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Edith Kaplan and the Boston Process

Approach
a b cd
David J. Libon , Rodney Swenson , Lee Ashendorf , Russell M.
e e
Bauer & Dawn Bowers
a
Department of Neurology, Drexel University College of Medicine,
Philadelphia, PA, USA.
b
Department of Neuroscience, University of North Dakota School
of Medicine and Health Sciences, Fargo, ND, USA.
c
Department of Psychiatry, Boston University School of Medicine,
Boston, MA, USA.
d
Psychology Service, Edith Nourse Rogers Memorial Veterans
Hospital, Bedford, MA, USA.
e
Department of Clinical & Health Psychology, University of
Florida, Gainesville, FL, USA.
Published online: 28 Aug 2013.

To cite this article: David J. Libon, Rodney Swenson, Lee Ashendorf, Russell M. Bauer & Dawn
Bowers (2013) Edith Kaplan and the Boston Process Approach, The Clinical Neuropsychologist, 27:8,
1223-1233, DOI: 10.1080/13854046.2013.833295

To link to this article: http://dx.doi.org/10.1080/13854046.2013.833295

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 The Clinical Neuropsychologist, 2013
Vol. 27, No. 8, 1223–1233, http://dx.doi.org/10.1080/13854046.2013.833295

Edith Kaplan and the Boston Process Approach

David J. Libon1*, Rodney Swenson2, Lee Ashendorf3,4,

Russell M. Bauer5, and Dawn Bowers5
1
Department of Neurology, Drexel University College of Medicine, Philadelphia, PA, USA
2
Department of Neuroscience, University of North Dakota School of Medicine and Health
Sciences, Fargo, ND, USA
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3
Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
4
Psychology Service, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA, USA
5
Department of Clinical & Health Psychology, University of Florida, Gainesville, FL, USA

The history including some of the intellectual origins of the Boston Process Approach and
some misconceptions about the Boston Process Approach are reviewed. The influence of
Gestalt psychology and Edith Kaplan’s principal collaborators regarding the development of the
Boston Process Approach is discussed.

Keywords: Edith Kaplan; Boston Process Approach; Neuropsychological assessment.

INTRODUCTION
The neuropsychological literature has long considered the Boston Process
Approach to be one of the primary approaches to neuropsychological assessment and
interpretation. It is rooted in the analysis of errors and process or the means by which a
patient reaches a solution to a problem, rather than solely relying upon an achievement
score. The Boston Process Approach is inextricably linked to its founder, Edith Kaplan,
who championed it from the 1960s until her passing on 3 September 2009. In this paper
we will review some of the scientific constructs upon which the Boston Process
Approach is based. In addition to the science that provides the foundation of the Boston
Process Approach it is important to understand the historical context in which the
Boston Process Approach was created. We refer, of course, to what was then known as
the Boston Veterans Administration Medical Center located at 150 South Huntington
Avenue in the Jamaica Plain section of Boston; and Kaplan’s colleagues—particularly
Harold Goodglass, Nelson Butters, Laird Cermak, and Norman Geschwind—all made
important contributions to the development of the Boston Process Approach and
contemporary neuropsychology.

GESTALT PSYCHOLOGY AND THE BOSTON PROCESS APPROACH

A fact that is not widely appreciated is that some of the intellectual and theoretical
roots of the Boston Process Approach can be traced directly to early twentieth-century

Address correspondence to: David J. Libon, Ph.D., Department of Neurology, Drexel University
College of Medicine, 243 North 15th St, 7th Floor, Philadelphia, PA, 19102, USA. Email:
dlibon@drexelmed.edu
(Received 24 February 2013; accepted 6 August 2013)

Ó 2013 Taylor & Francis

 1224 DAVID J. LIBON ET AL.

Gestalt psychology—specifically the notion that individual components of behavior,

