Behavior Therapy and Neuropsychology

Description of the Strategy

There have been significant advances in the integration of behavior therapy and neuropsychology since the first accounts of behavioral intervention with brain-injured individuals in the 1970s. Indeed, advent of a “behavioral neuropsychology” recognizes the increasing interdependence of these approaches in the coordinated care of individuals who have experienced brain injury. A neuropsychological approach to patient care emphasizes brain-behavior relationships, whereas a behavioral approach, as embodied by the operant and respondent technologies of behavior modification and behavior therapy, focuses on behaviorenvironmental relationships. Both approaches may be used to evaluate an individual's cognitive functioning, establish baselines against which progress or decline can be measured, clarify diagnoses, and assist in rehabilitation and treatment planning. Used in tandem, these approaches provide a greater understanding of brain injury than could be obtained through either tradition alone.

Although the conceptual framework underpinning each approach is vastly different, these approaches intersect at the point of observable behavior. Behavior reflects both brain integrity and the influence of the external environment. A behavioral assessment demonstrates reliable and orderly changes in behavior as a function of variables traditionally considered to be influenced by the external environment (e.g., environmental stimuli and contingencies of reinforcement), while neuropsychological assessment focuses on behaviors typically considered to be a function of changes in the internal environment (e.g., central nervous system disruption via anoxic episodes, tumors, gunshot wounds, etc.). In the latter case, patterns of test responses are interpreted within the context of documented injuries and their known sequelae. Although the current state of imaging techniques [Page 53]often yields the extent and location of a brain insult, the heterogeneity of these injuries mandates that the scope of impairment in any particular patient remains speculative until evaluated by neuropsychological examination. Addition of well-established behavioral technology to the practice of neuropsychology brings behavioral principles and procedures to bear upon an individual's functioning while recognizing effects of brain injury on the patient's ability to perceive and respond to his or her environment.

A behavioral approach to brain injury owes much to the tradition of the intensive study of individuals, with attendant operational definitions of target behaviors, procedures for obtaining reliable observation of those behaviors, and recording procedures that capture target behaviors with respect to their relevant dimensions (e.g., frequency, duration, and intensity). Procedures that use subjects as their own controls permit a finegrain analysis of the effects of environmental events, be they internal or external, on behaviors of therapeutic interest, both in clinic and in vivo. Once functional relations between a behavior and environmental antecedents and consequences have been determined, a treatment plan may be developed to influence occurrence of specific target behaviors. Establishment of behavioral baselines reflective of neuropsychological deficits allows for client improvement or decline to be monitored as a function of pathologic or recuperative processes, as well as medication effects. Therefore, an integrated approach to patient care explores behavior sensitive to brain impairment and environmental contingencies that might affect that behavior, yet each approach has its limitations. That is, while traditional neuropsychological assessment highlights brainbehavior performance at a moment in time, it imperfectly reflects patient performance day by day. In contrast, behavioral assessment samples behavior obtained under different environmental conditions, or contingencies of reinforcement, but may fail to capture the subtleties that often encompass brain injuries. In each case, findings may vary as a function of numerous variables, such as patient age, the nature and location of brain injury, or whether brain insult is an acute or static condition or the result of an acquired or developmental deficit.

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