TYPE Review PUBLISHED 09 September 2022 DOI 10.3389/fpsyg.2022.963287 George P. Prigatano’s OPEN ACCESS contributions to EDITED BY Florian Ph.S. Fischmeister, Medical University of Vienna, Austria neuropsychological REVIEWED BY Luis Quintanar, rehabilitation and clinical Autonomous University of Tlaxcala, Mexico Gisela Pusswald, neuropsychology: A 50-year Medical University of Vienna, Austria *CORRESPONDENCE perspective George P. Prigatano george.prigatano@commonspirit.org Alberto García-Molina1,2,3 and George P. Prigatano4* SPECIALTY SECTION 1 This article was submitted to Institut Guttmann, Institut Universitari de Neurorehabilitació, Universitat Autònoma de Barcelona, Neuropsychology, Barcelona, Spain, 2 Fundació Institut d’Investigació en Ciències de la Salut Germans Trias i Pujol, a section of the journal Barcelona, Spain, 3 Facultad de Psicología, Centro de Estudios en Neurociencia Humana y Frontiers in Psychology Neuropsicología, Universidad Diego Portales, Santiago de Chile, Chile, 4 Department of Clinical Neuropsychology, Barrow Neurological Institute, Phoenix, AZ, United States RECEIVED 07June 2022 ACCEPTED 17 August 2022 PUBLISHED 09 September 2022 CITATION García-Molina A and Prigatano GP In the 1970s and 1980s, a multitude of cognitive rehabilitation programs (2022) George P. Prigatano’s proliferated to facilitate recovery after brain injury. However only a few contributions to neuropsychological rehabilitation and clinical programs provided a framework for ameliorating disturbances in the neuropsychology: A 50-year cognitive, psychological, and interpersonal spheres of the brain-injured perspective. Front. Psychol. 13:963287. patient. Greatly influenced by Leonard Diller and Yehuda Ben-Yishay’s doi: 10.3389/fpsyg.2022.963287 ideas and methods, George P. Prigatano began, in early 1980, a holistic COPYRIGHT neuropsychological rehabilitation program at the Presbyterian Hospital in © 2022 García-Molina and Prigatano. Oklahoma City (Oklahoma). The objective of this paper is to summarize the This is an open-access article distributed under the terms of the contributions of George P. Prigatano to neuropsychological rehabilitation and Creative Commons Attribution License clinical neuropsychology during his 50th year of practice. The main body (CC BY). The use, distribution or reproduction in other forums is of the paper is structured in three sections. The first section briefly explains permitted, provided the original the history of neuropsychological rehabilitation in the twentieth century author(s) and the copyright owner(s) are credited and that the original and the emergence of holistic neuropsychological rehabilitation programs publication in this journal is cited, in in the 1970s. The second section describes the contributions of George P. accordance with accepted academic practice. No use, distribution or Prigatano to neuropsychological rehabilitation and clinical neuropsychology reproduction is permitted which does (written by AGM). In the third section, the second author (GPP) prepared not comply with these terms. an autobiographical statement, which attempts to summarize some of the personal and professional experiences which influenced his work. George P. Prigatano’s contributions to neuropsychological rehabilitation and clinical neuropsychology are essential to understanding the therapeutic approaches currently used in the treatment of brain-injured patients. KEYWORDS holistic neuropsychological rehabilitation, psychotherapy, impaired awareness, finger tapping test, clinical neuropsychology Frontiers in Psychology 01 frontiersin.org García-Molina and Prigatano 10.3389/fpsyg.2022.963287 Introductory comments but also to help them personally cope with their permanent deficits in a productive manner which reduced the frequency of Neuropsychological rehabilitation has a long history as catastrophic reactions. recently documented by García-Molina and Peña-Casanova The Second World War (1939–1945) provided a renewed (2022). The recent passing of two contemporary leaders in this impetus for developments in neuropsychological rehabilitation. field (i.e., Leonard Diller and Yehuda Ben-Yishay) prompted Oliver Louis Zangwill (1913–1987) addressed the rehabilitation the first author (AGM) to invite the second author (GPP) to needs of soldiers in England, while Alexander Romanovich participate in writing a paper documenting his contributions, Luria (1902–1977) did the same in Russia. Luria and his to date, in the fields of neuropsychological rehabilitation and colleagues suggested that the restoration higher cortical clinical neuropsychology. The first author (AGM) described, functions could be partially achieved by “de-inhibition” of a from his perspective, the contributions of George P. Prigatano temporary inactivated functional system via the process of to these two areas of clinical and academic work. The second diaschisis (Luria et al., 1969). The processes for achieving this author (GPP) prepared an autobiographical statement which important goal, however, were not easily defined. Luria’s work attempted to summarize some of the personal and professional highlighted the point that