barth_method-skeptics

barth_method-skeptics - Neuropsychology Review, Vol. 2, No....

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Unformatted text preview: Neuropsychology Review, Vol. 2, No. 3, I992 Forensic Neuropsychology: A Reply to the Method Skeptics Jeffrey T. Barth),3 Thomas V. Ryan,‘ and Gary L. Hawk2 Various critics or “method skeptics” have contended that clinical neuropsy- chology is not sufficiently developed as a science to be ofi‘ered as evidence in ' legal or trial proceedings. The present article attempts to balance the extreme position of the method skeptics with an overview of legal and research data that support forensic applications of neuropsychology. It is suggested that clini- cal evidence can usefully inform legal decision making and that the modem trend has been for courts to be increasingly open to such expert testimony. The relevance of studies of clinical judgment, experience, and actuarial prediction is discussed, and neuropsychological assessment validity is specifically ad- dressed. It is concluded that the arguments of the method skeptics should guide future research and caution forensic neuropsychologists, but that a retreat from the courtroom is unwarranted. 7 INTRODUCTION It was only ten years ago that McMahon and Satz (1981) addressed themselves to the “stimulating and challenging” issues associated with clini- cal neuropsychology in the forensic setting, and just six years since Caipls Z 5 ’ . «21%;. Which of us has not felt great satisfaction in assisting our patient g, and a trier of fact, in understanding some of the intricacies of brain-be- 1Department of Behavioral Medicine and Psychiatry, University of Virginia Medical School, Charlottesville, Virginia 22901. 2Institute of Law, Psychiatry and Public Policy, University of Virginia, Charlottesville, Virginia 22901. . , 3To whom correspondence should be addressed at Department of Behavioral Medicine and Psychiatry, University of Virginia Medical School, Box 203, Charlottesviile, Virginia 22901. 251 1040-7308/91/0900-025150650/0 0 1991 Plenum Publishing Corporation ‘1er my; , :;'f"\ @fifi?fifivxewnmrfiv=r‘""; “=A - Ea Sfififl.; pi g ufifi%r ‘Vfifi*3%F' mqsfifimnmnfiflfidEMEmwfififlfflfififfifiamqmsqggéasfigébiggflfie “I ' M,*%fi% 7fififififi%fiflfiflmmfififlfifififibfififififiufifififlfififiba ¢©5$mfliun= mfigfififl9 '(LL6I V 1qu Knusssld ;nq ‘90961 Apes pue s0g61 sq; u; 100p moonmos sq; u! 100; 2 Que peq sAeq flew Kfioloqo/(SJ '(686[ ‘uogegoossv mg ueonsLuV "80) ’- ssnss; go sfiue; pBOJq B Eugplefisl s;s;Soloqsfisd {110.1} Kuoumss; ;Jsdxs swos -[9M pue )[sss [{[supnw sunoo sq; ‘(6361 ‘;sned) unoo u} Kfiopqs/(sdomsu Jo smeA sq; Eugplefisl pssgel ussq sABq Jeq; snoussnb go suds u1 ADO’IOHOASJOHHEN OISN'ERIOJ (INV SGHVGNVLS rIVDEI’I 'sombs slqusm 2 mm; uopeuuogu; ;ueAs[sJ flue go nonmusssld sq; Jspysu03 o; 102; f0 by; sq; ssAooqsq sssuqe} go sumoop sq; mq ‘ssuqdyssyp [BogfiopquSd pL‘Ie {eagpsw Js'q;o Klqeu’mssld pue splay; quesq IEJUQLU sq; u;an suog‘mgwq aqymsps spuos go smme sm s;.1nos mq; s;ss§fins sum; (09,; ‘d) “mom unoo sq; 11101; SJJQdXQ sq; .mq 0; ma ‘uopunIBAs ogsuslo; much; 0; s; wslqmd sgq; o; ssuodss; besssosu pue s;e;.1d01dde sq;,, wq; p913933ns ;nq ‘sSugpssOOJd [eugwpo u; suopenxe/ss quesq [BJUQLU ogsusJo; [alsusfi fiugpmfisl ulsysg;dsi)ls Jgsq; s;ou o; uo msm qul (09;; 'd) “.IQJJO 0; qonul seq uepguq’s psugeJ; nsm sq; ‘sApostJsd sgq; LUOJd 'sspsnf psus;q3qus ‘sueugnq 30 may; I; pun sssuqe; go suogexspgs -uoo‘ Kq uuq; suqd‘gosgp sq; go sgse'q agnusyos sq; u; qua; Aq‘sssl psq‘mw” s; ubgugd’o quesq‘ [BJUQLU .1!an u‘; 139mm; S‘MEI sq; ‘JogA'eqsq-uewnq Eugous -ngu; 5310158; JO‘Sugpumsispun psuiuq pt‘m sloo‘; [esyuqs ssszdw! s‘Jeuogs -ss;01d qqesq ~|e;us1u spsusfi 910w sq; Bupspy'suoo usqm ps;ss§3ns (0361) ugfioqolg pue sgm‘Joa 5:2 ‘139’; ‘uI ‘psux'e‘qsu sq o; sAB’q Kumsssosu JOU op mq ‘ssJ‘Se‘ Kupe‘sj ueo [lie sm qr)ng o; ‘Koumug 8;; u! 