“Everything that can be counted does not necessarily count; Everything that counts cannot necessarily be counted.” (Attributed without certainty to Albert Einstein)
It is easy for both of the reviewers present to see this book as serving several functions. First and foremost, it is a posthumous festschrift for Dr Edith Kaplan, which strays toward paean at times, due to the obvious affection of her students. In this respect, the book, like Edith, is occasionally a bit over the top. But more importantly for clinical neuropsychologists, it also is a largely helpful workbook or lab manual for those who seek to employ or develop process approaches in their clinical and research work. It is especially welcome as there are few cogent explications of the Boston Process Approach (BPA) (with Milberg, Hebben, & Kaplan, 2009, being a notable exception). No available BPA treatments are as comprehensive as this volume provides. Given that the book editors and authors are a stellar community of her former students, this should not be surprising. Thus, this book is a “don't miss” acquisition for clinical neuropsychologists. It departs from what had been something of an oral history tradition for teaching this approach. There's a real gold here.
While tedious at times, and occasionally bordering on the pedantic, the complete specification of methods is indispensable in science. Indeed, as one critic of the BPA method close to the review authors has said, “If you can't say exactly what it is that you are doing; there is a good chance that you don't know what you are doing.” A second essential feature of science is the existence of clear opportunities for disconfirmation, which (e.g., notions of intelligent design in nature cannot attain) also has been a challenge for the BPA at times. This volume helps a great deal in that regard as well, but it remains an issue.
This book shines when it provides overviews of the research supporting the correspondence of certain types of errors with functional problems across various neurobehavioral syndromes, which is arguably the overarching purpose of neuropsychological assessment, writ on the level of the individual. A few chapter authors appear to get stuck in the weeds frequently on their way to these findings; however, chasing wild geese such as endless iterations of error analyses in the digit span test that have yet to be correlated with functional problems. While there is certainly value in showing even the not-yet-fully-formed conceptual derivatives of the BPA, continued emphasis on less-than-useful error analyses lays bare the all-too-human weaknesses of a qualitative approach, that is, the possibility of over-pathologizing random (natural) variations in performance; and creating a kind of qualitative analog of the Bonferroni problem that the measurement-happy suffer in a psychometric tradition. Illusory correlation can await in ambush in practice even for fully developed neuropsychologists. Put another way, a BPA toolbox, if not carefully managed, can become an overflowing mess, with no scientific basis to support its use.
Process analysis obviously requires experience and good knowledge of brain–behavior relationships and systems. Rare is the neuropsychologist who is both a master examiner and also a gifted analytic interpreter of data in everyday life. It seems that Edith was one of these rare individuals, as seen here through the eyes of her students. What emerges from the BPA in this volume is a greatly enhanced appreciation of the less obvious, but richer utility of our neuropsychological assessment tools. Shorter batteries in particular become infinitely more descriptive when internal patterns can be recognized, analyzed, and interpreted in context. With longer batteries, there are likely to be diminishing returns, given the burden placed on the scorer to properly quantify error scores and interpret drawings when there may be an abundance—or even overabundance—of information. Cherry picking is not clinical science.
Furthermore, there are endless numbers of possible qualitative features of assessment and its tools that tempt the natural tinkerer in every neuropsychologist; and “staying the course” in administering a test protocol is a difficult lesson for those in training to learn. Specification “in advance” of which qualitative features of performance are most informative is essential. That is done rather well in Chap. 7 by Giovannetti and colleagues on the analysis of errors on the Similarities subtest. In this case, the feature definitions facilitate clear and testable hypotheses. Trainees should be comforted, though, by the knowledge that they can “double back” when needed to test limits to heart's content if the trap line for such features was not optimally laid out and embedded in the formal testing. Again, knowledge of what matters most “in advance” will make all the difference between a successfully employed battery or protocol and a time-consuming (and worse, misleading) fishing expedition. To the extent that this book provides an overview of current research connecting functional signals of disease with performance on these assessments, it may act as a homing beacon at times, especially for those of us early in our careers.