understanding the mechanisms of experiences which influenced his work. recovery after brain injury not only serves the practical purposes Typically, descriptions of a person’s contributions to a given of rehabilitation but also raises important theoretical issues for field of study are written after their death with no input from neuropsychology. Shepherd Ivory Franz (1874–1933), in the them concerning what actually influenced their work. It was United States, made the same point several years earlier. the absence of this perspective, in other historical accounts, that After the Second World War, the Veterans Administration prompted the writing of this paper. Hospitals in the United States provided extensive rehabilitation for disabled veterans (integrating speech-language therapy, occupational therapy, physical therapy, psychology, and vocational rehabilitation). Yet holistic programs for Neuropsychological rehabilitation neuropsychological rehabilitation had not come into existence. and the development of holistic approaches Documents describing techniques and procedures for Holistic approaches to improving the cognitive functioning of people with brain neuropsychological rehabilitation injuries date back to the seventeenth century (García-Molina from the 1970s to 2020s and Peña-Casanova, 2022). It was not until the twentieth century, however, that neuropsychological rehabilitation began Between 1974 and 1976, Yehuda Ben-Yishay (1933– to develop. The First World War (1914–1918) precipitated 2021) and Leonard Diller (1924–2019), at the Rush Institute the emergence of large-scale efforts at neuropsychological of Rehabilitation Medicine at New York University School rehabilitation. Persons with traumatic brain injuries of Medicine, in conjunction with the Israeli government, (TBIs), typically secondary to gunshot wounds, survived at developed a pilot rehabilitation program for brain-injured unprecedented rates given advancements in neurosurgery and Israeli war veterans. Many of Goldstein’s ideas, coupled with the treatment of infections. Governments invested enormous the rehabilitation technology Diller had developed with stroke amounts of resources to rehabilitate these surviving soldiers. In patients and Ben-Yishay’s experience living in Israeli community countries such as the United States and Germany, it became a settings, were successfully applied to these patients. Their national priority. demonstration of successful outcomes resulted in a funded In 1918 Walter Poppelreuter (1886–1939) published 5-year clinical research study in the United States and the what is considered the first treatise on neuropsychological establishment of the Rusk Institute Brain Injury Day Treatment rehabilitation: Die Psychischen Schädigungen Durch Kopfschuss Program (New York). Based on the successful outcome of this im Kriege 1914/17 (Poser et al., 1996). At the same time, research study, the program became an established clinical Kurt Goldstein (1878–1965) developed a holistic model of service at the Rusk Institute, one which continues to this neuropsychological rehabilitation (Goldstein, 1939, 1942). He day (Ben-Yishay, 1996). The central tenant of this holistic argued that exclusively focusing on cognitive rehabilitation is approach is that “to restore a brain-injured individual to not adequate. He emphasized the importance of also addressing function optimally, it is necessary to establish a therapeutic the personal and social problems faced by war veterans. milieu that is experienced by the injured person as “safe” (in The aim of neuropsychological rehabilitation, according to the sense that, the chances for the occurrence of “catastrophic” Goldstein, was not only to help brain-injured soldiers recover responses by the patient to perceived threats will be reduced). or compensate for their higher integrative brain dysfunctions, In this “safe” environment, the injured individual can gradually Frontiers in Psychology 02 frontiersin.org García-Molina and Prigatano 10.3389/fpsyg.2022.963287 begin to use still intact capacities and learn compensatory Ben-Yishay. In the first decade of the twenty-first century, a skills. The compensation process helps the person attain clinical research project is now being developed at the Virgen de an enhanced functional adjustment. Improvements in their las Nieves Hospital of Granada (Spain) (Caracuel Romero et al., functional adjustment will facilitate those individuals’ calm 2005; Caracuel et al., 2012). acceptance of the life-altering changes, or limitations, that were caused by their brain injury. Acceptance -it is hoped- will also help these individuals to find new meaning in their lives after rehabilitation” (Ben-Yishay and Diller, 2011; p. xii). Prigatano’s contributions to Ben-Yishay and Diller’s holistic neuropsychological holistic approaches to rehabilitation program provided a framework for ameliorating neuropsychological rehabilitation disturbances in the cognitive, psychological, and interpersonal spheres of the brain-injured patient. The program was organized In the 1970s and 1980s, a multitude of cognitive in a hierarchy of six stages that must be met successfully while