to be integrated into neuropsychology, it is not, however, a replacement for the neuropsychologist.

      The thing that concerns me the most is the underlying resistance to technological integration I see throughout the field. There are certainly individuals who embrace technology and are developing novel methods to leverage and employ digital resources, but this is not a widespread attitude (at least in my experience). The concerning part is that the technology is going to be developed and integrated into cognitive assessment and intervention whether we like it or not.

      The question is, will neuropsychology be at the forefront or will we be left behind?

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    2. Indeed, let us not forget for a moment that the entire encounter - whether person-to-person or person-to-computer/automated assessment - encompasses an irreducible social psychological matrix in which one must, of necessity, be especially mindful of the affective components of the assessment process. Technology is certainly useful, but as neuropsychologists, we are dealing with a powerful clinically driven situation that still far outpaces what a largely computerized assessment can possibly achieve. How, for example, to deal with the emotional meltdown when a vocationally accomplished patient finds that they can no longer do what was previously taken for granted, as in, e.g., Digit Span, following a TBI? Too, the necessity of being able to assess not only the deficits but remaining strengths is, of course, critical, and conveying this in an understandable form to the patient and their family constitutes a valuable clinical skill that can't be reduced to a technician function. Still, this points to a something that has long been recognized in the substance abuse treatment community, and, to some degree, even within the neuropsychological community: recovery is not just about the individual, but the patient's family and social support system.
      Mindfulness, yes, by all means, but what does this actually entail with respect to 'healthy brain practices'? This begins to get into those concerns around that are evoked by cosmetic neurology and is a profoundly open issue.
      A very worthwhile blog that opens the door to any number of significant and relevant issues for us all. Thanks.

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    3. Thanks so much for these comments! Yogi Berra is alleged to have said "prognostication is difficult, especially when it comes to the future!" I do believe current trends show technology moving in directions that are hard to imagine today, and it is an amazing thought exercise to ask "what are human functions that could NEVER be taken over by machines?" I think the answers are harder and harder to specify. To take perhaps the most extreme example, the boundaries between uniquely "human" relationships and the relationships that people develop with machines are becoming less clear. I personally do not support a "transhumanist" vision of the future, and in our courses on Personal Brain Management i have been highlighting the tension that exists between authors like Ray Kurzweil ("The Singularity is Near"; "How to Create a Mind") and Jaron Lanier ("You are Not a Gadget"; "Who Owns the Future"). One bottom line from Lanier, is that we should recognize that the technology offers tools, and what we do is up to us, not the tools.

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  2. Most of my work is with older adults and in my own small way have been trying to promote the notion of accessing and building on strengths rather than just identifying areas of weakness and telling people "what is wrong with them". I hasten to add that this is not specifically a comment on neuropsychologists, but rather an expectation of the patient and their family. In the area of dementia in particular, people of often more willing to accept the decline rather than work with what is still intact thereby having a positive impact on wellbeing of both the person with dementia and their caregiver(s).

    While I agree that there can be resistance to technology and change more broadly, and certainly that the ethical codes and our quality of practice should continue to be of a high standard, I am much more interested and excited by some of the other content of Bob's final paragraph. As a snippet, from personal experience, I have seen the impact of being able to tell someone that yes, they do have a lot of areas of dysfunction due to their injury, but here is what we can work with, here's what you can achieve. There is some tendency to focus on cognitive aspects and not enough on emotional aspects. Positive neuropsychology at a very surface level seems to embrace both and I look forward to reading Randolph's book myself.

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