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Kuomgss; usdxs [eogfloloqofisdomsu go saueAsIsJ pue Impule sq; go uog;ssnb [muswepum sq; ';usw3pn[ [eoyuqs u; ssuspsdxs pue Bugugen JO sssuIansn sq; pue ‘spqusuI pue ssnbyuqos; SJ; go Impqu pue ‘Aomnooe ‘uopesnsquos sq; o; SQJBIQJ 3; s12 Kfiqoqo/(sdomsu [Boguqo JO KseLUpyfisI sq; Bugsswoo s19 “sopdsxs pqusLu” SB 8961 u! 0; pQJJQJQJ sguow wqm mq; pug mou 9M wk [’QLUOOJUO [Imogene/x pue [egoosoqo/(sd pue ‘uogemgqeq -sJ ‘ss/uno KJQAOOQJ ‘sgsoufieyp o; soueAsIsJ .1]an pue sdgqsuoyuqsx .xogAeq mm" pun ‘unxn ‘1".qu zgz 254 Barth, Ryan, and Hawk Experf'witnesses in court testify about subjects that are considered ' to be outside of lay knowledge. Prior to testimony, inquiry is typically made by the court into the qualifications of a proposed expert. A witness may be considered to be an expert based upon knowledge, skill, training, expe- rience, or education in a specialized area such as neuropsychology (Federal Rules" of Evidence, Rule 702, 1984). Educational degree, and licensing or certification, typically represent minimal or threshold qualifications for neu— ropsychologists who are offered as expert witnesses in court, but other standards and guidelines further emphasize the importance of additional specialized clinical and forensic training or experience (American Bar As— sociation, 1989; American Psychology—Law Society, 1990). Neuropsycholo- gists must have adequate clinical training and background to address the specific evaluation issues in a particular case. This is also a basic ethical parameter for the competent delivery of services (American Psychological Association, 1989). Forensic knowledge of the legal and professional stand- ards relevant to those participating in judicial proceedings is an additional and essential component of a psychologist’s qualifications as an expert (Shah and McGarry, 1986; Melton et al., 1987). The courts have too often been ill-served by well-meaning clinicians who lacked a basic understanding of the legal issues being adjudicated or how to relate their findings to that issue (l’oythress, 1979). Recent standards have also stressed the use of adequate evaluation methods in forensic practice (American Bar Association, 1989; American Psychology-Law Society, 1990). At the basic level, forensic assessment typi- cally calls for personal interviews with defendants or litigants, as well as proper documentation and awareness of the relevant confidentiality and consent issues. More specifically, forensic evaluation requires thorough background and record review, collateral interviews, and standardized as- sessment technology. Mata‘razzo (1990) has‘recently d‘esCribed “state of the art” psychological assessment, with an emphasis on neuropsychological ap- proaches, in which test findings are integrated with personal, educational, occupational, and clinical information (cf. Grisso 1986; Kennedy, 1986; Melton et al., 1987). Generally, the scope of the testimony offered by an expert witness will encompass scientific, technical, or other specialized knowledge that will assist the trier of fact in understanding the evidence or in determining a fact at issue (Federal Rules of Evidence, Rule 702, 1984). “Specialized knowledge” is not limited to scientific knowledge (American Bar Associa- tion, 1989, p. 120), and clinical experts such as neuropsychologists are usu- ally permitted to testify regarding aspects of their practice that may not necessarily be characterized by demonstrably high levels of scientific accu- racy. The admissability of expert testimony may require that it be consid- Forcnsic Neuropsychology: A Reply 255 ered incremental, or of assistance to the trier of fact, but not that it be dispositive (Bonnie and Slobogin, 1980). Rather than eXcluding opinion of marginal assistance, ’ ' ~ . eightaaa , "W‘lflfi-‘h ‘ v- hematite::hascsrofiahe' ). Cross-examination Serves as the appropriate 'termin‘ing' the ultimate usefulness of expert testimony and weight to be assigned to it, particularly mental health testimony (Ford v. Wainwright, 1986). There is broad agreement that testimony should stop short of “ultimate opinions” (e.g., whether a defendant is legally insane or civilly at fault) that represent moral or legal judgments for which the expert has no specialized knowledge, and are properly reserved for a judge or jury (e.g., American Bar Association, 1989; American Psychiatric Associa- tion, 1983; Melton et al., 1986). It has been suggested that “tests” applied by some