-
Co-Constructing a Workable Reality:The Use of Clinical
Neuropsychology
Victor Nell, Ph.D., and Carla Boer, M.A.
As in the medical model, a neuropsychological assessment
tradi-tionally follows an individually focused diagnosis-treatment
se-quence, leaving treatment to the referral source or other
agencies.This case study demonstrates that neuropsychology can
operatewithin a systems-oriented constructivist frame, even with an
aban-doned husband whose family refused to present for
family-therapysessions, and who, as a medical practitioner with
many years ofexperience, had an especially strong bias in favor of
the medicalmodel. In the process a new and more workable reality is
co-constructed.
TRADITIONAL NEUROPSYCHOLOGYAND SYSTEM-ORIENTED THERAPY
Person and "family" are two aspects of a continuous process
ofmutually determining change. . . . Clinicians working with this
modelengage in a "tacking" amidst the biological, the
psychological, and thesocial patient, looking for ports of entry
that allow them to be helpful.The logic in this view provides a
persuasive rationale for health careprofessionals to direct their
focus toward patients and contexts to-gether. In this technical
sense, it can be said that the "family" or the"context" itself
becomes the patient (15, p. 233).
The implicit assumptions underlying the practice of modern
clinical neu-ropsychology are that an accurate diagnosis, which
usually includes a set ofcausal attributions by which one or more
brain lesions is shown to explaina wide range of apparently
unrelated behaviors, points the way to appro-priate treatment. Such
treatment is characteristically multimodal, includingelements drawn
from rehabilitation medicine, psychopharmacology, the tra-
Victor Nell, Ph.D., is a senior lecturer in the Department of
Psychology, University of South Africa,Pretoria, South Africa.
Carla Boer, M.A., is acting head of and senior counselor in the
Centre forIndividual, Family, and Marriage Guidance, University of
South Africa, Pretoria, South Africa.
40 Family Systems Medicine, Vol. 6, No. 1,1988 FSM, Inc.
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Co-Constructing a Workable Reality 41
ditional acute-care therapies (physiotherapy, occupational
therapy, andspeech therapy), and the acquisition of coping
strategies drawn from cog-nitive-behavior therapy. In essence, this
is the diagnosis-treatment model ofclinical medicine, which is
focused on delivering an improvement to thephysical well-being of
the affected individual. This model draws its powerfrom its
effectiveness in the relief of suffering. A good part of the
voguecurrently enjoyed by clinical neuropsychology, and the
explosive growth ofthis area of behavioral medicine (3, 13),
derives from the use of this model,and the promise it seems to hold
out to "cure," or at least to ameliorate,some of the distressing
psychosocial symptoms of brain damage.
This individually focused model is not congruent with current
family-therapy approaches that derive from general systems theory
(4, 11). Theseapproaches hold that change cannot be brought about
in one element of thefamily system without affecting all the
others, and that the identified patientcan only be released from
his role by disruption of the surrounding systemand its
reorganization into a new pattern.
Clinical neuropsychology stands at the confluence of numerous
biomedicaland behavioral disciplines. The case of Dr. L is
presented because its unusualfeatures show with great vividness
that by drawing on medical diagnostictechniques on the one hand,
and systems-oriented constructionism on theother (1, 5), a powerful
rehabilitative momentum can be achieved. Essentialto this was the
construction, with the patient, of a new reality that was
bothacceptable to him and fit the "facts" of the case.
CASE PRESENTATION AND HISTORY
In June 1985, a 50-year-old medical practitioner arrived in the
PsychologyDepartment at the University of South Africa. He carried
with him a reg-istration form that had been mailed to him at his
request by the NationalRegister of Brain Injury and Support
Services, which is administered by thisdepartment. Because of his
slow and aprosodic speech, rather shuffling gait,and air of intense
single-mindedness, his arrival created something of a stir.