rehabilitation programs proliferated to facilitate recovery undergoing rehabilitation (Ben-Yishay et al., 1985): after brain injury. However, only a few programs embraced the holistic approach. Greatly influenced by Diller and Ben-Yishay’s • Engagement: The goal is to have the trainee/patient ideas and methods, Prigatano began, in early 1980, a holistic become optimally activated to engage in a purposeful neuropsychological rehabilitation program at the Presbyterian and deliberate manner various remedial tasks. Hospital in Oklahoma City (Oklahoma) (Prigatano et al., 1986) • Awareness: The goal is to have the trainee/patient as noted above. In 1984, he published the first outcome paper on become aware of one’s problems, without being the effectiveness of a holistic neuropsychological rehabilitation overwhelmed by this knowledge. program. Eighteen traumatic brain-injured patients enrolled • Mastery: The goal is to have the trainee/patient learn to in the program were compared to 17 untreated TBI patients. compensate for their cognitive deficits. The groups were compared on cognitive tests, personality • Control: The goal is to have the trainee/patient learn measures, emotional status, and employment measures. Treated to concentrate on the idea behind the act and on its patients had a higher incidence of employment, and their ultimate objective, rather than on the “mechanics,” or emotional status was considerably better than that of the how the act is to be carried out. untreated group. Ten years later, Prigatano and his colleagues • Acceptance: The goal is to have the trainee/patient begin provided empirical evidence that the therapeutic alliance with to feel that life, as is, is worth living and that they can still brain-injured patients and their families related to patients’ derive some pleasure in his/her present life. productivity status post rehabilitation. These findings provided • Identity: The goal is to have the trainee/patient learn to evidence that holistic milieu-oriented neuropsychological reconstitute, to some extent at least, his/her identity. rehabilitation approach for post-acute brain dysfunctional patients improved their psychosocial outcomes (i.e., increased Ben-Yishay and Diller’s holistic program has been the the likelihood of employment and reduced level of emotional model for several holistic neuropsychological rehabilitation distress) (Prigatano, 1999). programs over the world. Between 1979 and 1985, for Prigatano emphasized that it is artificial to separate cognitive instance, George P. Prigatano adapted that model to develop and emotional disturbances in these patients, since how we a holistic neuropsychological rehabilitation program at the feel affects how we behave and how we think. He argued Presbyterian Hospital in Oklahoma City (Oklahoma) (Prigatano that patients’ emotional and motivational reactions to their et al., 1986). In 1985, he moved to the Barrow Neurological impairments greatly contribute to their degree of disability. Institute (BNI) (Phoenix, Arizona) to continue this work and He, like Goldstein and Ben-Yishay before him, stressed the establish a Department of Clinical Neuropsychology. Anne- importance of establishing a therapeutic milieu as a key Lise Christensen (1927–2018), influenced by the work of Ben- component of the successful brain injury rehabilitation: “Group Yishay and Prigatano, founded a holistic program in 1985, the work alone does not define a holistic approach; rather, it Center for Hjerneskade in Copenhagen (Denmark) (Caetano is placing an individual in a therapeutic environment that and Christensen, 1999). In 1991, Marja-Liisa Kaipio created a influences psychosocial outcomes” (Prigatano, 1997, p. 497). holistic program at the Käpylä Rehabilitation Centre (Kaipio In 1999 Prigatano published Principles of Neuropsychological et al., 2000; Sarajuuri and Koskinen, 2006). In November 1996, Rehabilitation, one of the seminal books in contemporary the Oliver Zangwill Center was inaugurated in Ely (England), neuropsychological rehabilitation (Prigatano, 1999). Based on thanks to the perseverance and tenacity of Barbara A. Wilson his experience at the Presbyterian Hospital and the BNI, et al. (2000). In 2008, the ELEPAP-Rehabilitation for The Prigatano postulated thirteen principles that act as a guide Disabled Holistic Neuropsychological Rehabilitation Program for treatment of people with neuropsychological disorders (see was established in Athens in conjunction with the input of Dr. Table 1). These principles are aimed at enabling individuals Frontiers in Psychology 03 frontiersin.org García-Molina and Prigatano 10.3389/fpsyg.2022.963287 to regain a productive lifestyle and restore meaning to post-acute holistic neuropsychological rehabilitation programs their lives. Prigatano highlighted the importance of the for brain-injured children. Children usually return home patient’s premorbid cognitive and personality functioning as and/or to school with limited understanding regarding determinants of neuropsychological rehabilitation process and the management of their behavioral problems and the outcomes. Emphasis was also placed on understanding the