jurisdictions to determine the admissability of scientific-evidence call for standards of re- liability and validity that preclude most psychological or neuropsychological testimony (Ziskin and Faust, 1988). One of the most common of these is the Frye test, which demands of the technique or theory to be offered as evidence “general acceptance in the particular field in which it belongs (Frye v. (1.5., 1923). Various authors have pointed out, however, that such “general acceptance” does not require a particular level of scientific accu- racy or validity (Hoge and Grisso, 1992; Bonnie and Slobogin, 1980). More- over, when Frye has been applied to mental health testimony, it has focused on the scientific acceptability of the methodology underlying the testimony rather than the conclusions expressed by the expert (Kinports et al., 1983; American Bar AssoCiation, 1989). It has also been noted that "a standard broader than Frye has been included in the Federal Rules of Evidence (Rule 702, 1984), which allows opinion regarding specialized knowledge that will assist the trier of fact (Roesch et al., 1991). Also related to the accuracy of expert testimony are court rules that Y may require that an expert’s opinions be made with “reasonable medical certainty.” There is no agreement among physicians or psychologists as to what constitutes such reasonable certainty (cf. Rogers, 1986; Diamond, 1985), and it has been suggested that the term has the effect of transform- ing the probabilistic nature of most scientific and clinical conclusions into more absolute sounding language for courtroom consumption (Melton et al., 1987). The notion that reasonable medical certainty means “pretty likely accurate” (Faust and Ziskin, 1988) has been disputed by Hoge and Grisso n their opinionsiAn-ieriean rPsychology=Iizaw‘Societyftw903mm :ps110dsJ (1861) u01s1pusd pue uowsH ‘K11eu1d. 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As Meehl (1973) has pointed out, such situations involving rare or unique combinations of predictor or criterion variables would seem to favor the clinical approach. (p. 815) Faust et al. (1988) in one of the only neuropsychological studies on the topic, attempted to improve upon the work of Goldstein et a1. (1973), Leli and Filskov (1981) and Wedding (1983) in evaluating the role of ex- perience in neuropsychological judgment accuracy by recruiting a large sample of psychologists whose neuropsychological credentials ranged from listing it as a specialization area in national directories to the successful completion of postdoctoral fellowships and a diplomate designation in the field. They asked each of these professionals to evaluate one of ten ran- domly assigned neuropsychological cases (eight abnormal, two normal) and to determine, by reviewing Halstead—Reitan data, the presence or absence of neuropathology (abnormal vs. normal), progressive vs. static nature of the condition, lateralization, and pathological process or etiology, among other questions. ‘” ' " I ' ‘ ' " st thOgLQalwpflchSS.mAS‘t“ , ome of. the re,sear_ch,,on,,the.theragt- ationsh-ipgrottoutcome,amatchingaon,key,,yariablesmismxtremely b.u:t-t..;zevidencevtfor. such..relation-ships...,is ,dramatically watered ,ntthe (group) research.because-oftthe.complexity. of) criticalmatchr- _ tr» 195.9- The Faust‘et a1. (1988) study did not match neuropsychologi'st’s"back- ground and expertise (the “expert”) with appropriate cases and questions, as often occurs in forensic evaluation. In addition, only two of the patho- logical conditions studied were truly representative of the types of cases so often seen in court (personal injury-head trauma litigation). Nevertheless, it is important to note that the overall hit rate of 80% for normal vs. ab- normal diagnosis was excellent and confirmatory. This hit rate compares favorably to most medical diagnostic procedures as well as other neuropsy- chological validation studies (discussed later). The overpathologizing of the two “normal cases” (diagnosing them as abnormal) is more troubling, but not entirely unexpected given the artificial nature of the task, lack of in- formation regarding present functioning, and a conservative diagnostic