Pre-Doctoral Training in Neuropsychology

A view of the very brief history of neuropsychology reveals that it has enjoyed tremendous growth over the past 20 years. While the demand for neuropsychologists has grown rapidly, pre-doctoral training programs do not appear to have kept pace. The number of programs have increased from only a few in the 1970’s to 26 listed in 1993 in the US (Cripe, 1993), however, even with this increase the total production of neuropsychologists from such programs has not met the needs of this area. This is attested to by the fact that many students with superior credentials apply for a relatively few positions. The majority of these programs take 1 to 2 students per year but may receive 20 to 30 times that number of applications.

In contrast to the relatively little emphasis given to pre-doctoral training programs, much is being said and done about post-doctoral training in neuropsychology. This is perhaps related to the evolution of neuropsychology. During the early days in the 50’s and 60’s there were no pre-doctoral programs and individuals interested in human brain-behavior relationships were generally trained in physiological psychology and/or clinical psychology. Prior to the development of formal neuropsychology training programs these two areas were separate and fostered very little overlap. Many programs maintained an experimental and a clinical sub-specialty with separate students, faculty, and courses. Those interested in neuropsychology were usually affiliated primarily with one area but a few individuals managed to gain exposure to courses from the other areas to augment their training. In other cases, individuals were trained in one primary area and then made arrangements for some post-doctoral experience. Still others were neither exposed to pre- nor post-doctoral training and gained experience by attending workshops, individual study, clinical experience, and perhaps some privately arranged supervision. The majority appeared to have gained their neuropsychology knowledge by the latter or clinical experience method. We tend to view training in light of our own experience and since very few received formal pre-doctoral training in neuropsychology, then very few are likely to consider pre-doctoral training as the preferred method.

Other factors appear to relate to the fact that pre-doctoral training programs are difficult to establish and maintain. There is often considerable resistance from the clinical faculty and a lack of support from university administrations. It may also be due to the fact that practicing clinical neuropsychologists have made up the majority of the growth and relatively few are in academic settings. In fact, it is reported that only 85 of 1600 or only one-half of one percent of members of the National Academy of Neuropsychology have primary academic affiliations with psychology departments (Putente, 1991). While this speaks to the increasing demand for clinicians, it suggests that the ratio of basic researchers has diminished. Without continued basic research, future developments in the field will be limited.

The ultimate quality of the neuropsychologist is not determined by the method of training, but rather by the knowledge and experience acquired. Based on observations made over the past 22 years, it appears that the time required to establish acceptable levels of quality is much shorter by the pre-doctoral training method than either the post-doctoral or the individualized method. Many who have had a substantial impact on the development of neuropsychology began with a strong grounding in physiological psychology. Most of those involved in pre-doctoral training are of the belief that the eventual skill level achieved is significantly enhanced by early incorporation of basic core knowledge in neuroanatomy, neuropathology, brain-behavior relationships, and the understanding of the causes and effects of neurological impairment on cognitive functioning. A grounding in this information lays the foundation for subsequent knowledge and subsequent training experience is integrated into this basic system. Courses in neuroanatomy and neuropathology are not easily acquired later or are not likely to have the same impact as when they are acquired early in training. It is perhaps for these reasons that the recommendations of Division 40 of the APA have outlined a basic plan of training for pre-doctoral training programs. If effectively implemented, such a training program will accomplish the goals outlined above.

As the number of students who have completed pre-doctoral training in neuropsychology increases, the problem of quality control will diminish. Unfortunately, this is not the case at the present time. Many psychologists consider themselves neuropsychologists but appear to have invested nothing more than the consideration. They ofent have no basic knowledge in neuroanatomy, neuropathology, limited knowledge in neuropsychological assessment, and often no knowledge of the pathology in question. It is for this reason that current attempts at quality control have been made by credentialing boards. Two credentialing boards, the American Board of Professional Neuropsychology and the American Board of Clinical Neuropsychology, are working to identify qualified neuropsychologists. Yet, the activities of both boards have evaluated only a very small percentage of the individuals who present themselves as neuropsychologists. Clearly increased quality control is necessary and pre-doctoral training insures this probably better than any other method.

Pre-doctoral Training at UM:

The neuropsychology training program at The University of Memphis evolved out of the initiation of weekly discussions, in the late 1960’s, between psychologists and neurosurgeons regarding cybernetic models of brain function. It was during these discussions that it became clear to all of us that a physiological psychologist trained in clinical assessment had considerable resources available which were ideally suited to the diagnostic needs of neurosurgery. This interest from neurosurgery coupled with a series of presentations by Ralph Reitan led to the development of the neuropsychology training program at The University of Memphis in 1972 and the development of a joint university neuropsychology laboratory with The University of Memphis and the University of Tennessee Medical Units.

