This is one of the most frustrating things as a clinician in the VA system. With some (many?) pseudoneuropsychologists in the system, I have learned that it is actually likely iatrogenic/counterproductive to refer to neuropsych if they're going to be handling the case. I've seen such jaw-dropping errors as interpreting even slight variations from the mean (like, equivalent to 1/8th of a standard deviation) in the 'impaired' direction on particular subtests as 'evidence' of deficits relative to 'pre-morbid' (presumed) status. Mind you, there is absolutely no data point they can point to in order to reference any measured 'pre-morbid' status. The implicit (incredibly flawed) argument appears to be that we are just to assume that their scores/abilities prior to the 'injury' (concussion, stroke, whatever) were somehow magically precisely the 'mean' score in the reference population (or higher?). There is no apparent consideration of measurement error. There is no apparent consideration for natural subtest scatter (or that not everyone is going to be at the 50th percentile or above on every measured capacity). Reading the reports, it's as if the writer is actively trying to give a tepid diagnosis of some form of concrete 'brain injury' or neuropathology ('mild' forms) no matter what to appease the veteran and to 'answer' the consult. So the veteran comes back to psychotherapy with 'proof' that they are 'brain injured' and can't complete self-monitoring forms or 'can't remember' to do homework. All the 'recommendations' are the same and equally worthless. 'Mr. X could benefit from evidence-based psychotherapy protocols with the proper modifications.' Yeah...the guy is claiming (on some days) that he can't read/understand the printed word. But on half the days he is able to read, other half never able to read/comprehend. He has a gross 'tremor' that he produces on demand (when asked to work with the therapist to complete forms in session) but was absent when he was filling out the PCL-5 earlier in the session (with perfect circles around every '4'). Tremor and inability to read/write also conspicuously absent when he was filling out his 'travel pay' paperwork (which is in something like 4-point font). He apparently completed (successfully) a complete course of group CPT (and all the forms involved in that) just last year (which 'didn't help'). He claims not to know what an ABC sheet is or how to fill it out. I could go on, but you get the idea. Of course, the pseudoneuropsychologist didn't include any stand-alone or embedded tests of symptom or performance validity (or if any of the tests they gave included them, they were not scored and interpreted)--as I understand it, this is supposed to be considered an essential component of neuropsych evals in particular contexts.
If a patient complaining of 'a TBI' is referred to a pseudoneuropsychologist I get something like the above. However, if they are referred to our actual board-certified legit neuropsychologist, they do a good job...they do a good history to establish that this veteran with severe clinical depression, incapacitating PTSD symptoms, self-reporting only 2 hours/night of sleep, uncontrolled sleep apnea, recently divorced and homeless veteran who is drinking a gallon of whiskey per day....might need to have those factors assessed and treated prior to concluding that the brief possible alteration in consciousness he self-reports from 12 years ago from bumping his head on a door is evidence of some form of 'brain injury.'
The difference is night and day.