repercussion of their cognitive deficits. This situation not patient’s phenomenological experience in relation to their brain only has a negative impact on children but also on parents injury. Prigatano’s contributions facilitated our understanding and teachers. Prigatano proposed that the effectiveness of the of important ingredients in neuropsychological rehabilitation in pediatric neuropsychological rehabilitation programs should adult brain-injured patients. be evaluated in four domains: (1) academic performance, With his emphasis on the need to clinically address (2) peer relationships, (3) parents’ level of anxiety, and (4) the emotional and motivational disorders experienced by teachers’ level of anxiety. In brain-injured adults, the central brain-injured patients, Prigatano highlighted the importance problem is coping with lost normality and helping them to of psychotherapy in neuropsychological rehabilitation. When be productive and maintain interpersonal relationships, while this idea was introduced in the 1980’s, many professionals fostering their own individuality. In children, the goal of post- thought that psychotherapy was contraindicated in brain- acute neuropsychological rehabilitation is to facilitate normal injured patients. Prigatano proposed that the “loss of normality” developmental trajectories. after brain injury can be understood as a loss of the possibility When commenting on the future of neuropsychological to fit into societal standards, cultural notions, or archetypes - rehabilitation, Prigatano et al. (2021) proposed that in the Jungian sense- regarding what is considered desirable neuropsychological rehabilitation is entering a new era. and valuable in human beings (i.e., beauty, intelligence, Understanding the mechanisms of change associated with success) (Salas, 2021). Therefore, he posited that psychological improvement in higher integrative brain functions requires a interventions for brain injured survivors can incorporate close collaboration with scientists involved in understanding Jungian insights in their care. It helps brain-injured patients neuroimaging findings and markers of positive and negative explore new cultural symbols to find a place in the world neuroplasticity changes. In this regard, studying the complex and rebuild meaning in their life (i.e., work, love, and play) phenomena of diaschisis, at both the cortical and subcortical (Prigatano, 1989, 2012). Prigatano argued that psychological levels, may well guide neuropsychological rehabilitation in the tools should be adapted to facilitate the reconstruction of the self future just as Luria et al. (1969) originally suggested. after injury. Psychotherapy should teach the patient to learn to behave in his or her best self-interest. This does not mean selfish self-interest. It means learning to meet one’s own needs fairly Prigatano’s contributions to and consistently. clinical neuropsychology Prigatano explicitly stated that psychotherapy could be of value to brain-injury survivors in several areas (Prigatano et al., Prigatano is known principally for his contributions 1986). It should attempt to: to holistic approaches to neuropsychological rehabilitation. However, his professional work has also influenced clinical • Provide a model that helps the patient understand what neuropsychology. has happened to him or her. While working at Presbyterian Hospital in Oklahoma • Help the patient deal with the meaning of the brain City, Prigatano noticed that many of the patients showed an injury in his or her life. apparent lack of self-awareness of their cognitive and behavioral • Help the patient achieve a sense of self-acceptance. impairments and minimized the impact of their brain disorder • Help the patient make realistic commitments to work on daily functioning (Prigatano, 1999). In October 1988, with and interpersonal relations. Daniel L. Schacter he organized a scientific conference on the • Teach the patient how to behave in different phenomenon of altered deficit awareness after brain injury. The social situations. papers of the conference were published in 1991 under the title • Provide specific behavioral strategies to compensate for Awareness of Deficit after Brain Injury: Clinical and Theoretical neuropsychological deficits. Issues (Prigatano and Schacter, 1991). This book brought the • Foster a sense of realistic hope. study of impaired awareness to the attention of many clinical neuropsychologists, who not had previously considered it to be Prigatano’s work with children with brain injuries is an important area of clinical investigation. less well known. At the Brain Injury Rehabilitation Trust Twenty years later, in October 2008, Prigatano organized a Biannual Conference, held in September 2011, Prigatano second meeting to address anosognosia and related syndromes. presented the paper Challenges and opportunities facing Two years later, he published The Study of Anosognosia holistic approaches to neuropsychological rehabilitation (Prigatano, 2010). In the preface of that book, Prigatano stated (Prigatano, 2013). He points out that there are almost no that the study of anosognosia is important for