Dr. L's initial consultation with the Psychology I course leader
was abouthis work as a student; he then asked to speak with the
person who coor-dinated the National Register, the first author of
this paper. Despite thecovering letter routinely sent with all
registration forms, which explains thatthe National Register of
Brain Injury is a data-gathering exercise and canoffer no services,
Dr. L made it clear he would like to give a history. Hepresented
the following facts about himself, more or less in the given
order:He had been attacked by a patient during his psychiatric
residency, and wasfound by colleagues some hours after the
incident, unconscious on the floorwith a left frontal wound. There
were no witnesses. He was unconsciousfor seven days. He had been
married for over 20 years; his eldest child hadleft home, and the
household was currently made up of his wife, "a work-aholic," a
daughter in high school, an ineducable retarded son of 12, and
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42 Family Systems Medicine, Vol. 6, No. 1, Spring 1988
Dr. L's mother-in-law. He went on to say that there was a great
deal ofstress at home because his wife had cut off contact with
him, although beforethe accident they "used to talk tremendously."
He concluded by saying thathis goal at that moment, as a
brain-injured person, was to be useful to otherbrain-injured
people. If this happened, he would feel that his accident hadnot
been in vain.
He explained that this alternative goal was necessary because he
no longerfelt able to work as a medical practitioner, though he had
done so quitesuccessfully for a 30-month period beginning six
months after the injury.He had, however, felt that his memory was
too unreliable and had beenworried that he would make a mistake.
Accordingly, he had retired as dis-abled, though he remained on the
medical register and was, therefore, li-censed to practice. Despite
this explicit appeal for help, the first author didno more than
place the material on file, though he felt guilty at not doingmore
for this devastated individual who seemed to have stepped out of
thepages of Luria's The Man with a Shattered World (10):
Because of that head wound I'd become an abnormal
personexceptthat I wasn't insane. . . . My mind was a complete
muddle and con-fusion all the time, my brain seemed so limited and
feeble. Before, Iused to operate so differently (p. 24).
Two weeks later, the second author, a counseling psychologist
trained insystems-oriented family therapy, who wanted to gain
clinical experience inthe diagnosis and treatment of brain damage,
needed a case to work up atthe Edenvale Hospital Head Injury
Outpatient Clinic. Not surprisingly, theseeds sown by Dr. L's
presentation now thrust forth, and the first author,a
neuropsychologist, telephoned Dr. L to ask if a complete
neuropsycho-diagnostic evaluation might not be useful to him,
emphasizing that therapymight not be offered, and that the
examination would take place with stu-dents present. He agreed with
alacrity, saying that he wanted to understandhimself better.
The unique features of this history and presentation can be
outlined asfollows:
1) The client (a term, which, in the present context, has
special weightbecause of the client's determined efforts to
identify himself as a patient)is a medical practitioner whose
expectations of a health-care interventionderive from the medical
model with which he is most familiar.
2) The client's self-identification lays the greatest possible
emphasis on thephysical origin of the condition and, therefore, its
hopelessness, since itis a neurological truism that
central-nervous-system tissue does not re-generate. The nature of
this self-identification as a brain-damaged personbecomes clear if
an analysis of the presentation is made. Dr. L began byhaving an
academic consultation about his difficulties as a brain-damaged
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Co-Constructing a Workable Reality 43
student. He then presented himself, with a document formally
acknowl-edging his brain injury, at an agency that had already
informed him itwas unable to offer any services. The patient's
selection of informationfrom his history and his dramatic behavior
become a carefully histrionicplea for "treatment" in the context of
incurable brain damage, the attackon his person, the destruction of
his professional career, and the im-pending dissolution of his home
life.
3) The patient's presentation has an excellent fit with the
medical modeland a very poor fit with the family-therapy model: He
arrived unaccom-panied and, as noted below, all members of his
family explicitly or tacitlysupported the view that he should be
treated for his "disease" in isolation,because his condition had
nothing to do with them.
We will argue that these paradoxes produced a fertile
therapeutic climatethat illustrates some of the ways in which the
diagnostic and therapeuticcomponents of clinical neuropsychology
can draw on two effective modelsthat usually operate in isolation
from one another. Specifically, though thedifficulties standing in
the way of a family-therapy approach appeared in-superable, this
abandoned husband was in fact treated as a member of afamily;
secondly, the diagnosis-treatment-discharge circle was broken at
anumber of points by scheduling unexpected "family-therapy"
sessions be-tween the diagnostic procedure and the communication of
the results, andby insisting that the patient participate in the
formulation of the diagnosisby co-creating it.