separate but in concert with an ultimate solution, convey considerable knowledge about
brain–behavior relationships. As related to modern neuropsychological assessment, this
idea suggests that while a psychometrically determined test score helps to identify level
of impairment and suggest the presence of derailed brain–behavior relationships,
specificity regarding these relationships is often found through the analysis of the process
by which a test score is achieved and the analysis of the errors that are generated.
Experimental psychology began, in large part, in Germany during the last quarter
of the nineteenth century. At the time, Wilhelm Wundt’s laboratory in Leipzig was
quite influential, attracting authors and researchers such as G. Stanley Hall, James
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McKeen Cattel, and Edward Bradford Titchener (see E.G. Boring, 1950, for a review).
Psychological phenomena at that time were understood in mentalistic terms, such that
the role of the psychologist was to investigate perception and other behavior by
distilling unique component parts, often employing the experimental paradigm of
introspection (Titchener, 1902). In this sense reductionism was the method of choice.
Gestalt psychology originated in Germany in the early part of the twentieth
century and is associated with the work of Max Wertheimer, Wolfgang Köhler, and
Kurt Koffka. Gestalt psychology developed as an alternative to the atomistic concep-
tions of structuralism and related approaches to behavior (see Barr, 2008, for a review).
Gestalt psychology is primarily associated with “laws” of perception; however, research
based on the tenets of Gestalt psychology covers a wide array of topics. For example,
Köhler used what is essentially a sorting technique to investigate memory, and found
evidence that effective recall was influenced not just by stimuli as a whole, but also the
constituent components contained with the test stimuli (Köhler, 1972). The dynamic
interaction between test stimuli and their constituent parts was a theme employed by
Heinz Werner (1937), Kaplan’s undergraduate and graduate school mentor, to explain
the cognitive processes that underlie “global–local” processing (p. 357) and sorting
objects on the basis of both perceptual and semantic features (p. 361). Werner and
Kaplan (1952) also employed principles of Gestalt psychology in their monograph on
children’s acquisition of word meanings, noting the interaction between explicit versus
implicit cognitive operations. Several subtests now part of the Delis-Kaplan Executive
Functions Systems (Delis, Kramer, & Kaplan, 2001) are based on this early work.

Kurt Goldstein and the Abstract Attitude

Reading Kurt Goldstein’s work always rewards the effort, even when his views
may seem paradoxical (Geschwind, 1964). Perhaps the quintessential Goldstein is the
monograph he wrote with Martin Scheerer, Abstract and Concrete Behavior – An
Experimental Study with Special Tests (1941).1 Goldstein and Scheerer were interested
in investigating how neurologic illness disturbed what they termed abstract or “integra-
tive mental functions” (p. 1). Goldstein and Scheerer noted that the relationship
between concrete and abstract behavior could be determined by a multitude of factors
not least of which were the nature of the test(s) used to assess the patient. To this point
Goldstein and Scheerer wrote (1941, p. 17):
If the examiner orients himself merely by plus and minus scores, he will find to
his surprise, on different occasions, failure and success in the same or closely similar
task. This is the case … when the task proper lacks the stringency of permitting only
 THE BOSTON PROCESS APPROACH 1225

one way of solution. For instance, in the subtest on the Binet scale which demands the
finding of similarities between two or more objects a female patient behaved
differently on different occasions. At one time wood and coal are found to be similar
“because they both burn”; at a later date, however, she insists that they are totally
different since “one is brown and the other black.
The gist of this passage revolves around the merits and liabilities of evaluating a
patient’s response solely in terms of whether a response was correct or incorrect (i.e.,
pluses or minuses). Goldstein and Scheerer go on (p. 17) to say that:
Any quantitative rating as to success or failure constitutes an infinite source of
error, unless it follows a qualitative analysis. The construction of the usual test …
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consists of a scale of ascending steps of difficulty. These steps are meant to represent
either progressive mental age levels (as in Binet), or performance levels of increasing
accomplishment. Therefore, in principle, a subject who has failed in a subtest which,
on this scale represents an easier task is expected to fail also on the subscale higher up
on the scale.
As related to the Boston Process Approach this comment suggests that common
phenomena such as intra-test scatter and the errors made on neuropsychological tests
should be closely examined. Kaplan observed that on many frequently administered
neuropsychological tests, such as the Information subtest from the Wechsler corpus
and the Boston Naming Test, neurologic patients often failed so-called “easier” test
items but could go on to achieve a psychometrically determined score that might be in
the average or even above-average range. The examination of errors, as related to a
referral question and known components of the patient’s presumed neurologic illness,
often yields important and highly clinically relevant information. An example of this
can be found in Goldstein and Scheerer’s description (1941, p. 19) of patients’
construction using Kohs’ Block Test:2
The usual scoring method based on a scale of difficulty which has been
standardized on a statistical basis offers no adequate instrument for determining the
nature or degree of impairment in a patient. Unless one takes into account the entire
procedure, the specific reasons for the difficulty the patient encounters, one cannot
simply read off from the score which task represents a greater difficulty and which a
lesser. Any statistical evaluation has to be based upon a qualitative analysis of test
results: qualitative has to precede statistical analysis.
Joy, Fein, Kaplan, and Freedman (2001) and Paolo and Ryan (1994) obtained
Block Design protocols from healthy controls and neurologic patients. Base rates for a
wide number of errors were provided. Whatever a patient’s scaled score, such data can
be particularly useful to diagnose subtle neurological deficits or to chart recovery from
neurologic illness.
Goldstein and Scheerer and Werner were not alone among their contemporaries
who cautioned against the over-reliance on statistical methods. Halstead (1947), in his
monograph Brain and Intelligence,3 was quite cognizant of the limitations of statistical
modeling regarding theories about brain and cognition. Halstead’s quote (1947, p. 7)
from J. P. Guilford (1936) regarding factor analysis is revealing:
It may have to be admitted that the same factor does not carry the same relative
weight for a task in different individuals or in the same individual at different times …
it may even be true that the same test does not draw upon the same abilities when it is
relatively easy for a population and when it is relatively difficult.
 1226 DAVID J. LIBON ET AL.