several reasons: Frontiers in Psychology 04 frontiersin.org García-Molina and Prigatano 10.3389/fpsyg.2022.963287 – Patients with brain disorders may have reduced self- deficits after brain injury (Prigatano et al., 1986). Following awareness of residual neurological or neuropsychological a discrepancy-based approach, the PCRS is administered impairments that negatively impact their clinical care. to the individual with a brain injury and an informant – Understanding the biological and neuropsychological (e.g., family member or rehabilitation professional). Both mechanisms responsible for anosognosia in its various are asked to judge the individual’s ability to do a variety forms may reveal important insights into brain of everyday tasks. The resulting total discrepancy score organization and how human consciousness is possible. indicates the overall level of self-awareness. Currently the – The comparative study of anosognosia in patients with PCRS is one of the most widely utilized questionnaire- brain disorders in comparison to patients with psychiatric based measures of self-awareness (Kolakowsky-Hayner, disorders may provide rich insights into the “body- 2010). mind” problem. Prigatano (1999) observed that traumatic brain injured – Understanding the basis of how anosognosia changes patients who finger tapped slowly in Halstead Finger Tapping with time (i.e., “recovers” or “worsens”) may provide Test tended to overestimate their behavioral competence in important insights into mechanisms of “recovery” and comparison with relatives’ reports. Years later, Prigatano (1999) “deterioration” after various brain disorders. This has clear demonstrated that speed of finger tapping may be a useful implications for treatment and patient management. behavioral marker for predicting goal attainment during early stages of neurorehabilitation after a unilateral stroke. These In bringing attention to the fact that many people findings led Prigatano to consider that this apparently “simple” with different brain disorders overestimate their abilities, task of speed of finger movement would be sensitive to the presumably because of their altered awareness of deficits, severity of disturbances of self-awareness and rehabilitation he also developed, in collaboration with his colleagues in outcome (Prigatano, 1999). Oklahoma City, the Patient Competence Rating Scale (PCRS), Among the best known, and most used, cognitive which was designed as a scale to determine awareness of screening tests are the Mini-Mental State Examination TABLE 1 Prigatano’s principles of neuropsychological rehabilitation. Principle 1 The clinician must begin with patient’s subjective or phenomenological experience to reduce their frustrations and confusion to engage them in the rehabilitation process. Principle 2 The patient’s symptom picture is a mixture of premorbid cognitive and personality characteristics as well as neuropsychological changes directly associated with brain pathology. Principle 3 Neuropsychological rehabilitation focuses on both the remediation of higher cerebral disturbances and their management in interpersonal situations. Principle 4 Neuropsychological rehabilitation helps patients observe their behavior and thereby teaches them about the direct and indirect effects of brain injury. This may help patients avoid destructive choices and better manage their catastrophic reactions. Principle 5 Failure to study the intimate interaction of cognition and personality leads to an inadequate understanding of many issues in cognitive (neuro) sciences and neuropsychological rehabilitation. Principle 6 Little is known about how to retrain a brain dysfunctional patient cognitively, because the nature of higher cerebral functions is not fully understood. General guidelines for cognitive remediation, however, can be specified. Principle 7 Psychotherapeutic interventions are often an important part of neuropsychological rehabilitation because they help patients (and families) deal with their personal losses. The process, however, is highly individualized. Principle 8 Working with brain dysfunctional patients produces affective reactions in both the patient’s family and the rehabilitation staff. Appropriate management of these reactions facilitates the rehabilitative and adaptive process. Principle 9 Each neuropsychological rehabilitation program is a dynamic entity. It is either in a state of development or decline. Ongoing scientific investigation helps the rehabilitation team learn from their successes and failures and is needed to maintain a dynamic, creative rehabilitation effort. Principle 10 Failure to identify which patients can and cannot be helped by different (neuropsychological) rehabilitation approaches creates a lack of credibility for the field. Principle 11 Disturbances in self-awareness after brain injury are often poorly understood and mismanaged. Principle 12 Competent patient management and planning innovative rehabilitation programs depend on understanding mechanisms of recovery and deterioration of direct and indirect symptoms after brain injury. Principle 13 The rehabilitation of patients with higher cerebral deficits