In order to sharpen these conceptual issues, diagnosis and
remediation aredealt with in the following exposition as if
separate, though in reality theseactivities were concurrent.
DIAGNOSIS
Intake Interview
Those present at the intake interview were Dr. L, the authors of
this paper,two first-year clinical psychologists doing their
two-month rotation at thishead-injury clinic, and a visiting
observer. During this interview, in con-formity with the diagnostic
aspect of the medical model, the counselingpsychologist remained
passive, taking notes, while the neuropsychologistconducted the
interview. As in the first interview, Dr. L's responses to
ques-tions were made at an extraordinarily slow pace and in a dull
monotonethat had a soporific effect on all those present.
A question that produces a rich information yield during the
intake in-terview of a brain-damaged person is the following: "In
what ways do youthink you have changed as a result of your brain
damage?" In reply, Dr. Lsaid: "I have had a complete personality
change. Before the accident I wasa heavy drinker, and for many
years I was a member of Alcoholics Anon-
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44 Family Systems Medicine, Vol. 6, No. 1, Spring 1988
ymous. I was a very depressed person with frequent thoughts of
suicide. Idid try to kill myself a number of times. Alcohol was my
tranquilizer. NowI have no need to drink. I am not anxious, and I
have no suicidal thoughts.I did a leucotomy on myself."*
During his years as an alcoholic, Dr. L continued, his wife had
been anactive member of AA and an office-holder in Alanon. Now that
he hadstopped drinking and was no longer suicidal, she had cut off
contact fromhim. They no longer have intimate contact, she is
continually depressed,suffers particularly from lower-back pain,
and is readily upset by manythings that he says or does. He
describes his living situation by saying, "I'vegot to be so
careful."
Dr. L's main complaints centered on his dissatisfaction with his
familysituation. He said that when things got too stressful at
home, he would moveout and live with his mother, now in her 70s. He
does not enjoy stayingthere and gets irritated, but says that "at
this stage" he has no option. Hedescribed everybody in his own home
except his teenage daughter as "nuts."He believes he is nuts
because of his brain injury,** his wife because of herdepression
and being a "workaholic," his son because of his retardation,and
his mother-in-law because of her inconsistency. A second set of
com-plaints focused on the absence of life goals. He did not feel
competent topractice as a medical practitioner, and said that his
life had no purpose.
Testing Sessions
Immediately after the completion of the intake interview, the
counselingpsychologist took over the case and commenced testing,
which, includingthe discursive interpolations described below,
occupied a total of four anda half hours spread over the remainder
of the intake session and one ad-ditional testing session.
Behavior during testing. Effort and concentration during testing
wereexcellent. Dr. L enjoyed the interaction during testing,
thrived on praise, andgave the examiner plentiful feedback about
what he was doing and expe-riencing during the testing. He enjoyed
"being understood," and often saidhe was looking forward to getting
the results so he could understand hisbrain injury better.
Test performance. Dr. L brought with him a report from a
clinical psy-*Claims of an improvement in personality as a result
of brain injury are not uncommon. Sometimes
these arise because of a lowered arousal level with a consequent
diminution of dyscontrol and aggression;sometimes because
inhibitions are lifted and a shy introvert finds it easier to
approach people and initiateconversations; sometimes, as in the
present case, because depression is relieved, and the patient
enters(as with Dr. L) an anxiety-free ego-syntonic state. An
elevation of mood is often associated with injuriesto the
retrolandic nondominant hemisphere, which, given the left frontal
impact Dr. L sustained, is aplausible location for a contracoup
injury.
**An item of evidence Dr. L drew on to confirm his "craziness"
was a vivid recollection of talkingsensibly to people at his
bedside when he was emerging from coma, only to be told later that
he hadbeen speaking "rubbish," i.e., jargon. This rare insight into
the subjective experience of jargon aphasiais in itself of
interest.
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Co-Constructing a Workable Reality 45
TABLE 1Results of 1984 and 1985 Assessments of Dr. L
Subtest
InformationComprehensionArithmeticDigits
combinedSimilaritiesPicture completionObject assemblyBlock
designDigit symbolPicture arrangement
Verbal IQ:Performance IQ:Full Scale IQ:
13389
112
Standard scores
1984 1985
13189 11
1017 16'/2
7Vi89 9Vi7Vz 7
12
chologist who had assessed him nine months earlier. His standard
scores onthe SA Wechsler Adult Intelligence Scale at this 1984
assessment, togetherwith the scores on the four subtests repeated
during the current assessment,are reported in Table 1.