Werner’s Orthogenetic Principle and the Boston Process Approach

Fundamental to the establishment of the Boston Process Approach were ideas
drawn from Heinz Werner’s Organismic Psychology. In Werner’s paper entitled
“Process and Achievement”, published in the Harvard Educational Review in 1937, he
argued that the means by which a test score is obtained is at least as important as the
test score itself. The developmental psychologist Herman Witkin (1965, p. 311) wrote:
In [Werner’s] important paper, “Process and Achievement” (1937), written not
long after his arrival in America, during his year at Harvard, he spoke out strongly
against the preoccupation he found here with outcome, to the neglect of underlying
processes or operations. He believed that experimental studies were too often designed
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to permit only glimpses of phenomena in cross-section rather than a view of extended

units of activity which alone permit a reconstruction of underlying processes.
Witkin (1965) also noted that an important construct that guided Werner’s
thinking was the need to examine behavior from an orthogenetic perspective. This
construct suggests that behavior often proceeds from a state of relative lack of
differentiation to a state of increasing differentiation and hierarchic integration.
Werner’s orthogenetic principle is similar to Luria’s (1980) ideas regarding the
hierarchical nature of perseveration. Lamar and colleagues (1997) applied these
theoretical ideas in the analysis of perseverations made by Alzheimer’s disease (AD)
and vascular dementia (VaD) patients. Lamar and colleagues (1997) found distinct
differences such that graphomotor perseverations generated by AD patients were
context-dependent in the sense that they could be viewed as subordinate to the lexical
retrieval and/ or semantic knowledge deficits known to afflict patients with AD. By
contrast, graphomotor perseverations produced by patients with VaD were context-
independent and related to derailed rudimentary motor operations. Such qualitative
differences in behavior provide not just a means to operationally define important
cognitive constructs, but can also be used to formulate predictions regarding underlying
brain pathology. In sum, all of this work suggests that the Boston Process Approach
reflects the intellectual richness of its predecessors.

THE BOSTON PROCESS APPROACH AND NORMATIVE DATA

An oft-encountered misconception suggests that the Boston Process Approach is
either inconsistent with or even antagonistic towards normative or quantitative
neuropsychological data. In fact, Kaplan fully appreciated the need for normative
information. On the basis of our personal experience, Kaplan would not sit down to
conduct supervision until all test data were properly scored. Not surprisingly the
analysis of errors often took center stage.
An example of how the analysis of errors conveys additional information over
and above a statistically determined scaled score is provided by Giovannetti and
colleagues (2001). These researchers studied deficits in concept formation through the
analysis of errors made on the WAIS-R Similarities subtest. Patients with Alzheimer’s
disease (AD) and vascular dementia (VaD) associated with white matter alterations
were studied. Giovannetti and colleagues found no between group differences for
parameters such as scale scores or the number of one- or two-point responses.
Giovannetti and colleagues noted that patients with VaD often produced out-of-set
 THE BOSTON PROCESS APPROACH 1227

