Les 1 05/02/2026
The profession of clinical neuropsychologist
Definition: clinical neuropsychology is a specialty within professional psychology that applies
principles of assessment and intervention based upon the scientific study of human behaviour as it
relates to normal and abnormal functioning of the CNS. Within health care, clinical
neuropsychologists are professionals who offer services to the benefit of patients with cognitive and
behavioural symptoms related to neurological, developmental, and psychiatric disorders. The impact
of all disorders affecting the nervous system is considerable both globally and in Europe.
To get an idea about the impact, we can look at the total European costs of brain disorders
(psychiatric and neurological), which was 798 billion euros in 2010 (consisting of direct health care
costs, direct non-medical costs and indirect costs). This is a huge amount of money and a huge
impact. They split this up for many different brain conditions. If you look at the mood disorders, there
are enormous costs involved. Mainly due to the indirect costs (e.g., people not being able to work
due to their disorder). Also, for dementia, there are a lot of costs, in this case the direct non-medical
costs (e.g., people need special nutrition or transportation) are very high. Another one that stands
outs are the psychotic disorders where the indirect costs are also very high. This illustrates that this
impacts people who suffer from the conditions, but it also has a broader impact and there are a lot of
costs involved.
They made an overview of different countries, their populations and the estimated number of active
clinical neuropsychologists and the ratio of practitioners per population. The ratio between countries
differs a lot. However, this is also dependent on the definition of clinical neuropsychologist and
whether this title is protected by law. There are many more people dealing with clinical
neuropsychology in the population then just clinical neuropsychologists, so this affects the ratio.
Especially cognitive screening happens in different specialties such as nurses, paediatricians,
logopaedics. But also, full NPS assessment is conducted not only by clinical neuropsychologists (but
the majority is).
In general, core competencies for specialty in clinical neuropsychology based on a review of
guidelines in seven countries with well-established specialties in clinical neuropsychology:
- Foundational competencies
1. In-depth knowledge of general psychology including clinical psychology, including
knowledge about ethical and legal standards.
2. Expert knowledge about clinically relevant brain-behavioural relationships and functional
neuroanatomy.
3. Comprehensive knowledge about and skills in related clinical disciplines, in particular
clinical psychology, psychiatry and neurology
- Functional competencies (incl. knowledge-based and applied-based)
4. In-depth knowledge about and skills in NPA, incl. decision-making and diagnostic
competency according to current classification of diseases
5. Competencies in the area of diversity and culture in relation to general psychology and
clinical neuropsychology
6. Communication competency of neuropsychological findings and test results to relevant
and diverse audiences
7. Knowledge about and skills in psychological and neuropsychological intervention, incl.
treatment and rehabilitation.
Cost-effectiveness (there is a lot of money involved in brain injury and brain disorders. If you work in
a medical field, you sometimes need to justify why your discipline is important)
,If we think about a clinical neuropsychological examination, there are different domains that can be
tested (e.g., intelligence, processing speed, attention, memory and learning, EF, social cognition, etc.).
The administration of neuropsychological tests, scoring, interpretation and report of test results is
time consuming. “Brief” assessments take around 2 hours, extensive assessments 8 to 10 hours
(without scoring, interpretation and reporting). Consequently, neuropsychological examinations are
expensive and so, neuropsychological examinations might need justification (particularly in times of
financial cutbacks). So, you need to be able to justify what kind of value you have.
Example of costs of clinical neuropsychological examinations (forget about the numbers but think
about what they represent). In the US, the costs for NPA are e.g., 600.000 per year to establish and
maintain small department of clinical neuropsychology in non-profit hospital/medical centre. There
are also always indirect costs (additional 20%). So, let’s say that the total costs for one year is 720.000
dollars. Then there are charges, these are the costs charged for the services that you provide. Let’s
say that a clinical neuropsychologist provides neuropsychological services around 25 to 30 hours per
week. The fees range from 140 to 200 dollars per hour, so in total for 4 clinical neuropsychologists this
would be 672.0--- dollar. So, the hospital would nearly break even. However, the problem is that
these charges never reflect the actual fees received. The fees are the amount actually paid (money
that comes back via insurance). The amount paid is often considerably lower than the charges.
According to these fees, the reimbursement of psychotherapy is 100 dollars per hour, and NPA is 71-
80 dollars per hour. If we then calculate this, the revenue produced in reality is 105.000 dollar,
however the costs are 720.000. So, we need additional sources of revenue, e.g., boost of revenue by
medicolegal cases, involvement in research (support by grants), however this requires additional
effort and time (!) by/of clinical neuropsychologists (obtaining funds, publishing, conference
participation) (time that cannot be spend on your patients).