The test instrument used in the current assessment, the Nell
Neuropsy-chological Screening Procedure (12), which incorporates
four Wechsler sub-tests, is a 22-item battery that assesses 12
discrete functional domains suchas arousal and orientation, motor
and sensory function, visuomotor per-formance, cognitive
flexibility, language production and comprehension, andcomplex
processes such as humor and metaphorical language.
Significantfindings were as follows:
Cognitive flexibility was notably impaired. On the
Goldstein-Weigl-Scheerer Color-Form Sorting Test (6), Dr. L took
190 seconds to sort thecounters in a different way after his
initial sort by shape. Although heverbalized "color" to himself, he
was repeatedly drawn back to the shapesof his previous sorting
principle. This difficulty in breaking away from anexisting
cognitive set was confirmed by the strong echopraxis.
The most significant language deficit was impoverished
controlled asso-ciate generation, with only three, five, and four
words to the letters c, /, and/. This is a performance preeminently
associated with left-sided prefrontallesions.
Verbal memory and learning: Immediate recall on two 22-item
paragraphswas 13 and 12, about two standard deviations above the
population mean(8), but seven for each of the two paragraphs after
a 30-minute delay oc-cupied by other testing. Since delayed-recall
scores in control subjects havebeen shown to run only one or two
points below immediate recall scores(8), this loss of five to six
items is diagnostic of poor encoding and retrieval.
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46 Family Systems Medicine, Vol. 6, No. 1, Spring 1988
This finding was confirmed by the "frontal plateau" phenomenon
(16) onthe verbal learning task, in which 10 words are to be
acquired under con-ditions of homogenous interference and selective
reminding. On this pro-cedure Dr. L scored five, six, three, and
five on each of four trials, and threeafter a 30-minute delay.
Visual memory was markedly better. On the 7/24 pattern memory
test(8), all seven counters were placed correctly on the second
trial, with perfectrecall at 30 minutes. Similarly, four of the
five geometric designs were spon-taneously recalled.
Formulation
The picture that emerges is one of a somewhat ponderous
individual withexcellently preserved intellectual abilities that
are compromised by two def-icits that are consistent with a left
frontotemporal injury: reduced cognitiveflexibility, which gives
rise to a somewhat viscous cognitive style; and re-duced verbal
fluency and verbal memory, with impaired learning of newmaterial.
These changes are sufficient to justify a diagnosis of
traumaticbrain injury with marked sequelae in thinking and
behavior. Within neu-ropsychology's traditional frame, if
remediation were offered, it would verylikely be within the
cognitive-behavior therapy modality that is the theo-retical base
for many current cognitive rehabilitation programs. Our ap-proach,
described below, focused on a personal redefinition rather
thancognitive retraining.
REMEDIATION
The Informing InterviewThe catastrophic erosion of self-esteem
that accompanies intellectual and
adaptive changes after a brain injury seems to derive less from
the deficitsthemselves than from the perplexity (9) that surrounds
these changes. Likethe owner of a clock that has suddenly struck
13, the perplexed survivormistrusts even correct responses and
decisions (8). In this context, sharinginformation has the unique
power to at least partly resolve the perplexityby drawing a map of
the affected individual's strengths and weaknesses inways that
augment the victim's resources and self-esteem on the one hand,and
his or her grasp of reality on the other (12).
A session dedicated to a review of the client's test
performance, and theappraisal of these performances for the light
they throw on future planning,is not a standard part of
neuropsychodiagnostic procedure. In many settings,client contact
ceases at the termination of testing, and the findings are
com-municated to the referral source in written form. Once
incorporated in theclient's file, these findings may either be used
by a variety of disciplines orlie dormant. In either case, failure
to communicate the findings directly to
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Co-Constructing a Workable Reality 47
the client means that the potential benefits of several hours of
intensiveskilled observation are lost, or, at best, dissipated in
their passage througha variety of filters before they reach the
patient. Moreover, a unique aspectof the neuropsychologist's
professional skill is the grasp he or she has ofcognitive
psychology in relation to its neuroanatomical substrates, so
thatboth the origins and the implications of performance deficits
for thinkingand adaptive problem-solving can be vividly and clearly
conveyed.