errors (e.g., dog–lion: “one barks, the other roars”). This kind of response clearly
shows that the patient is not in mental set; that is to say, the patient appears not to
understand that they are asked to provide the optimal supraordinate relationship
between the members of the word-pair. Such behavior contrasts with the in-set errors
often produced by AD patients (e.g., dog–lion: “you can have them”). Here the mental
set of providing a supraordinate relationship appears to be intact, but the response is
too vague according to Wechsler scoring criteria. Both are zero-point responses.
Consistent with Goldstein and Scheerer (1941), both responses might suggest a failure
to assume an abstract attitude.
But do both types of errors reflect the same underlying cognitive deficit? When
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these error types were subjected to a principal component analysis Giovannetti and
colleagues (2001) found that out-of-set errors loaded with variables clearly suggesting
an underlying dysexecutive mechanism, likely related to greater frontal lobe or frontal
systems impairment. On the other hand, in-set errors loaded with variables suggesting
more restricted (i.e., context-dependent) problems, perhaps related to depth of process-
ing or access to lexical or semantic information, operations likely associated with the
left posterior cortex.
Another example of how the analysis of errors may be used to operationally
define cognitive construct and provide clues regarding underlying brain pathology is
provided by Lamar and colleagues (2007; Lamar, Catani, Price, Heilman, & Libon,
2008). These researchers quantified errors obtained from the Backward Digit Span Test
undertaken by dementia patients. The severity of MRI white matter alterations was
measured using the Junque Leukoaraiosis Scale (Junque et al., 1990). At the time this
research was conducted these white matter lesions were believed to be caused by
ischemia. The Backwards Digit Span test was developed in part to operationally define
constructs derived from Baddeley’s model of working memory. The Backwards Digit
Span test consists of seven trials of three-, four-, and five-digit span lengths for a total
of 21 trials. Percent ANY ORDER correct is scored by summing the number of digits
correctly recalled regardless of serial position. This metric is believed to reflect
less-complex aspects of working memory characterized by short-term storage and
rehearsal mechanisms. Percent SERIAL ORDER correct was scored by summing digits
correctly recalled in accurate serial position. This metric is believed to measure aspects
of working memory associated with mental manipulation, disengagement, and temporal
re-ordering. Lamar and colleagues (2007, 2008) studied AD and VaD dementia
patients re-grouped and divided in terms of the severity of MRI-defined white matter
alterations. No difference for ANY ORDER recall was noted, suggesting no gross
effect of short-term storage or rehearsal. However, dementia patients with significant
white matter load scored lower for SERIAL ORDER recall, suggesting greater
working memory/mental manipulation deficits. Moreover, reduced SERIAL ORDER
recall was significantly correlated with greater white matter alterations involving the
left posterior horn and left frontal centrum semiovale.
Kaplan (1988), Kaplan (1990) pointed out that an analysis of process and errors
could be applied to virtually any test. Take, for example, the Mini-Mental State
Examination (MMSE; Folstein, Folstein, & McHugh, 1975); one of the most
commonly administered neuropsychological tests. It is well accepted that patients with
AD are often particularly disadvantaged on tests of declarative memory and semantic
knowledge, while patients with dementia syndromes such as VaD and dementia
 1228 DAVID J. LIBON ET AL.

associated with Parkinson’s disease (PD) present with greater impairment on tests of
working memory, executive control, and motor functions. Jefferson et al. (2002) con-
ducted a process analysis of errors made on the MMSE (Folstein et al., 1975) obtained
from dementia patients clinically diagnosed with AD, VaD, and PD to assess how or
to what extent deficits in declarative memory and executive control underlie MMSE
test performance. In this research the three dementia groups did not differ on the total
MMSE summary score. However, the analysis of errors revealed that AD patients
obtained lower scores on MMSE indices that measure temporal orientation and mem-
ory compared to VaD and PD groups. By contrast, VaD and PD patients obtained
lower scores on MMSE indices that measure motor/construction and working memory.
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Moreover, VaD and PD patients made a greater number of perseverations and other
errors when asked to write a sentence and copy intersecting pentagons compared to
AD patients. Correlations with neuropsychological tests revealed that MMSE orienta-
tion indices were significantly related to poor performance on tests of naming and
memory, but that MMSE working memory and motor/ construction indices were corre-
lated to poor performance on test that assess executive control. This research suggests
that if clinical decision making was made solely on the basis of the total test score,
important information might be overlooked. Equally important is that the correlations
between MMSE errors and specific neuropsychological tests suggest the presence of
differing underlying brain pathology in these groups of dementia patients.
Thus, rather than being antagonistic to statistically derived normative information,
the research described above demonstrates how the process analysis of errors can be
quantified to define important cognitive constructs.