So, why do we do this? The costs of all this are higher than the income, so why would you do this?
Because of markers of value. You have more value than just the numbers and how it is defined in
money. So, what is very important in the context of cost-effectiveness are the markers of values.
Markers of value refers to money equivalent (e.g., cost saving) of the service received. So, the
consequences that your NPA or intervention have. So, in the end, you have a comparison between
costs of assessment and treatment with money saved by avoiding other health care costs and by
returning an individual to work and social responsibility.
Objective markers of value
Reduce costs and liability
- Example: a young man suffers TBI in an accident. Assessment shows that extent and nature of
impairments reduce his capacity to maintain line of work for which he was trained.
Consequently: hundreds of thousands of lost dollars because of brain injury (his income as he
can’t do his job). However, because you as a neuropsychologist document the consequences
of his brain injury, this can be used to capture most of the man’s lost income via litigation.
Through this, there can be a reduction of costs for society by neuropsychological medicolegal
assessment of around 3.000 dollars. In addition, because it is a legal case, you get a fee.
- Example: savings associated with identification of malingerers (malingering = intentional
production of false or grossly exaggerated physical or psychological symptoms, motivated by
external incentives). There are a lot of costs involved, about 43 million additional costs per
year (e.g., unnecessary medical treatment, trial defence costs). If we can identify if someone
is feigning symptoms, we can prevent/reduce this.
- Example: savings associated with differential diagnosis on basis of NPA, e.g., between
dementia and depression (e.g., are the symptoms due to dementia or depression).
Treatments are totally different, so it is important to make an accurate differential diagnosis
as there is psychiatric treatment available for depression which might result in productive
, lifestyle of people with depression. If neuropsychological findings are indicative of early
dementia, another value that you have is that the people with dementia and their families
can plan for the early significant decline in cognitive and behavioural functioning that is to
come.
Improve quality of life
- Example: a 53-year old male is treated for a brain tumour (surgery and radiotherapy). He is
the owner of a big furniture store. After treatment, he received NO NPA. However, due to his
brain injury he made bad financial decisions and investments and went bankrupt after 18
months post treatment with considerable debts. NPA then revealed impairments in EF and
WM. His subjective complaint was that co-workers and friends laugh at him since time of
surgery. If the NPA would have been done earlier on, this could have ended differently. This is
another marker of value.
Assess the effectiveness of treatment
- Any type of treatment (pharmacological, neurosurgery, neurofeedback, cognitive training,
etc.). All of these can be used and can show that there are improvements.
Guide treatment procedures
- Example: neuropsychological findings contribute significantly to decision whether someone
undergoes epilepsy surgery. If someone already has severe cognitive impairments before
neurosurgery, they might decide against it and might not have the capacity to compensate, so
there is also guidance.
Prevent the use of more expensive/additional diagnostic tools
- Example: neuropsychological findings can better predict the diagnosis of AD than other
techniques (i.e., CSF and PET).
Provide a continuum of care
- Example: clinical neuropsychologists can consult with affected people and their families
about the deficits and provide information. This prepares them to deal with intermediate and
long-term consequences of a person’s brain dysfunctions.
Improve physician education and decision making
- Example: affected people and their families may suffer from pain, stress and economic
burden when a person returns prematurely to work.
Subjective markers
Reduce a person’s sense of psychological aloneness with daily problems
- Example: relief of a person with a brain tumour (“I am not mad”) when describing an
association between deficits and tumour location.
Reduce a person’s expectations, confusion and frustration about the nature of their disturbances
Affected people and their families often have unrealistic expectations or wrong understandings about
deficits and their development. You can provide explanations to reduce this. Here psychoeducation
also is very important.
Help family members feel less guilty in making decisions regarding brain-dysfunctional adults and
children.
Many families struggle with the issue of placing a loved-one in a residential/nursing home. If you can
provide explanations on what is to come, this might help people. In children: often considerable relief
when parents learn that problems (e.g., ADHD) are not the consequence of “poor” parenting or
, psychodynamic processes. Example: feelings of guilt and self-reproach of father who slapped
daughter in the face and who got a brain tumour diagnosed 10 days later (providing an explanation
for behavior).
Conclusion: even if you look from the money point of view, clinical neuropsychological interventions
cost a lot of money, but there are a lot of markers of value (especially in the longer run), that point
out that NPA pay off in the long run for society. So, it pays off for society. And of course, this was only
about assessments, but there are further savings by administering neuropsychological treatment.