Structured information-giving was singularly successful in
resolving someof Dr. L's difficulties.
Cocreating the Informing InterviewTraditionally, the work load
at the informing interview is skewed, with
the neuropsychologist much more active than the client and
family. WithDr. L, who certainly expected this traditional
"treatment" model to befollowed, a format based on the principle of
system-oriented family therapywas followed. This required that the
selection of content areas for discussion,and the sequence in which
these were to be dealt with, were determined notby the
diagnostician alone, but by the client and the therapist jointly.
Thisprocedure may be termed the cocreation of the informing
interview. It is nomore time-consuming than the standard informing
interview, yet creates thecontext in which the ecological force of
the findings, which are linked atevery point to the client's inner
world, is greatly increased. This is becausethe client's perception
of his or her own performance can more easily belinked backward to
interview data and aspects of the history, and forwardto vocational
and family-life goals.
A conceptual framework for this process is provided by
constructionism,which explains: "the processes by which people come
to describe, explain,or otherwise account for the world (including
themselves) in which theylive. . . . Descriptions and explanations
of the world themselves constituteforms of social action" (5, pp.
266268).
Emotions are thus also construed as socially determined
"patterns of ritualaction" rather than natural passive states (1).
These formulations accordwith Keeney's (7) suggestion that living
process and mental process areidentical.
The informing interview began with the following question to Dr.
L: "Ifyou cast your mind back to the test sessions, what do you
think you didwell on?" Later in the interview, the question was
turned around and theclient was asked to specify the procedures on
which he thought he had donebadly. By way of illustration, one
aspect of this information-giving is de-scribed: In a session soon
after the completion of testing, Dr. L shared withthe counselor his
feelings of loneliness, inadequacy, being misunderstood,and being
called names that drew attention to his brain injury.
Thoughresenting these barbs, he had studied his own brain scan, and
was himselfconvinced that he was little more than a "vegetable"
because of what he
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48 Family Systems Medicine, Vol. 6, No. 1, Spring 1988
described as gross prefrontal damage and severe contracoup
injuries in theright parietal lobe.
The neuropsychologist took this cue to say: "Your scan shows
that thefrontal damage is confined to the left hemisphere. The
gross personality andbehavior changes you attribute to yourself
require extensive bilateral dam-age." The neuropsychologist then
described the case of a young medicalpractitioner whom the
neuropsychologist had seen some years previously,emphasizing this
unfortunate person's fatuous jokiness and gross social
dis-inhibition.
"It is very striking that you display none of these gross
disorders. In fact,both of us have been impressed by your social
skill and your considerationto others. Your motivation is
excellent, and you have shown that you canstay with a task over
long periods. These achievements are not consistentwith the kind of
injury you attribute to yourself." Dr. L was
extraordinarilyattentive during this part of the session.
By the end of the informing interview, Dr. L was able to
construct ametaphor of his inner ecology. He said he had built a
wooden fortress aroundhimself for defense, and within this stockade
he had behaved in ways ap-propriate for a brain-damaged person,
because all those outside the stockadeexpected this of him. The
thought that this fortress might be breached if heno longer had to
think about himself as "brain-damaged" was frightening,because he
saw he now had a choice about whether to see himself as
brain-damaged or not. He was also afraid that his wife would not
share theexcitement of his new perception, and that she might find
it unacceptable.Accordingly, the counselor accepted Dr. L's
suggestion that until such timethat Mrs. L presented for a
family-therapy session, Dr. L would keep onbehaving as if he was
brain-injured, so he could continue to wear the "brain-injured"
label he and the family had hung around his neck. In response
toqueries about what had taken place at the interview, it was
agreed that hewould say, "Things don't look as bad as I
thought."
A striking aspect of the informing interview was the change that
had takenplace in Dr. L in the weeks since the intake interview.
His speech rate hadincreased, his inflection was more vivid, his
facial expression was more lively,his walking brisker, and his
spontaneous movement when sitting was freer.