The program at MSU was initially a subspecialty in the experimental program. Several years of negotiation resulted in the clinical faculty allowing students to take clinical assessment courses and the University of Tennessee allowing our students to enroll for courses at the medical center. In return we arranged for medical students and residents to enroll in our courses or take clinical or research practica at MSU. During these early years it became clear that more clinical experience was needed as well as an internship. It was for this reason that in 1975 the neuropsychology training program was transferred to the clinical specialty.

The neuropsychology pre-doctoral program included the requirements for the psychology department, those required by the clinical specialty, as well the neuropsychology core which includes the following: Neuropsychology I (Basic Physiological Psychology), Neuropsychology II (Issues in Neuropsychology), Neuropsychology III (Child Neuropsychology) Neuropsychology IV (recovery of function and/or rehabilitation), Neuroanatomy, and Neuropathology (at the medical center). Other courses included clinical and research practica and placement involving 1 year of research in the department, 1 year at the joint university neuropsychology lab, one year in a rehabilitation facility and one year in a general clinical setting. Since students must take all of the requirements for the department and the clinical specialty, the neuropsychology training occupies what used to be electives. While the neuropsychology courses and the courses at the medical center provide a critical foundation for future work in neuropsychology, the student’s own unique skills are developed in the corresponding clinical and research experience in neuropsychology. It is in these activities that students can combine methods and procedures from other areas and pursue their own research interests.

The primary goal of the UM neuropsychology training program is to train neuropsychologists who seek a university or medical center position and have a primary interest in research. They are encouraged to present research at conferences and submit their work for publication. The goal is to have 4 to 6 publications and 10 to 12 presentations by the time that they graduate. This is aided by departmental and university fellowships where the student can pursue their own line of research. In some years as many as 5 neuropsychology graduate students received such fellowships and a number have received them for their last 2 or three years. As designed, pre-doctoral training provides the foundation at a critical time in the student's development. Basic issues and methodology is integrated into their 4 or more years of pre-doctoral training that can't be easily duplicated. As the program exists, students generally spend 5 years in residence and one year on internship.

The graduates are very competitive for internship positions and the vast majority are accepted to their first choice internships. Since the graduate students have a strong grounding in neuropsychology from the Halstead-Reitan orientation, they are encouraged to select a position that will provide a broad range of clinical experiences. Post-doctoral Training: My own views are that post-doctoral training provides an opportunity to develop specialty skills in neuropsychology for those who have graduated and were not afforded this as pre-doctoral training. For students completing a formal pre-doctoral training program in neuropsychology, post-doctoral training should remain a research position with perhaps some limited clinical experience. Unfortunately, many post-doctoral positions involve mostly clinical service and appear to represent more of a source of cheap labor rather than training.

Present Trends:

All indications are that the growth in neuropsychology has leveled off. Several factors appear to be contributing to this. First, many of the job opportunities in the past have been associated with direct health care delivery. With health care shifting from 3rd party pay to HMO’s, PPO’s and managed care, and many hospitals are privatizing their psychology staff, there is a decrease in referrals to outside sources. Second, the initial rush into rehabilitation facilities has satisfied these demands. Third, there is a hesitancy to develop new programs when the future of health care delivery is so ambiguous and the role of psychology is unknown. Finally, many of the demands for neuropsychologists have been met by employing psychologists with training in other subspecialties; a trend that should be reduced by proper conredntialling.

Future Directions:

It should be mentioned that while the future demand for neuropsychology as it has been defined in the past may be limited, there are, nevertheless, clearly important avenues where neuropsychology can make important contributions and satisfy unmet needs. To do so will undoubtedly involve (1) further organization and implementation of pre-doctoral training programs in neuropsychology that have been effective, (2) research in brain-behavior relationships and the application of cognitive theory to enruopathology, and (3) increasing credentialling to the point that it becomes an effective additional quality control to pre-doctoral training.

Uniqueness of Neuropsychology:

The uniqueness of neuropsychology is the focus on human brain-behavior relationships, the assessment, and to some extent, the treatment of the functional consequences of neuropathology. This has led to the close working relationship with neurology and neurosurgery and has afforded the opportunity to work with medical patients. This has been particularly important since my research and clinical experience has demonstrated that approximately 70% of medical patients also have significant emotional factors contributing to their symptoms.