Brain damage as a family affair (brain disorders have a huge impact on the person who is suffering
from it, but also the system surrounding that person)
International classification of functioning, disability and health
If you have a health condition, this has an impact on many different aspects of
life. Firstly, a health condition has an impact on body functions & structure. In
addition, it also impacts your activities (what you can do, sports, job, etc.).
Related to that is participation (can you participate in society, have social
contacts/support/network, etc.)? This shows the broad impact that brain
disorders can have. In relation to this, we have the contextual factors which
consist of the environmental factors (social support) and personal factors
(where do you live, your personality, etc.). All this illustrates and impacts how
you deal with a certain disorder and family plays an important role in this.
Example: if we look at the health condition of panic disorders, we know that the impairment is
anxiety. Activity limitation could be that someone cannot go out alone. Participation restriction could
be that people’s reactions leads to no social relationships. So, you can see impact on different levels.
Example: health condition is that a person who formally had a mental health problem and was
treated for a psychotic disorder. There is no impairment nor activity limitation. However, participation
restriction is that employment is denied because of employer’s prejudice. So, also here, the
environment and its attitude play a role. This illustrates that there is a big system around a condition.
Related to this there is also a lot of work done researching intervention and prevention. We can look
at this at the different levels of health condition, impairment, activity limitation and participation
restriction.
The nature and severity of problems experienced by family members differs from family to family
depending on:
- Type and severity of brain damage (e.g., someone dealing with a partner with Parkinson’s
disease is completely different compared to TBI or severity)
- The affected person’s symptoms (you see a lot of variety within a diagnostic group)
- Premorbid cohesiveness (the family relations prior to the brain injury)
- Family attitudes about illness and responsibility (how people think and feel about this)
- Financial and social support (e.g., do they have the funds to change houses/car if necessary?)
- Etc. these are all examples to illustrate that there is a lot of variability, and it depends on
many different factors
Also, the problems experiences differ among family members (primary caretaker frequently carrying
the greater part of burden).
Families often experience emotional abandonment, and caretakers feel worn out (people do this for a
long period of time not just a few weeks). A cause of this could be that an affected person cannot
provide emotional support or that others who could give comfort no longer come around.
The profession of clinical neuropsychologist
Definition: clinical neuropsychology is a specialty within professional psychology that applies
principles of assessment and intervention based upon the scientific study of human behaviour as it
relates to normal and abnormal functioning of the CNS. Within health care, clinical
neuropsychologists are professionals who offer services to the benefit of patients with cognitive and
behavioural symptoms related to neurological, developmental, and psychiatric disorders. The impact
of all disorders affecting the nervous system is considerable both globally and in Europe.
To get an idea about the impact, we can look at the total European costs of brain disorders
(psychiatric and neurological), which was 798 billion euros in 2010 (consisting of direct health care
costs, direct non-medical costs and indirect costs). This is a huge amount of money and a huge
impact. They split this up for many different brain conditions. If you look at the mood disorders, there
are enormous costs involved. Mainly due to the indirect costs (e.g., people not being able to work
due to their disorder). Also, for dementia, there are a lot of costs, in this case the direct non-medical
costs (e.g., people need special nutrition or transportation) are very high. Another one that stands
outs are the psychotic disorders where the indirect costs are also very high. This illustrates that this
impacts people who suffer from the conditions, but it also has a broader impact and there are a lot of
costs involved.
They made an overview of different countries, their populations and the estimated number of active
clinical neuropsychologists and the ratio of practitioners per population. The ratio between countries
differs a lot. However, this is also dependent on the definition of clinical neuropsychologist and
whether this title is protected by law. There are many more people dealing with clinical
neuropsychology in the population then just clinical neuropsychologists, so this affects the ratio.
Especially cognitive screening happens in different specialties such as nurses, paediatricians,
logopaedics. But also, full NPS assessment is conducted not only by clinical neuropsychologists (but
the majority is).
In general, core competencies for specialty in clinical neuropsychology based on a review of
guidelines in seven countries with well-established specialties in clinical neuropsychology:
- Foundational competencies
1. In-depth knowledge of general psychology including clinical psychology, including
knowledge about ethical and legal standards.
2. Expert knowledge about clinically relevant brain-behavioural relationships and functional
neuroanatomy.