ap- proach, which is typical of most clinical practitioners. It is also difficult to evaluate these findings when the actual “normal” data are not presented. _,_ . n, v, .. ,, _... t, .1 N... ,. ,..:.. .. paw, . EDS/QTY... Forensic Neuropsychology: A Reply 259 Removing these two cases reveals an 86% hit rate on the overall appraisal, with an 88% accuracy on the two head trauma cases. These are reassuring findings when considering the sterile nature of the task, the diversity of experience and understanding of the test data, and the presumed use of actuarial, clinical judgment, and combinational diagnostic methods. More- over, the design of this portion of the study does not allow for great dis- crimination between experienced and inexperienced clinicians (since all had similar high bit rates and significant though different training and experi— ence); thus the negative findings lack meaning when addressing this issue. These results support the contention that diagnosing cerebral dysfunc— tion is not necessarily a difficult or complex task, and can be understood and appreciated early in one’s clinical neuropsychological studies. There are also some findings in the literature cited by Garb (1989) that “experts” in psychology/neuropsychology do perform better on basic diagnostic tasks than do “typical clinicians” with either high- or low-experience levels (Gold— berg, 1959), and that training is “positively related to validity for some as- sessment instruments and some tasks” (Garb, 1989, p. 391). More complex issues such as static vs. progressive lesions, localization, and etiology, as well as the important tasks of description of cognitive and behavioral strengths and weaknesses, treatment planning, and implications for every- day functioning, arguably require additional information and substantial cli- nician experience and training to even be considered. For example, when addressing the timeworn question of presence or absence of brain damage in a head injury case, a history of significant alcohol abuse may be irrelevant if purely answering a yes or no question, particularly if an actuarial ap- proach is utilized and etiology is not addressed. Yet the alcohol variable may have a significant effect on expert opinion regarding etiology and re- Accurate neurodiagnosis and understanding of neurobehavioral con- sequences and outcome is based upon analysis of many variables, the com- , bination of which have not been adequately investigated in the clinical judgment and experience literature. The research cited by the method skep— tics does not address the intuitively obvious issues of truly matching exper- tise which neuropathological condition or severity of disorder. Neuropsychological testimony actually involves probability statements that are clearly influenced by at least three dimensions: (1) amount of infor~ mation about the patient (including test data, observations, and history), (2) severity (and types) of disorders, and (3) level of experience with par- ticular pathologies. We are not referring to general neuropsychological ex- perience, but rather experience with the specific neuropathological process upon which the expert is being asked to testify. 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Extracting valid clinical inferences from a set of neurobehavioral test scores is dependent upon the presence and quality of normative data. Clini— cal neuropsychologists have been well aware of the need for such compari- son information as evidenced by emerging reports in the literature over the last several years (Yeudall et al., 1987; Franzen, 1989; Spreen and Strauss, 1991). Consideration of demographic variables in data interpreta— tion has been widely accepted as a crucial issue in neuropsychological analy— ses, with particular relevance for forensic clinicians. Heaton et a1. (1991) most recently published comprehensive norms for 54 cognitive, sensory, and motor measures, including the Halstead~Reitan procedures, on a demog- raphically diverse and large sample (N = 486). Raw scores can easily be converted into scaled and t scores. In his review of this comprehensive nor— mative publication, Boll (1991) stated that “the norms are without