Contemporary psychological literature as well as the preceding papers (Mateer & Sohlberg, 2003; Wilson, 2003; Ylvisaker, 2003) emphasise the individual patient's personal ecological context as a crucial factor in the delivery of cognitive rehabilitation services. Testing and assessment procedures in neuropsychology have been enjoined to take increasing notice of the patient's historical, cultural and social background in providing services (American Psychological Association, 2003). Similarly, the design and delivery of treatment services must take into account how and where patients are living their lives post-injury. This has the benefit of moving cognitive rehabilitation from an emphasis on the more obvious or face-valid concerns about sterile “cognitive” models to individual ways of facilitating learning and information transfer improvement in the real world. In this way of approaching the problem, the patient's cultural and demographic context as well as their emotional adaptations are not confounding variables but critical design variables. The challenge now in delivering these paradigms of care is to show that they are appropriate and effective in some place in healthcare delivery systems, whether traditional or alternative. Questions of effectiveness of cognitive rehabilitation treatments and cost should be balanced in an equation relating to the probability of objective and demonstrable patient enhancement in living. Goals set and achieved must have consensual value that cannot be captured by traditional cost-benefit analysis in preventive or curative healthcare economic methodology. Cognitive rehabilitation as a family of interventions has little to no chance of being evaluated as efficacious using traditional treatment designs, using traditional neuropsychological measures as dependent variables, and involving research designs with crossover, sham or placebo conditions.