Over the years, clinical applications of neuropsychology have shifted from a predominately diagnostic role to a descriptive one. In more recent years the focus has shifted yet again to a more predictive one. Neuropsychology overlaps with many psychological areas (cognitive, clinical, school, biopsychology, industrial/organizational, and rehabilitation) and other non-psychology areas (vocational assessment and treatment, and neuroscience). The difference remains the focus on neuropathology and its consequences. Thus, while neuropsychologists may deal with cognitive issues, it is usually with regard to the relationship of such issues and brain function or the particular cognitive weaknesses in neurologically impaired individuals. Likewise, with regard to vocational assessment, neuropsychologists might become involved in predicting the individual’s ability to function in a certain capacity but such predictions are based on the integrity of the nervous system and its function rather than on the predicted performance of non-neurologically impaired individuals.

The primary difference between neuropsychology and other areas relates to the fact that neuropsychologists have dealt with brain behavior relationships and study individuals with cognitive dysfunction due either to injury or disease. While we have enjoyed a long history of contributing to the diagnostic decisions in neurosurgery and neurology, future activities will relate more to our ability to assess the functional consequences of neurological impairment and predict outcome as well as develop and implement treatment plans for neurologically impaired individuals. These activities will shift from diagnosis to application of neuropsychological test findings to real world applications. Such activities may overlap with traditional clinical psychology, rehabilitation psychology, vocational assessment and treatment, industrial/ organizational psychology and school psychology. Neuropsychologists are already attempting to employ cognitive research in assessment and treatment of neurological patients and others. By assessing various cognitive functions, the neuropsychologist can serve in an important capacity of using this information in solving real world problems. Our cognitive assessment also relates directly to the ability of individuals to undergo vocational assessment and/or training as well as to job performance. Unfortunately, we do not have sufficient actuarial data to be effective in this regard, but the opportunity is there. Clearly, expansion in the areas outlined above are already underway and represent a significant opportunity for neuropsychologists to meet the needs of a large segment of our population.

The future of neuropsychology hinges on the relevant research that is conducted. Not only does basic research provide the foundation for future clinical applications, it is relatively less effected by buercratic changes in health care delivery. We clearly need to do a better job of training basic researchers in neuropsychology who can work toward the development of a meaningful taxonomy of cognitive constructs, a better understanding of how various tests relate to such constructs, to develop an understanding of ecological validity of neuropsychological test findings, and develop more effective assessment strategies. Building stronger ties with other areas of psychology and medicine can aid in this regard.

Although the program at UM is relatively unchanged since the beginning, in recent years there has been a shift in emphasis in the neuropsychology program. Since UM has a strong cognitive program, a number of students have taken cognitive courses and conducted research in the cognitive labs.

In view of the interest in training researchers and particularly in view of the developments in cognitive and biopsychology, UM has also developed an experimental neuropsychology subspecialty in the experimental area. Students in this subspecialty will apply and enter the experimental area either in cognitive, biopsychology, or developmental. They will have an academic advisor in their respective experimental area but will take the neuropsychology core courses and conduct research relating neuropsychology to their core area. These students will not take the clinical courses, will not apply for an internship, and will not be trained for clinical neuropsychology. Their aim is to conduct research in their primary area but focus their research on neuropsychological issues. Other programs will undoubtedly make modifications to capitalize on other strengths in their departments or universities. Such modifications should aid in pre-doctoral programs adjusting their programs to anticipated future needs and directions in neuropsychology.

Organization of Pre-Doctoral Training Programs:

Perhaps one way that we can better develop pre-doctoral training programs in neuropsychology is in the development of a working organization for pre-doctoral training. Such an organization could: (1) evaluate and compare training plans, course outlines, etc., (2) Work toward developing a reasonably equivalent training program, (3) Establish ways to secure representation in relevant groups concerned with training, (4) Provide this information to others interested in developing a pre-doctoral training program. To be effective, such a group should be composed of all neuropsychologists actively involved in pre-doctoral training and not some representatives of one professional group or another.

Reports of the INS - Division 40 Task Force on Education, Accreditation, and Credentialing, (1987). The Clinical Neuropsychologist, 1, (1), 29-34.

Cripe, L.I. (1991). History of training programs in clinical neuropsychology -- 1991. The Clinical Neuropsychologist, 5 226-337.

Cripe, L.I. (1993). List of training programs in clinical neuropsychology -- 1993. The Clinical Neuropsychologist, 7 371-419.