THE BOSTON PROCESS APPROACH AND THE CLINICAL ASSESSMENT

OF MEMORY
A fact that is likely not well appreciated is that anyone who administers any
version of the California Verbal Learning Test (CVLT; Delis, Kramer, Kaplan, & Ober,
1987) is utilizing the Boston Process Approach. Kaplan’s work in the development of
the CVLT constitutes one of her greatest legacies. However, to truly appreciate how an
analysis of process and errors contributes to our understanding of patterns of
performance obtained from verbal serial list-learning tests in dementia one needs to
understand the work of Butters and Cermak. During the 1970s and 1980s Butters and
Cermak conducted pioneering research studying patients with Wernicke-Korsakoff
syndrome and Huntington’s disease—research that helped define the parameters of the
amnestic state.
The collaboration of Cermak and Butters began in the early 1970s. As told by
Cermak, they met at a regularly scheduled meeting that was convened under the
auspices of the prestigious Boston consulting firm Bolt, Beranek, and Neuman
(Cermak, 1994).4 A number of well-known cognitive psychologists participated. At that
time there was no great interest in what neurologic patients could contribute regarding
the processes that underlie memory and learning. Much of the contemporaneous
memory research and subsequent models of memory was based on research examining
so-called “normal memory” (Butters & Cermak, 1980); that is, data obtained in
university laboratories from the ubiquitous college sophomore.
 THE BOSTON PROCESS APPROACH 1229

During the 1970s ideas about memory tended to be dominated by mechanistic

models where storage mechanisms were viewed as rather passive entities. An alterna-
tive model had been put forth by Craik and Lockhart (1972). This model suggested
that the transfer of information from short-term to long-term storage was better under-
stood in terms of depth of processing or through an analysis of the variety of complex
cognitive constructs that could either facilitate or inhibit permanent long-term learning.
Butters and Cermak combined the depth of processing model as suggested by
Craik and Lockhart (1972) with interference theory as described by McGeoch (1932)
or the notion that forgetting or the failure of information to transfer from one storage
mechanism to another was due, in part, to competition among stored items. A
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fortuitous circumstance was the availability of neurologic patients for study. Here is an
example of having a base of operations in a hospital setting, i.e., the Boston VA
Medical Center, turned out to offer opportunities not available from the college
laboratory. Harold Goodglass, who was at that time Director of Psychological Research
at the Boston VA, enthusiastically supported memory research.
In a series of studies Butters and Cermak (see Butters & Cermak, 1980, for a
review) examined patients with Wernicke-Korsakoff and Huntington disease, i.e.,
patients with very distinct underlying neuropathology, with experimental paradigms
where word list length, the type and presence of an interference condition, and the
semantic content of the stimulus material were systematically manipulated. The nature of
the episodic memory difficulty varied as function of each of these parameters. This
research is consistent with the Boston Process Approach and is an example of how the
analysis of process and errors is able to elucidate the dynamic, underlying cognitive
processes by which patients with dense anterograde amnesia fail to encode or transfer
information from a short-term to a long-term store; and how the analysis of errors
suggests differences in brain pathology. Moreover, the bench to bedside translational
nature of this work is readily apparent as all of these experimental techniques were
incorporated into the development of the California Verbal Learning Test (CVLT)
paradigm—a paradigm that has proven useful in disambiguating the processes that
underlie memory failure across a wide variety of dementia and other neurobehavioral
syndromes.