requires both scientific and phenomenological approaches. Both are necessary to maximize recovery and adaptation to the effects of brain injury. Frontiers in Psychology 05 frontiersin.org García-Molina and Prigatano 10.3389/fpsyg.2022.963287 (MMSE) (Folstein et al., 1975) and the Montreal Cognitive when making important life decisions. Those teachers also Assessment (MoCA) (Nasreddine et al., 2005). The usefulness emphasized, in my philosophy courses at Loyola University of these two cognitive screening tests in neurorehabilitation, in Los Angeles (1962–1966), that no theory is “right” or however, has been questioned. In the 1990s Prigatano created a “wrong.” The usefulness of a theory depends on its ability specific a cognitive screening test to assess patients with brain to explain or predict a given phenomenon. This instilled a injuries called The Barrow Neurological Institute Screen for questioning attitude toward any “dogma” which told clinical Higher Cerebral Functions (BNIS) (Prigatano et al., 2022). The neuropsychologists how to practice their profession. BNIS includes an assessment of affect and awareness, along with measures of various cognitive domains. This broader scope account for the BNIS’s more accurate predictions of Early influences in the study of rehabilitation outcomes. It also demonstrated that disturbances psychology in affect, as measured by this screening test, were sensitive to various brain disorders. During my undergraduate education, both philosophy and His influence in clinical neuropsychology, therefore, was psychology were emphasized. I was therefore very much to expand the scope of a traditional neuropsychological influenced by the debate been Carl Rogers and Burrhus Frederic assessment to include assessments of awareness and affect. He Skinner at that time. It was true that behavior is a function also demonstrated that impairments in self-awareness exist in of its consequences (as Skinner scientifically demonstrated). various patient groups even when frank anosognosia is not However it was also true that entering the patient’s subjective present. Finally, his research on finger tapping emphasizes the experiences, in order to help them clarify how they are need to have “simple,” direct measures of behavior that can experiencing themselves and the world around them, could be monitor the recovery and deterioration of brain function over very important in helping them find meaning in their lives time. This perspective expanded the role of neuropsychological and reduce their psychological suffering in its many forms assessment from diagnosis to prognosis. (i.e., anxiety reactions, depression, angry outbursts, impaired interpersonal relationships etc.) as Carl Rogers quietly but persuasively stated. Autobiographical summary During pre-doctoral academic training as a clinical (Prepared by GPP) psychologist, my teachers emphasized the role of learning-based techniques for reducing behavioral problems. I was taught such I was born on September 13, 1944. My father was the procedures as systematic desensitization to reduce certain types product of the Great Depression and left school in the of anxiety or avoidance behaviors in college students seeking 8th grade to work to save the family’s home. My mother services from the Department of Psychology’s Psychological was born in Sicily and moved to the United States at Clinic. The theories of Freud, Jung and Adler were glossed age 4. One of her brothers became a physician while the over in my academic doctoral training program and considered other became a chemist trained at Princeton University. having no scientific and little clinical value. This second brother (i.e., Uncle Joe) spent a lot of Later, during my pre-doctoral clinical internship at time with me during my childhood and served as an the University of Oklahoma Health Science Center, I was important role model who emphasized the importance of confronted with the real problems of psychiatric patients (i.e., education, working hard, and speaking one’s mind. My alcohol abuse, psychosis, severe depression and anxiety, severe father and his father emphasized the very same values as personality disorders, etc.). Listening to these patients’ life I was growing up. stories and current struggles, it became clear that the teachings Being a product of an Italian-American family, I was of Rogers and Skinner were only partially helpful. The teachings raised Catholic and attended Catholic grammar school and of Freud, Jung, and Adler suddenly seemed to be very relevant high school. At around age 8, I read about the life of “Father to these psychiatric problems. Damien.”1 It had a deep personal significance for me. It I was fortunate to obtain excellent supervision from was a true “hero’s story” that moved me consciously and experienced psychiatrists particularly influenced by Freudian unconsciously into a clinical profession. and Neo-Freudian theories during this time. The role of In college, I was educated by Jesuit priests who emphasized unconscious influences on behavior now became clearer to me; the importance of the individual to think for themselves working with these influences seemed to produce meaningful behavioral changes and a reduction of personal (psychological) suffering in some of the patients I helped treat. 