Failed Family Therapies
In the weeks before and after the informing interview, 11 failed
family-therapy sessions were conducted. They were failed in the
sense that despiteelaborate arrangements, Mrs. L failed to show up.
By using the Milan group'scircular questioning technique (14), it
was possible to "include" the wholefamily in the interviews,
thereby creating new complexities and realities forDr. L.
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Co-Constructing a Workable Reality 49
Outcome
Reports from the three women in Dr. L's lifehis mother, his
wife, andhis mother-in-lawindicated a good deal of movement away
from previous"illness behaviors."
Though no further attempts were made to involve Mrs. L after the
fourthsession, she later initiated contact with the counselor
because she was dis-turbed by the changes in her husband. She said
he had become more ag-gressive, did not accept everything as he had
before, and "was a differentperson." She agreed to phone after the
summer recess for an appointment,but never did so.
Dr. L's mother reported that he had lived in his own home for
fourmonths, the longest continuous period since his accident. She
said he hadbecome more assertive and confident, his memory seemed
to have improved,his speech was livelier, and there was less
tension in his home because heseemed to be relating to his wife in
a more relaxed way. Even the behaviorof the retarded son was seen
as improved.
Dr. L's mother-in-law, a vigorous lady who was the family's
housekeeper,complained that he had become more aggressive and did
not do things theway she wanted them done. She made it clear that
she would continue totreat him as brain-damaged. The counselor
reframed this opposition bysuggesting that he and his mother-in-law
were good for one another becauseboth were strong people, and by
opposing one another, each made the otherstronger.
Dr. L adopted the view that he had sustained brain damage but
could stillfunction adequately in many areas. Accordingly, he
enrolled in a universitycorrespondence course in psychology, and
decided to return to medical prac-tice, though he refused to
prescribe medication. His aim as a practitionerwas "to help other
people with brain injury." He also said he was determinedto get
divorced unless relations with his wife improved by the end of
thecurrent year, at that time nine months off.
SUMMARY
This single case study indicates that an isolated individual can
be treatedwithin a family context, and that significant behavioral
change can beachieved by following a family-therapy model under
circumstances that ap-pear to be inauspicious. It also demonstrates
that the informing interviewcan be recast within a systems
framework to create an ecologically morerelevant context. There are
also indications that a settled pattern of illnessbehavior, with
gross maladaptive histrionic overlays, can be substantiallymodified
by a combination of neuropsychological diagnosis and
systems-orientated remediation. These gains are the more striking
in the present case,in which the expectations for a traditional
diagnosis-treatment approachwere particularly strong.
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50 Family Systems Medicine, Vol. 6, No. 1, Spring 1988
In August 1987, in the time between first submission of this
paper andits revision, Dr. L died a few days after he had been
burned in a fire at hishome. Until the end of 1986, he had attended
monthly therapy sessions;between December and May 1987, he and his
wife attended four jointsessions, saying at the last session that
there had "never before been suchlove and understanding between
them." Then they drifted apart again, sheplanning a holiday on her
own and he going back onto tranquilizers.
In 1972, Bateson wrote: "Let me then conclude with a warning
that wesocial scientists would do well to hold back our eagerness
to control thatworld which we so imperfectly understand. The fact
of our imperfect un-derstanding should not be allowed to feed our
anxiety and so increase ourneed to control. Rather, our studies
could be inspired by a more ancient,but today less honoured motive:
a curiosity about the world of which weare part. The rewards of
such work are not power but beauty" (2, pp.239-240).
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1. Armon-Jones, C. Prescription, explication, and the social
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Behaviour, 1985, 15, 122.
2. Bateson, G. Steps to an ecology of mind. London: Chandler,
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Journal of Clinical and Experimental Neuropsychology, 1985, 7.4.
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mondsworth: Penguin, 1975.11. Minuchin, S. Families and family
therapy. London: Tavistock, 1974.12. Nell, V. Neuropsychological
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1985.13. Nell, V. Proposals for the training and credentialing of
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South Africa. In K. W. Grieve & R. D. Griesel (Eds.),
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14. Penn, P. Circular questioning. Family Process, 1982, 21,
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Requests for reprints should be sent to Victor Nell, Ph.D.,
Department of Psychology, University ofSouth Africa, Box 392, 0001
Pretoria, South Africa.