doubt the most extensive compilation of data on normal subjects that is available anywhere" (p. 13). This type of data base is essential to strengthen the validity of neuropsychological inferences. The method skeptics have also criticized neuropsychology on the grounds that test scores and indexes have not demonstrated value in relation to practical and everyday functional skills (Faust, 1989). As a profession, clini- cal neuropsychology has recently recognized the importance of ecological va- lidity apart from the diagnostic validity and descriptive purposes for which these cognitive and behavioral measures were originally designed. Some initial studies, however, have indicated that neuropsychological assessment tech— niques are capable of predicting various abilities unrelated and removed from the testing laboratory with modest accuracy (Dunn et (11., 1990;. Ryan etrrall,” 1990). Weaknesses in more traditional assessment approaches, particularly in relation to ecolOgical and rehabilitative validity and utility, have been de- scribed in conjunction with a proposal for the development of a practical, or problem-referenced, strategy of assessment (Heinrichs, 1990). It is clear that the field of clinical neuropsychology has mobilized in response to appropriate concerns raised both within, and outside, its profession. CONCLUSIONS 'Webster’s 1967 7th New Collegiate Dictionarysflefi es ea teen ‘ v. - hear-FDC~Eh®dss25k6pi§ics;.-fr0{,3. .. . .leaming—basedrperspective; even: though their rhetoric sometimes Forensic Neuropsychology; A Reply 263 appears "reactionary; overly-“negative,and “definitive'vvhen‘discussing the value of‘neurOpsycholOgical expert‘testimony. They have been successful in remind- ing us that our science is not perfect, and that we must not become so content with our knowledge base, research findings, validity and reliability of methods, and clinical judgments based upon data training and experience, that we fail to engage in critical self-examination. Clearly, we must continue to define and remediate our deficits. Their approach has involved the presentation of considerable general mental health research data suggesting that clinical judg- ment, in most instances, is inferior to actuarial methods in simple diagnosis, and that amount of experience does not necessarily relate to accuracy in such diagnostic exercises. They go on to generalize from these findings to forensic neuropsychology and contend that since this research indicates some weak— ness in some of our methodology, expert neuropsychological opinions should perhaps be barred from the courtroom. They further argue that since they are able to cite so much research in support of this view, and that a coun- teresearch literature is generally lacking, being good scientists, we must accept this view or suffer a terrible forensic fate. As we have attempted to suggest, much of the literature that the method skeptics utilized, although arguably flawed in some respects, is convincing with regard to some general trends in the mental health/psychology context, but may not be entirely applicable to forensic neuropsychology. We become method skeptics ourselves when evaluating this approach, and suggest that one must be very careful when generalizing this literature to neuropsychology and espousing such a radical position. The literature they cite has not com- pelled the courts to routinely exclude neuropsychological expert testimony. On the contrary, such testimony is typically admitted and the trend of appellate cases has been to expand the role of the neuropsychologist in the courtroom. Moreover, as Guilmette and Guiliano (1991) have recently demonstrated, the points that the method skeptics have made most forcefully are not the com- plete picture. While the neuropsychologist in court must be mindful of the . method issues, they can be addressed substantively with a broader data per- spective and adjustments in our approach to assessment. While everyone would agree that a great deal of research must yet be done to clarify the array of clinical judgement issues, we do not view a retreat from the courtroom in the interim to be an appropriate or constructive response. , REFERENCES American Bar Association. (1989). ABA Criminal Justice Mental Health Standards, Author, Washington DC. American Psychiatric Association. (1983). American Psychiatric Association statement on the insanity defense. American Jonmal of Psychiatry 140: 681-688. 