1 Father Damien (1840–1889) was a Belgian priest who worked as a During my pre-doctoral clinical psychology internship, I missionary at the Molokai leprosy settlement (Hawaii’s fifth largest island). In 1884 he contracted leprosy. Even though the illness was slowing his was also introduced to the field of neuropsychology by Oscar body down, Damien engaged in a lot of activities during his last years. Parsons, who emphasized the importance of writing a clear Frontiers in Psychology 06 frontiersin.org García-Molina and Prigatano 10.3389/fpsyg.2022.963287 neuropsychological report and publishing one’s findings in a clinical and theoretical question. Was it possible for a brain concise manner. This influence persists in my professional life dysfunctional person to have altered self-awareness of a as a diagnostician, a psychotherapist, and a researcher. neuropsychological disturbance due to the direct effect of a brain disorder (i.e., anosognosia or impaired self-awareness) and at the same time minimize the presence or extent of a Post-doctoral influences neuropsychological impairment as a method of coping with anxiety over the presence of that impairment (i.e., defense Many individuals had a substantial impacted my clinical denial)? That question lead to a long series of studies done with and research work, as acknowledged in previous publications colleagues to help arrive at a reasonable answer. The answer was (Prigatano, 1999, 2019). In the area of neuropsychology “yes.” assessment, the work of Ward Halstead and Ralph Reitan Undoubtedly, however, the biggest influence on my work was especially influential, particularly when it came to in neuropsychological rehabilitation came from my professional choosing neuropsychological tests to administer to patients interactions with Leonard Diller and Yehuda Ben-Yishay. The when attempting to answer the old question of whether development of a holistic approach that including both cognitive there were reliable and valid behavioral indicators of rehabilitation and psychotherapy now became a passion for me. underlying brain pathology. Hearing Dr. Reitan tell clinical Dr. Ben-Yishay played a very special role in helping me organize neuropsychologists at professional meetings that they were a day treatment program and provided me with a methodology not very good at assessing individual differences in normal for approaching the cognitive rehabilitation of patients with neuropsychological functioning left a lasting impression chronic brain injuries who had not benefited from traditional on me. I was further influenced by Gertrude Baker’s use of forms of rehabilitation. projective techniques when evaluating persons suspected of an Being impressed with the importance of impairments of “underlying organic brain syndrome” (Baker, 1956). Her work self-awareness in the rehabilitation process, I worked with provided unique information as to what a brain dysfunctional patients to determine if their emotional state could be improved. person experiences when confronting vague or unclear visual However, it was unclear to me as to the best way of approaching stimuli. this domain of the patients’ lives. Early in our rehabilitation I also found the writings of Karl Pribram especially work, a young man presented me with a spontaneous drawing, interesting since he discussed Freudian concepts within the which reflected his phenomenological experience of his brain context of the neurosciences (Pribram, 1962; Pribram and Gill, injury on his life and how he was attempting to come to 1976). After presenting a paper at a conference in Oxford, grips with the consequences of his brain injury in the most England, I met Karl Pribram. I expressed my interest in productive manner. A picture of the drawing is found in understanding how memory and emotion are organized in the Prigatano et al., 1986, p. 85, Figure 5.4. The picture captured brain and how they are affected by various brain disorders. many important themes, but most importantly the artistic Dr. Pribram invited me on the spot to come to Stanford and work of the patient presented new insights as to what many study with him. It was not a difficult decision but a risky one. brain dysfunctional patients personally struggle with following Having just been promoted to a tenured position as an Associate their injuries. It provided insights as to how to best help Professor, I would have to leave that security to purse what was them with their emotional and motivation struggles. The most meaningful to me. With the support of Dr. R. Barton Carl, role of individual and group psychotherapy was now firmly neurosurgeon, that decision was made, which was a life changing established in the holistic programs of neuropsychological event for me. rehabilitation I developed (both in Oklahoma City and Phoenix, In my initial efforts at holistic neuropsychological Arizona). rehabilitation with post-acute young adults with severe Many individuals influenced my thinking about traumatic brain injury, I became impressed