3. Comprehensive knowledge about and skills in related clinical disciplines, in particular
clinical psychology, psychiatry and neurology
- Functional competencies (incl. knowledge-based and applied-based)
4. In-depth knowledge about and skills in NPA, incl. decision-making and diagnostic
competency according to current classification of diseases
5. Competencies in the area of diversity and culture in relation to general psychology and
clinical neuropsychology
6. Communication competency of neuropsychological findings and test results to relevant
and diverse audiences
7. Knowledge about and skills in psychological and neuropsychological intervention, incl.
treatment and rehabilitation.
Cost-effectiveness (there is a lot of money involved in brain injury and brain disorders. If you work in
a medical field, you sometimes need to justify why your discipline is important)
,If we think about a clinical neuropsychological examination, there are different domains that can be
tested (e.g., intelligence, processing speed, attention, memory and learning, EF, social cognition, etc.).
The administration of neuropsychological tests, scoring, interpretation and report of test results is
time consuming. “Brief” assessments take around 2 hours, extensive assessments 8 to 10 hours
(without scoring, interpretation and reporting). Consequently, neuropsychological examinations are
expensive and so, neuropsychological examinations might need justification (particularly in times of
financial cutbacks). So, you need to be able to justify what kind of value you have.
Example of costs of clinical neuropsychological examinations (forget about the numbers but think
about what they represent). In the US, the costs for NPA are e.g., 600.000 per year to establish and
maintain small department of clinical neuropsychology in non-profit hospital/medical centre. There
are also always indirect costs (additional 20%). So, let’s say that the total costs for one year is 720.000
dollars. Then there are charges, these are the costs charged for the services that you provide. Let’s
say that a clinical neuropsychologist provides neuropsychological services around 25 to 30 hours per
week. The fees range from 140 to 200 dollars per hour, so in total for 4 clinical neuropsychologists this
would be 672.0--- dollar. So, the hospital would nearly break even. However, the problem is that
these charges never reflect the actual fees received. The fees are the amount actually paid (money
that comes back via insurance). The amount paid is often considerably lower than the charges.
According to these fees, the reimbursement of psychotherapy is 100 dollars per hour, and NPA is 71-
80 dollars per hour. If we then calculate this, the revenue produced in reality is 105.000 dollar,
however the costs are 720.000. So, we need additional sources of revenue, e.g., boost of revenue by
medicolegal cases, involvement in research (support by grants), however this requires additional
effort and time (!) by/of clinical neuropsychologists (obtaining funds, publishing, conference
participation) (time that cannot be spend on your patients).
So, why do we do this? The costs of all this are higher than the income, so why would you do this?
Because of markers of value. You have more value than just the numbers and how it is defined in
money. So, what is very important in the context of cost-effectiveness are the markers of values.
Markers of value refers to money equivalent (e.g., cost saving) of the service received. So, the
consequences that your NPA or intervention have. So, in the end, you have a comparison between
costs of assessment and treatment with money saved by avoiding other health care costs and by
returning an individual to work and social responsibility.
Objective markers of value
Reduce costs and liability
- Example: a young man suffers TBI in an accident. Assessment shows that extent and nature of
impairments reduce his capacity to maintain line of work for which he was trained.
Consequently: hundreds of thousands of lost dollars because of brain injury (his income as he
can’t do his job). However, because you as a neuropsychologist document the consequences
of his brain injury, this can be used to capture most of the man’s lost income via litigation.
Through this, there can be a reduction of costs for society by neuropsychological medicolegal
assessment of around 3.000 dollars. In addition, because it is a legal case, you get a fee.
- Example: savings associated with identification of malingerers (malingering = intentional
production of false or grossly exaggerated physical or psychological symptoms, motivated by
external incentives). There are a lot of costs involved, about 43 million additional costs per
year (e.g., unnecessary medical treatment, trial defence costs). If we can identify if someone
is feigning symptoms, we can prevent/reduce this.
- Example: savings associated with differential diagnosis on basis of NPA, e.g., between
dementia and depression (e.g., are the symptoms due to dementia or depression).
Treatments are totally different, so it is important to make an accurate differential diagnosis
as there is psychiatric treatment available for depression which might result in productive
, lifestyle of people with depression. If neuropsychological findings are indicative of early
dementia, another value that you have is that the people with dementia and their families
can plan for the early significant decline in cognitive and behavioural functioning that is to
come.
Improve quality of life
- Example: a 53-year old male is treated for a brain tumour (surgery and radiotherapy). He is
the owner of a big furniture store. After treatment, he received NO NPA. However, due to his
brain injury he made bad financial decisions and investments and went bankrupt after 18
months post treatment with considerable debts. NPA then revealed impairments in EF and
WM. His subjective complaint was that co-workers and friends laugh at him since time of
surgery. If the NPA would have been done earlier on, this could have ended differently. This is
another marker of value.