THE BOSTON PROCESS APPROACH: CLINICAL AND RESEARCH

APPLICATION
A final point to be made about the Boston Process Approach is that Kaplan
stressed that there is no fundamental difference between the clinician carrying out formal
evaluations in the consultation room versus the researcher conducting experiments in
the laboratory. And if one stops to think about it, “testing” and “experimentation” in
neuropsychology are essentially the same. The work of Butters and Cermak that resulted
in the development of the CVLT is a prime example. Another example where there was
really very little difference between clinical and experimental work is the collaboration
between Norman Geschwind and Edith Kaplan (Geschwind & Kaplan, 1962).
Geschwind was arguably one of the most important and influential neurologists
of the latter twentieth century. In the early 1960s Kaplan and Geschwind worked
together on the Neurology Service at the Boston VA Medical Center. At that time the
 1230 DAVID J. LIBON ET AL.

department chair of the VA Neurology Service was Fred Quadfasel, a European-trained

neurologist who was very aware of the classic European behavioral neurology litera-
ture. Quadfasel had started a weekly seminar on neurologic disorders and suggested to
Kaplan that to fulfill her Ph.D. requirements she translate from German papers on pure
motor agraphia (PMA). The syndrome of PMA relates to a selective disturbance in
writing whereby a patient is able to read and speak but is unable to write. Following
Quadfasel’s direction, Kaplan read a paper by Bouman and Grunbaum (1930), which
argued that the motor disturbance in PMA was the product of a grasp reflex, a primi-
tive reflex in which the hand will close when the palm is stroked or when an object is
placed in it. It was Kaplan’s appreciation of this disorder that would serendipitously
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allow her to make key observations and thus discover a syndrome that would help
change the history of neuropsychology (see Kaplan, 2002, for a detailed description).
As it happened Kaplan observed patient PJK walking down the corridors of the
neurology ward grasping door knobs and having great difficulty letting go. The
apparent presence of a grasp reflex in this patient gave her an opportunity to evaluate
Bouman and Grunbaum’s thesis. The most critical observation in her subsequent
assessment was that PJK could write and respond appropriately with his right hand,
but was completely aphasic and demonstrated other neuropsychological impairment
when using his left hand. Kaplan shared these observations with Geschwind and they
both realized that their patient was likely suffering from a disconnection syndrome.
This was notable because, in 1961, disconnection syndromes had only been described
in the German and French literature and were generally unknown to the neurobehav-
ioral community. However, Geschwind had just recently re-examined the classic
nineteenth- and early twentieth-century works of Wernicke, Bastian, Dejerine, Charcot,
Liepmann and others (Geschwind, 1964), and in this context he was keenly interested
in the behavioral consequences of callosal lesions, thus making him also keenly
interested in Kaplan’s observations. This case study, as well as other observations
(Geschwind, 1962a; Geschwind, 1962b), ultimately resulted in Geschwind’s two-part
magnum opus on disconnection syndromes in humans and animals (Geschwind,
1965a; Geschwind, 1965b).5
Kaplan and Geschwind (Geschwind, 1962b) reported preliminary data on this
case at a regular meeting of the Boston Society of Psychiatry and Neurology on 14
December 1961. Hans-Lukas Teuber was in attendance and commented that he had
personally seen patient PJK—and suggested that interference between the two hemi-
spheres, rather than disconnection, might have been responsible for Kaplan’s
observations.
It is important to mention that the Geschwind and Kaplan (1962) case, a
landmark in the history of behavioral neurology and neuropsychology, was remarkable
in that little formal testing was conducted and that imaging technology we now take
for granted had yet to be invented. The discovery of the first known case of a human
disconnection syndrome since before the two world wars was due, in part, to Kaplan’s
approach to assessment; an approach that is fundamentally rooted in an understanding
of key neurobehavioral mechanisms reflected in the analysis of process and errors. The
paper of Geschwind and Kaplan (1962) was important not just because it was the first
contemporary case of human disconnection, but for setting forth an approach to
evaluation that would contribute to the development of neuropsychology and
behavioral neurology for decades to come.
 THE BOSTON PROCESS APPROACH 1231