One of the least attractive features of this explication of the BPA (and the approach in general) is that it (at times) not too subtly implies those not having had the benefit of having been trained in this approach in Boston are somehow handicapped in understanding qualitative elements of neuropsychological test performance and behavior. Indeed in the preface, the editors suggest that “Much of what people think they know about the Boston Process Approach is twaddle” (p. xx). This is as unfortunate as it is untrue. In a similar manner, the closing chapter implies that “in theory” one could do a process analysis of a Halstead–Reitan Battery protocol. There is nothing theoretical about this; it is done every day. These are here (hopefully) the last fading echoes of the “battery wars” that reigned in the contributors' professional childhoods, with only limited PTSD remains of those days now. The take away point should be that there is a spectrum of competence that spans neuropsychological approaches. There are “Three card Monte” practitioners of the BPA and also psychometric hacks who think that their conscious task is over after they administer and score a test and then look at “norms”. But as well, there are master practitioners of the BPA, and also those skilled practitioners using other methods of neuropsychological assessment, and attending quite carefully to qualitative features quite well, thank you.
The organization of the book also leaves a little to be desired. The reader may have benefitted from one chapter devoted explicitly to defining BPA to orient the naïve. Rather, many chapters tackle this definition in idiosyncratic ways, leaving the reader with the impression that the BPA may simply be a “state of mind,” rather than a system of analyses that can arguably provide good specificity and sensitivity to key aspects of patients' functional problems, which may otherwise go unnoticed. Not all chapters do their own idiosyncratic definitional thing though, and some of the best “BPA capture” can be seen on pages 14–15 and 32–35. The reader may also have benefitted from a more conceptually consistent grouping of the chapters, with one concise introductory chapter followed by a section on neuropsychological features of common (and not so common) disorders, then tests, then future applications. This would provide more of a foundation from which to understand and emphasize the undoubted usefulness and unique value of the BPA.
A complete chapter on apraxias, while providing very useful information, will show where neuropsychology and behavioral neurology coexist but do not yet “abide,” even now. That said, the entire community of behavioral neurologists that was organic to Edith Kaplan's work has been the most vital intellectual force in behavioral neurology, with wide and sustained impact on the parent medical specialty here and abroad. The best of this intellectual tradition is on display in the book, showing international scholarship, and clinical acumen in the formative and initial “bloom” times in Edith's career. It was a time-limited gathering of unique, providential, and fortuitous elements of a “perfect storm” for behavioral neurology and clinical neuropsychology (viewed in today's rear-view mirror). There was time to search for notional Central European Physicians who had seen “something like this” long ago. This is a luxury not available to most. There was also a surfeit of time to see patients, with no special pressure to do their “case management,” and certainly a pipeline of interesting cases from the communities that held this whole medical Athens in justifiably high regard. And, at the same time, there was no imaging and criterion test buffet available in Edith's time, until the period after her retirement from the VA in 1987. This circumstance rendered the sensitivity and specificity of her approach all the more necessary and, none the less, remarkable in achievement.
Edith Kaplan was obviously a force in and for neuropsychology and a tour de force herself during exciting formative times and beyond. Her achievements are all the more noteworthy given her Boston professional career as a woman and a psychologist. One of us as a reviewer now feels extra-haunted by the need to scrutinize Block Design, clock drawing, and other tasks going ahead, as recurrent and permanent considerations. We wish to emphasize that Edith going from research assistant to staff psychologist to valued senior colleague was a steep climb back in a male medical Boston environment where psychologists—for all their egalitarian noises in this volume—have only in recent times gained something like “real” equal career traction as non-physicians with adequate academic rank, appointments, and privileges. Edith's career helped to make this possible. In this context, she also should be honored for showing the character to promote her ideas and wares as important. Her presence is felt heavily throughout this volume, and it is clear that the authors, her students, and colleagues feel a profound sense of indebtedness to her contributions to the field.
So should we all honor a true founder and a colleague who was always ahead on the “clock” intellectually and developmentally, in the Eriksonian sense. This book is a fitting tribute and much more as a continuation of her gifts to our field.