Assess the effectiveness of treatment
- Any type of treatment (pharmacological, neurosurgery, neurofeedback, cognitive training,
etc.). All of these can be used and can show that there are improvements.
Guide treatment procedures
- Example: neuropsychological findings contribute significantly to decision whether someone
undergoes epilepsy surgery. If someone already has severe cognitive impairments before
neurosurgery, they might decide against it and might not have the capacity to compensate, so
there is also guidance.
Prevent the use of more expensive/additional diagnostic tools
- Example: neuropsychological findings can better predict the diagnosis of AD than other
techniques (i.e., CSF and PET).
Provide a continuum of care
- Example: clinical neuropsychologists can consult with affected people and their families
about the deficits and provide information. This prepares them to deal with intermediate and
long-term consequences of a person’s brain dysfunctions.
Improve physician education and decision making
- Example: affected people and their families may suffer from pain, stress and economic
burden when a person returns prematurely to work.
Subjective markers
Reduce a person’s sense of psychological aloneness with daily problems
- Example: relief of a person with a brain tumour (“I am not mad”) when describing an
association between deficits and tumour location.
Reduce a person’s expectations, confusion and frustration about the nature of their disturbances
Affected people and their families often have unrealistic expectations or wrong understandings about
deficits and their development. You can provide explanations to reduce this. Here psychoeducation
also is very important.
Help family members feel less guilty in making decisions regarding brain-dysfunctional adults and
children.
Many families struggle with the issue of placing a loved-one in a residential/nursing home. If you can
provide explanations on what is to come, this might help people. In children: often considerable relief
when parents learn that problems (e.g., ADHD) are not the consequence of “poor” parenting or
, psychodynamic processes. Example: feelings of guilt and self-reproach of father who slapped
daughter in the face and who got a brain tumour diagnosed 10 days later (providing an explanation
for behavior).
Conclusion: even if you look from the money point of view, clinical neuropsychological interventions
cost a lot of money, but there are a lot of markers of value (especially in the longer run), that point
out that NPA pay off in the long run for society. So, it pays off for society. And of course, this was only
about assessments, but there are further savings by administering neuropsychological treatment.
Brain damage as a family affair (brain disorders have a huge impact on the person who is suffering
from it, but also the system surrounding that person)
International classification of functioning, disability and health
If you have a health condition, this has an impact on many different aspects of
life. Firstly, a health condition has an impact on body functions & structure. In
addition, it also impacts your activities (what you can do, sports, job, etc.).
Related to that is participation (can you participate in society, have social
contacts/support/network, etc.)? This shows the broad impact that brain
disorders can have. In relation to this, we have the contextual factors which
consist of the environmental factors (social support) and personal factors
(where do you live, your personality, etc.). All this illustrates and impacts how
you deal with a certain disorder and family plays an important role in this.
Example: if we look at the health condition of panic disorders, we know that the impairment is
anxiety. Activity limitation could be that someone cannot go out alone. Participation restriction could
be that people’s reactions leads to no social relationships. So, you can see impact on different levels.
Example: health condition is that a person who formally had a mental health problem and was
treated for a psychotic disorder. There is no impairment nor activity limitation. However, participation
restriction is that employment is denied because of employer’s prejudice. So, also here, the
environment and its attitude play a role. This illustrates that there is a big system around a condition.
Related to this there is also a lot of work done researching intervention and prevention. We can look
at this at the different levels of health condition, impairment, activity limitation and participation
restriction.
The nature and severity of problems experienced by family members differs from family to family
depending on:
- Type and severity of brain damage (e.g., someone dealing with a partner with Parkinson’s
disease is completely different compared to TBI or severity)
- The affected person’s symptoms (you see a lot of variety within a diagnostic group)
- Premorbid cohesiveness (the family relations prior to the brain injury)
- Family attitudes about illness and responsibility (how people think and feel about this)
- Financial and social support (e.g., do they have the funds to change houses/car if necessary?)
- Etc. these are all examples to illustrate that there is a lot of variability, and it depends on
many different factors
Also, the problems experiences differ among family members (primary caretaker frequently carrying
the greater part of burden).
Families often experience emotional abandonment, and caretakers feel worn out (people do this for a
long period of time not just a few weeks). A cause of this could be that an affected person cannot
provide emotional support or that others who could give comfort no longer come around.