SUMMARY
Toward the end of her life, Edith Kaplan expressed some disappointment that
the Process Approach had yet to become the modal model for training in neuropsycho-
logical assessment. Yet, in a recent survey on selection criteria for neuropsychological
internships, Ritchie, Odland, Ritchie, and Mittenberg (2013) found that, when asked
about the importance of various types of prior assessment experiences in choosing
interns, 67% of respondents said that prior experience with the Process Approach was
either essential or very important. Thus the Boston Process Approach, whose origins
derives from classic psychology theory and enjoys considerable empirical support, is
alive, well, and growing.
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Notes
1. Kurt Goldstein is clearly one of the most fascinating figures in the history of neuroscience. Schooled in
neurology by Wernicke, both neurology and neuropsychology lay claim to Goldstein’s intellect and
insight. Goldstein wrote this benchmark work on The Abstract Attitude while a member of the faculty at
Tufts Medical College. Many of the tests described in his monograph were incorporated into the Boston
Diagnosis Examination of Aphasia as supplemental assessment procedures. In 1938–1939 Goldstein was
invited to give the William James Lectures at Harvard University. These lectures were later published in
1951 in a book entitled Human Nature. Here Goldstein continued to emphasize the advantages of
examining neurological alterations within the context of the “entire organism”. More information about
the life and times of Kurt Goldstein, including his imprisonment by the Nazis, is described by Teuber
(1966) and Quadfasel (1968).
2. This was the test from which David Wechsler derived the more familiar Block Design subtest.
3. Kaplan noted that Halstead made many qualitative observations of patients’ behavior including
observing patients in their home and place of employment.
4. Cermak recalls hearing Butters speak at one of these meetings and going home to tell his wife, “that I
thought I had met someone with whom I could collaborate on a project or two” (Cermak, 1994, pp. 31–32).
This is quite an understatement as Butters and Cermak were destined to work together for the rest of their
lives, a collaboration that continued for approximately 20 years.
5. This work was carried out contemporaneously with Roger Sperry’s “split-brain” research. In 1981
Sperry shared the Nobel Prize for Physiology and Medicine with David Hubel and Torsten Wiesel.

REFERENCES

Barr, W. B. (2008). Historical development of the neuropsychological test battery. In J. E. Mor-

gan & J. H. Ricker (Eds.), Textbook of clinical neuropsychology. New York, NY: Psychol-
ogy Press.
Boring, E. G. (1950). A history of experimental psychology. New York, NY: Appleton-
Century-Crofts.
Bouman, L., & Grünbaum, A. A. (1930). Über motorische Momente der Agraphi. Mschr.
Psychiat. Neurol, 77, 223.
Butters, N., & Cermak, L. S. (1980). Alcoholic Korsakoff’s syndrome: An information processing
approach to amnesia. New York, NY: Academic Press.
Cermak, L. S. (1994). Processing deficits of amnesic patients. In L. S Cermak (Ed.), Neuropsy-
chological exploration of memory and cognition—Essays in honor of Nelson Butt eds
(pp. 31–43). New York, NY: Plenum Press.
Craik, F. I. M., & Lockhart, R. S. (1972). Levels of processing: A framework for memory
research. Journal of Verbal Learning and Verbal Behavior, 11, 671–684.
 1232 DAVID J. LIBON ET AL.

Delis, D. C., Kramer, J. H., Kaplan, E., & Ober, B. A. (1987). The California Verbal Learning
Test. San Antonio, TX: The Psychological Corporation.
Delis, D. C., Kramer, J. H., & Kaplan, E. (2001). The Delis-Kaplan Executive Functions Systems
Test. San Antonio, TX: The Psychological Corporation.
Folstein, M. E., Folstein, S. E., & McHugh, P. R. (1975). Mini-Mental State: A practical method
for grading the cognitive state of patients for the clinician. Journal of Psychiatry Research,
12, 189–198.
Geschwind, N. (1962a). The anatomy of an acquired disorder of reading. In J. Money (Ed.),
Reading disability (pp. 115–139). Baltimore, MD: Johns Hopkins University Press.
Geschwind, N. (1962b). Random reports: Human split-brain syndromes. New England Journal
of Medicine, 266, 1013.
Downloaded by [University of Saskatchewan Library] at 21:14 03 February 2015

