foundations from the Foundation:

LEONARD DILLER

Diller, L. (1993). Cognitive Remediation in Traumatic Brain Injury: Update and Issues. Archives of Physical Medicine and Rehabilitation, 74(2), 204-213.

Leonard Diller, Ph.D. (1924–2019) was a distinguished psychologist and a pioneer in the field of rehabilitation psychology. A graduate of Yeshiva Torah Vodaas in Brooklyn, he later earned a bachelor’s degree from City College of New York and went on to receive his PhD from New York University.  Diller joined the faculty at New York University in 1958 where he founded the first cognitive rehabilitation program in New York in 1976.   He also joined the faculty at CUNY, Queens College Graduate School as an adjunct professor in 1982.  Dr. Diller spent his remarkable career in consulting and leaderships roles including enjoying appointments as a fellow of the American Psychological Association, past president of the American Congress of Rehabilitation Medicine, and chairman of the Research Committee for the National Head Injury Foundation.   Diller received many honors including Licht Award for his scientific writing in 1986, Caveness-Memorial Award for Distinguished Contribution in the Field of Head Injury from the National Head Injury Foundation as well as international acclaim for his work in Japan, Yugoslavia, Israel, Egypt, India and Taiwan.  His reputation for innovative approaches to treating Brain Injury considerably advanced the field of Rehabilitation Psychology.

In the attached Foundational 1993 article, "Cognitive Remediation in Traumatic Brain Injury: Update and Issues ", Dr. Diller and Dr.  Ben-Yishay outline the philosophical, conceptual and technical considerations related to the introduction of cognitive remediation (CR) as a treatment for traumatic brain injury.  The authors diplomatically review and provide thoughtful and empirical-based commentary surrounding both the evidence in support of and positions refuting the value of CR in its nascency.   While acknowledging legitimate concerns related to the validity and efficacy of the treatment and a lack of unifying neuropsychological basis, Diller and Ben-Yishay highlight with important specificity some of the challenges inherent in treating traumatic brain injury (i.e. differing levels of severity, the absence of a standardized CR treatment protocol, lack of adequate subtyping of brain-injury taxonomy) with CR. In doing so, the authors provide a diplomatic and compelling case for establishing a clear definition for and objectives of CR. 

This seminal framework defines cognitive remediation as an intervention for disorders of language, memory and perception that utilizes the application of specific techniques for enhancing or improving specific functions and/or problem-solving ability in an effort to foster increased functioning in daily life tasks after injury.  The authors define further two primary but distinct approaches toward CR (i.e. restorative vs. compensatory) including techniques aimed at restoring functioning and techniques designed to provide compensatory skills where reinstatement of functioning is not possible.  

The authors carefully delineate core aspects of each approach that must be considered and addressed in research and clinical settings.  As an example, restorative-oriented CR requires retraining protocols to consider multiple deficits as well as severity of impairment and incorporate accommodation for both factors in the baseline assessment and intervention techniques utilized. Meanwhile, the substitutive or compensatory approach must examine cognitive processing ability as well as functional competency using existing resources to accomplish and master the functional activities required in daily life.  

Ben-Yishay and Diller also stressed the significance of recognizing the level of awareness and role that self-concept play in the success of cognitive remediation.  Citing unawareness, cognitive deficits, impaired generalization and resulting maladaptive behaviors as common barriers to successful retraining, the authors maintain CR must address denial and limited self-awareness in order to ensure engagement and long-term positive outcome.  

Finally, the authors conclude the paper by outlining empirical work conducted by Ben-Yishay that incorporates the framework from the article highlighting promising results as well as the inherent potential of cognitive remediation to improve the lives of individuals suffering from traumatic brain injury.  Their call to action over thirty years ago has significantly influenced the development of cognitive remediation and retraining programs and helped many people worldwide. 

Dr. Diller’s contributions extend far beyond the basic framework proposed in this article.  However, this influential article illustrates the perspective he exemplified throughout his career; an emphasis on the unique needs of people with functional deficits or impairment and a concerted effort to establish assessment and treatment protocols that best serve them. 

Cognitive Remediation in Traumatic Brain Injury: Update and Issues