that many of psychotherapy. They are listed by name in the Preface these patients seemed to not be aware of or were denying of my most recent book (Prigatano, 2019). By and large, the presence and severity of various neuropsychological however, it was the writings of Carl Gustav Jung and his impairments. Reviewing the existing literature at the time, trainees that have had the greatest impact. After reading I came across Weinstein and Kahn’s (1955) book Denial Bach’s (1969) book The Spontaneous Paintings of Severely of Illness: Symbolic and Physiological Aspects. It was the ill Patients: A Contribution to Psychosomatic Medicine, I only book that seem to address this important issue. I sought out a personal consultation with Dr. Bach, a Jungian asked Edwin Weinstein to participate in an American analyst living in London. The discussion left an indelible Psychological Association symposium I had organized on mark on how I thought about the unconscious and how neuropsychological rehabilitation. Weinstein accepted the it influences various art expressions that can inform the invitation, and we began several dialogues about denial psychotherapist about what the patient is experiencing. These phenomenon. Weinstein’s insights helped clarify an important art forms often point to the next step in their psychological Frontiers in Psychology 07 frontiersin.org García-Molina and Prigatano 10.3389/fpsyg.2022.963287 development as clearly described in Kalff’s (1980) book to establish a Holistically Oriented Neuropsychological Sandplay. Rehabilitation Program like the one he developed at These professional dialogues lead to several papers on Presbyterian Hospital in Oklahoma City. That program the importance of symbolism in the neuropsychological was influenced and supported of two key figures -Yehuda rehabilitation process. Helping patients relate to their symbols Ben-Yishay, Ph.D. and R. Barton Carl, M.D.-. He was the of work, love and play guided psychotherapeutic efforts Founder and first Chairman of the Department of Clinical when supporting their return to a productive lifestyle and Neuropsychology at the BNI from 1985 to 2014. From 2014 re-establishing meaning in their lives. Symbols involving to this date, he has been the Emeritus Chairman and has the hero’s journal now became an important prototype remained clinically and academically active. He served as of the psychotherapeutic process for many individuals the President of the National Academy of Neuropsychology (Prigatano, 1999). It continues to influence my present-day in 1998. In conjunction with Neil Pliskin edited the first psychotherapeutic work with patients with various brain book on the importance of cost outcome research for the disorders as well as functional movement disorders. future of clinical neuropsychology (Prigatano and Pliskin, 2003). Over the course of his career, Dr. Prigatano has lectured Summary comments nationally and internationally on the various topics listed above. His most recent workshop was held at the National Academy of The intent of this paper was to first summarize the Neuropsychology meeting in December of 2021. He spoke on contributions of George P. Prigatano during his 50th year of the important role of providing psychological care for persons practice from the perspective of a part-time amateur historian with various brain disorders. The lecture was devoted to the and to then to combine that perspective with Prigatano’s memory of Leonard Diller and Yehuda Ben-Yishay. own views of the primary influences on his work. Normally, the person’s professional career is reviewed by others, and the person’s own view of what influenced their work is not present. We believe both sources of information can be useful Author contributions in historical accounts. It is our hope that this paper has All authors listed have made a substantial, direct, and achieved that goal. intellectual contribution to the work, and approved it At the conclusion of this paper, we include an for publication. Addendum that summarizes George P. Prigatano’s professional career to date. Acknowledgments Addendum: Brief review of George P. Prigatano’s 50 year career We thank Dr. Tiffany Meites for her editorial assistance in preparing the manuscript for publication. George P. Prigatano obtained his Ph.D. in Clinical Psychology on August 31, 1972 from Bowling Green University in Ohio. He attended Bowling Green University because it Conflict of interest offered a joint Ph.D. degree in both Industrial and Clinical Psychology, but soon his interests turned to Clinical Psychology. The authors declare that the research was conducted in the During his pre-doctoral clinical psychology internship at the absence of any commercial or financial relationships that could University of Oklahoma Health Sciences Center, he was be construed as a potential conflict of interest. introduced to a new field of study called neuropsychology. After completing his Clinical Psychology Internship, he became an Assistant Professor of Psychiatry and Behavioral Sciences and was the Director of the Neuropsychology Testing Laboratory. 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