Geschwind, N. (1964). The paradoxical position of Kurt Goldstein in the history of aphasia.
Cortex, I, 214–224.
Geschwind, N. (1965a). Disconnection syndromes in animals and man I. Brain, 88, 237–294.
Geschwind, N. (1965b). Disconnection syndromes in animals and man II. Brain, 88, 585–644.
Geschwind, N., & Kaplan, E. (1962). A human cerebral disconnection syndrome: A preliminary
report. Neurology, 12, 675–685.
Giovannetti, T., Lamar, M., Cloud, B.S., Swenson, R., Fein, D., Kaplan, E., & Libon, D. J.
(2001). Different underlying mechanisms for deficits in concept formation in dementia.
Archives of Clinical Neuropsychology, 16, 547–560.
Goldstein, K. (1951). Human nature. Cambridge, MA: Harvard University Press.
Goldstein, K., & Scheerer, M. (1941). Abstract and concrete behaviour: An experimental study
with special tests. Psychological Monographs, 53(2).
Halstead, W. C. (1947). Brain and intelligence. Chicago, IL: University of Chicago Press.
Jefferson, A. L., Cosentino, S., Ball, S. K., Bogdanoff, B., Leopold, N., Kaplan, E., & Libon, D.
J. (2002). Errors produced on the Mini-Mental State Examination and neuropsychological
test performance among patients with Alzheimer’s disease, ischaemic vascular dementia, and
Parkinson’s disease. Journal of Neuropsychiatry and Clinical Neuroscience, 14, 311–320.
Joy, S., Fein, D., Kaplan, E., & Freedman, M. (2001). Quantifying qualitative features of block
design performance among healthy older adults. Archives of Clinical Neuropsychology, 16,
157–170.
Junque, C., Pujol, J., Vendrell, P., Bruna, O., Jodar, M., Ribas, J. C., … Marti-Vilalta, J. L.
(1990). Leukoaraiosis on magnetic resonance imaging and speed of mental processing.
Archives of Neurology, 47, 151–156.
Kaplan, E. (1988). A process approach to neuropsychological assessment. In T. Boll & B. R.
Bryant (Eds.), Clinical neuropsychology and brain function: Research, measurement, and
practice: Master lectures. Washington, DC: The American Psychological Association.
Kaplan, E. (1990). The process approach to neuropsychological assessment of psychiatric
patients. Journal of Neuropsychiatry and the Clinical Neurosciences, 2, 72–87.
Kaplan, E. (2002). Serendipity in science: A personal account. In A. Y. Stringer, E. Cooley, &
A. Christensen (Eds.), Pathways to prominence in neuropsychology: Reflections of 20th
century pioneers (pp. 157–170). New York, NY: Psychology Press.
Köhler, K. (1972). The task of Gestalt psychology. Princeton, NJ: Princeton University Press.
Lamar, M., Catani, M., Price, C. C., Heilman, K. M., & Libon, D. J. (2008). The impact of
region specific leukoaraiosis on working memory deficits in dementia. Neuropsychologia,
46, 2597–2601.
Lamar, M., Podell, K., Carew, T. G., Cloud, B. S., Kennedy, C., Goldberg, E., … Libon, D. J.
(1997). Perseverative behavior in Alzheimer’s disease and subcortical ischaemic vascular
dementia. Neuropsychology, 11, 523–534.
 THE BOSTON PROCESS APPROACH 1233

Lamar, M., Price, C. C., Libon, D. J., Penney, D. L., Kaplan, E., Grossman, M., & Heilman, K.
M. (2007). Alterations in working memory as a function of leukoaraiosis in dementia.
Neuropsychologia, 45, 245–254.
Luria, A. R. (1980). Higher cortical functions. New York, NY: Basic Books. Quadfasel, F. A.
(1968). Aspects of the life of Kurt Goldstein. Cortex, 4, 113–124.
McGeoch, J. A. (1932). The influence of the degree of interpolated learning upon retroactive
inhibition. The American Journal of Psychology, 44, 695–708.
Paolo, A. M., & Ryan, J. J. (1994). Base rates of WAIS-R qualitative information for persons 75
years and older. Assessment, 1, 83–88.
Ritchie, D., Odland, A.P., Ritchie, A. S., & Mittenberg, W. (2012). Selection criteria for
internships in clinical neuropsychology. The Clinical Neuropsychologist, 26, 1245–1254.
Downloaded by [University of Saskatchewan Library] at 21:14 03 February 2015

Teuber, H.-L. (1966). Kurt Goldstein’s role in the development of neuropsychology. Neuropsych-
ologia, 4, 299–310.
Titchener, E. B. (1902). Experimental psychology: A manual of laboratory practice. New York,
NY: MacMillan.
Werner, H. (1937). Process and achievement. Harvard Educational Review, 7, 353–368.
Werner, H., & Kaplan, E. (1952). The acquisition of word meanings: A developmental study.
Monographs of Social Research in, Child Development, 15(Whole number 51).
Witkin, H. A. (1965). Heinz Werner: 1890–1964. Child Development, 36, 306–328.