'gg-gz :EL (ammofid pub molamaN fa mummy 'aauafimauu! 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SIEUO!SSD_}()Jd Imuoq [muaux JO mo: mLL '(0861) '3 ‘ugfioqms pun "u ‘nguuog > ‘fi-gI :8 1111311113 Halal/QICCdoxnaN [0 (we -pmV]monnN at“ 'suopeanddn [noguno pun sfiuypugj qamasm ‘suonaauuoo nqumfiownq :lfiauag uelgaa—peaaslefi papuudxa ue 10} suuou mgsuaqmdwog :smngAaJ mu, '(1660 "L ‘nog log-LL; ‘dd Suck maN Wan,“ ‘Afiolozple‘domaN [vaguyg jo )[ooqpupy ‘('sp9) 'f “L ‘nog pure “5; 's ‘onslgg uI ‘KJaueg AfloloqofisdomoN umgsH—puaxslen mm ‘(1350 ‘f '1, ‘H08 ' ’ - 'ZISI'SOSI =6£z aouaps- 'souapgAs ognuaps JO Mugqessgmpe at” 10} spmpums [939' fiugAIO/(a '(8850 ‘g ‘xnelg '[z-g 'dd ‘xiox MQN ‘KQHM ‘KBOIOIIOICYCI 91:11::be f0 .yooqpunH ‘('spa) 31 'V ‘sssH put: "3 '1 ‘J's'ugaM ut “Kfiomqokd oysuanJ‘JO £10133} ([351) 'w 'V ‘loimg pue "H '3 '[ozmg '[r-3 :[1' sMaN KJQIQOS M127-A30101pfid' uvoysmy ’s1sgfioloqa/(sd agsuaJo; Jo} ssugppgnfi Mlngaads (0660 'Klagaos meq-K‘Boloqoflsd ueaymluv 565-055 2917 15730101/91CS‘J unsymuy '(papuawu) slsyflogoqofisd JO snldpung [young '(586[) 'uoylepossv [eagfioloqofisd ueagmluv mm" pun ‘unflu ‘Inmgy r93 266 Barth, Ryan, and Hawk Reitht't, R? M. (1958). Validity of the Trail Making Test as an indicator of brain damage. Perceptual and Motor Skills 8: 271-276. Reitan, R. M. (1984). Aphasia and Sensory-Perceptual Deficits in Adults. Neuropsychology Press, Tucson, AZ. Reitart, R. M., and Wolfson, D. (1988). Traumatic Brain Injury, Volume 11: Recovery and Re- habilitation. Neuropsychology Press, Tucson, AZ. Roesch, R., Golding, S. L, Hans, V. P., and Reppucci, N. D. (1991). Social science and the c0urts: The role of amicus curiae briefs. Law and Human Behavior 15: 1-12. Rogers, R. (1986). Conducting Insanity Evaluations. Van Nostrand Reinhold, New York. Ryan, T. V., Sautter, S. W., Capps, C. F., Meneese, W., and Barth, J. T. (1992). Utilizing neuropsychological measures to predict v0cationa| outcome in a head trauma population. Brain Injury 6: 175-182. Schticver, D. J., Goldman, H., Kleinmttn, K. M., Goldfader, P. R., and Snow, M. Y. (1976). The relationship between independent neuropsychological and neurological detection and localization of cerebral impairment. Journal of Nervous and Mental Disease 162: 360-365. Shah, S. A., and McGarry, A. L. (1986). Legal psychiatry and psychology: Review of programs, training, and qualifications. In Curran, W. J., McGarry, A. L., and Shad, S. A. (eds.), Forensic Psychiatry and Psychology, F. A. Davis, Philadelphia, PA. pp. 7—41. Sprc en, 0., and Strauss, E. (1991). A Compendium of Neuropsychological Tests: Administration, Norms, and Commentary, Oxford University Press, New York. Tsushima, W., and Wedding, D. (1979). A comparison of the Halstead~Reitan Neuropsy— chological Battery and computerized tomography in the identification of brain disorders. Journal of Nervous and Mental Disease 167: 704-707. Warner, M. D., Boutros, N. N., and Peabody, C. A. (1990). Usefulness of Screening EEG’s in a psychiatric inpatient population. Journal of Clinical Psychiatry 51: 363—364. Wedding, D. (1993). Clinical and statistical prediction in neuropsychology. Clinical Neuropsy- clzology 5: 49-55. Wedding, D., and Faust, D. (1989). Clinical judgment and decision making in neuropsychol- ogy. Archives of Clinical Neuropsychology 4: 233-265. Yeudall, L. T. Reddon, .l. R., Gill, D. M., and Stefanyk, W. O. (1987). Normative date for the Halstead—Rcitan Neuropsychological Tests stratified by age and sex. Journal of Clini- Cttl Psychology, 422' 346-367. Ziskin, .l., and Faust, D. (1988). Coping with Psychiatric and Psychological Testimony, Vol. 2. Law and Psychology Press, Marina del Ray, CA. 10. ll. 12. . Manuscripts, in quadruplicate and in English, should be submitted to et'. Gerald Goldstein Research (151R) Veterans Administration Medical Center Highland Drive Pittsburgh, Pennsylvania 15206 or Antonio E. 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